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Therapists overlap tasks for patients’ benefit
You, and everyone else you know in rehab, surely are familiar with the interdisciplinary model for health care. Everybody’s doing it. But have you heard of the transdisciplinary approach? Transdisciplinary is the newest buzzword in rehab, as hospitals around the country are beginning to experiment with a completely new way of doing therapy. It turns teamwork on its head, breaking down the walls between disciplines to eliminate barriers that keep patients from returning home.
In the interdisciplinary model, a speech therapist might hear from a nurse during a team meeting that a patient is having trouble transferring from the wheelchair to the toilet. In the transdisciplinary approach, that speech therapist would help the patient get to the bathroom and use the event as a teaching opportunity.
At SSM Rehab in St. Louis, the various rehab disciplines — nursing, occupational therapy (OT), physical therapy (PT), speech therapy, social work, psychology, and case management — work together to set a collective goal for a patient’s discharge and then identify the barriers to that discharge, says Lori Adams, MSP, CCC/ SLP, regional speech therapy manager. "The issues that are important are mobility, ADLs [activities of daily living], communication, discharge, and medical status. Everybody involved in the team is involved in all those areas to some degree," she explains. "There’s a lot more overlap; there are less boundaries. Truly, the patient is the center of all the care that occurs. It makes rehab occur throughout a 24-hour day instead of just when the patient is in therapy," Adams says.
Under the interdisciplinary model, a speech therapist would work on communication goals but wouldn’t worry about carrying over PT or OT goals. But with the transdisciplinary approach, the speech therapist might go to the PT area, walk the patient back, and help the patient transfer to a regular chair to start the speech session. And instead of asking the patient to talk about the sequence of steps required to brush his teeth, the speech therapist might go to his room in the morning and ask him to tell the steps and then actually do them. "You’re helping them to become more functional," Adams says. "Interdisciplinary is certainly team-oriented, but there are still those boundaries between the therapies and nursing because I’m gearing in on my specialty only."
In just a year of using this approach, the results have been unbelievable at SSM Rehab, she adds. Patient satisfaction scores rose from 93% willing to recommend SSM’s service to 100% in the first three months. Discharges home increased 3% on average. The hospital goal is 75% discharges home, and the transdisciplinary team has consistently met that goal and, at times, has gone as high as 88%. Com-munication has improved with the model, according to the Staff Perception of Communication Effectiveness Survey.
In October 2002, the effectiveness on a scale of 1 (poor) to 4 (good), was 2.5 overall. By March 2003, the score rose to 3.32 overall. Adams says the transdisciplinary team also has been significantly better at predicting functional patient outcomes with the accurate setting of goals.
One of the reasons for the increased discharges home is that caregiver education begins preadmission. "Usually, it is only close to discharge that they get the hands-on training. But we’re finding that if you don’t bring in the caregivers until the end, they think the patient hasn’t made much progress," she explains. "They get scared and think they couldn’t possibly take the patient home. But if they see the progress along the way and have the chance to practice while the nurse or therapist is there, they feel much more comfortable. We’ve had some patients who would have gone to a nursing home go home instead."
Team conferences have changed from going around the room and letting each discipline speak to focusing on the barriers to discharge. Those barriers are set by the patients, not just by the therapists. SSM staff have found that often the things they are most concerned about are not what the patient feels will keep him from going home.
"Now it’s problem-oriented," Adams says. "We’ll say, How is his mobility? How’s he doing with his ADLs?’ and it opens the meeting up for anyone to speak. We get a lot more input that way."
In one example, the speech therapist felt the patient was ready to discharge but the physical therapist said she was having trouble following directions in the gym. So the speech therapist joined in the PT session and saw a whole different person who could not process directions in a distracting environment. Since real life often is distracting, there was more work to be done, Adams points out.
It wasn’t easy at the beginning to get therapists and nurses to hand over parts of their jobs to one another, she says. But once they saw how much better it was for the patients, the buy-in came. "Speech therapists are not as proficient at transfers obviously as physical therapists, but really that gives more connection to how the patient will function at home with a caregiver who may not be great at transfers either," Adams says.
Angela Dietsch, MA, CCC/SLP, a speech language pathologist for SSM Rehab in St. Joseph Health Center in St. Charles, MO, says the biggest benefit of the new approach is that it is so patient-focused. "Everything that happens from before the patient ever arrives until after the patient leaves is individualized to that person’s needs instead of the predetermined set of ideas about what a person should be achieving," she says.
One of the hardest aspects for therapists is separating what they might want if they were in a patient’s shoes and what the patient actually wants. "Our training is very much, You work on this and then you work on this,’ because normally skill retraining does happen in a sequence," Dietsch adds. "But the things that are obvious to work on from a therapeutic standpoint aren’t always the things that are most important for that particular person."
For example, speech therapists might work on developing automatic speaking skills, such as saying, "Fine," when someone asks, "How are you?" Then they might move on to filling in the blanks, so the patient would respond to "salt and" with "pepper," she continues. "But in real life, those things don’t happen in order. In real life, I might skip three of those steps in the process and go to a multimodal form of communication. This person needs to be able to tell me when they need to go to the bathroom. I’m not going to worry about whether they can fill in the blank but whether they have a way to get their immediate needs met."
Another patient might have his own goal of becoming independent at a wheelchair level. "Normally once a patient can stand, we would work on walking," Dietsch says. "But for that patient, walking might not be as important as the ability to transfer by himself. So we may put all our energy into transfer skills so he can be independent at home."
Any part of the patient’s day can be used as a teaching opportunity, she says. If it’s time for the patient’s speech session but she is not yet dressed for the day, the speech therapist can help the patient dress while focusing on a speech goal such as answering yes-or-no questions or following a two-step command. "I have to use my creativity to make each activity a speech lesson," says Dietsch. "The big benefit as therapists is that we’re all working on all these things that the patients will have to do when they get home. We’re overlapping all day long."
Chris Walck, OTR/L, an occupational therapist also with SSM Rehab at St. Joseph, says she appreciates the way communication is continual among the staff throughout the day. "The red flags overlap between the disciplines, and we can brainstorm together on how to deal with them. For example, bowel and bladder used to be a nursing thing. Now, we look at it as an essential component for the patient to go home. The nurse might encourage the patient to use a walker rather than just getting them to the toilet the quickest way possible."
Therapists have to get used to new habits, but the effort is worth it, Walck says. "This is the right thing to do. The intent with all therapists is to provide the best for our patients, but sometimes the mechanism to accomplish that isn’t conducive to that. This has improved our communication from the morning huddle where we talk about barriers to the change in the team conference format," she says. "There’s an openness to educate and train other disciplines about things that need to be reinforced throughout a person’s stay."
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