Combining resources a must for home rehab
Here’s how Rehab at Home works
Before patients are admitted to Bryn Mawr Rehab at Home, a clinical liaison evaluates them in the acute care hospital to see if they meet the admission criteria for the program.
The team meets with the family, assesses the home, and works with the acute care team to decide what kinds of equipment will be needed and what goals the patient and family can expect to meet. The team designs a rehab program that takes into account architectural barriers and furniture, community resources, and other aspects of environment in which the patient lives.
The core treatment team includes a rehabilitation nurse, who visits patients six or seven times a week; a physical therapist and occupational therapist, who treat patients five or six times a week; a rehabilitation aide, when needed; and a case manager/social worker. The team is led by a physician, usually a physiatrist, who visits the patient at home several times a week.
Speech therapy, psychology, assistive technology services, respiratory therapy, and nutritional consulting staff are called in as needed. A recreational therapist may join the team when the patient is functional enough to return to leisure activities. Patients can expect to receive treatment for five to seven hours a day, six days a week.
As director of the program, Dana Trainor, CRRN, CCM, visits patients periodically to supervise the team members. When team members are not present, she checks on patients’ conditions.
A physician and an emergency response system are on call 24 hours a day. Laboratory, X-ray, and diagnostic studies, medications, and IV therapies are available as prescribed.
The program is based in a Thomas Jefferson University Health System hospital in the middle of its service area. The location gives the team direct access to lab and pharmacy services.
Team members are expected to go to the administration site daily and to attend formal patient conferences at least weekly. Those who can’t get to the conference may participate by speaker phone.
Meeting notes from patient conferences are sent to the insurance case manager and the primary care physician. The patient and family are also included in the patient care conference by conference call or in person if they are able to attend.
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