Community therapy moves rehab out of the hospital

Program prepares patients for discharge

A former rehab patient once told Melinda Staveley, MS, RN, "Nobody told me that in order to go home, I had to leave the hospital."

Her poignant comment illustrates how many patients feel about their transition back to their homes and communities, says Staveley, vice president of clinical services/chief operating officer at the Rehabilitation Institute at Santa Barbara (CA).

"Patients learn things in the hospital, but when they go into the community, they have a hard time translating them to the home environment," she says.

For that reason, the institute has enhanced its community-based rehab program with a goal of conducting more of the traditional therapy sessions in the community instead of within the hospital walls.

Community presents more challenges

The community-based rehab program takes into account that learning to do something in the hospital setting isn't the same as doing it in the community where there are more distractions, more obstacles, and a constantly changing environment, Staveley points out.

"With shorter lengths of stay and fewer approvals for day and overnight passes, we don't have enough time for the learning to sustain itself if it all takes place in the hospital setting," she explains.

The institute's community-based program is far more comprehensive than the old practice of taking patients for a community outing during their rehab stay. Under the old system, patients were grouped by diagnosis, and most were taken into the community only once during their stay.

The patients in a community-based treatment group come from all diagnoses. "It doesn't matter if you are recovering from a brain injury, spinal cord injury, or stroke if what you need is the same kind of intervention and to achieve the same functional levels," Staveley says.

The number of community-based treatments a patient receives depends on the individual patient, she says. However, the therapy staff are encouraged to take patients into the community to work on their skills as frequently as they can.

"It's probably a bit more costly than hospital-based therapy, but if it achieves the outcome in a shorter length of stay, then it's a win-win situation from the payer's perspective and our perspective," Staveley says.

The institute has virtually no fee-for-service patients. The majority of patients are on per diem or case rates, she says.

The cost of running the van is the primary additional cost, she says.

"However, from a gross productivity perspective, if a therapists can do 45-minute treatments one right after another, they can do more direct treatment in a certain time frame than if they are gathering patients, getting them into a van, driving them off campus, and driving them back. But if we do it correctly and make maximum use of the time, we can achieve outcomes more quickly," Staveley says.

For instance, the trips into the community are expected to be heavily treatment-based, including the trip in the van, during which the patient work on their verbal and cognitive skills.

Grocery store is one destination

Here's how community-based treatment works: A speech pathologist, an occupational therapist, and a physical therapist may take three or four patients to the grocery store, where they will work on goals within their discipline in the community setting.

At the store, the speech pathologist may work on cognitive processing as the patient buys the items and counts the change. The physical therapist may work on gait and ambulation, while the occupational therapist concentrates on upper body coordination as the patients put groceries into the cart.

Ideas for the community-based rehab trips are recommended in team conferences, evolve from informal conversations among therapists, or arise during hospital-based group treatments.

"Not every patient needs the same kinds of intervention, but all benefit from being in a more functional environment," Staveley says. "It's a group treatment, and they also gain a good deal from peer reinforcement."

At this point, community-based therapy groups are scheduled during regular time slots during the week.

The therapy staff are being encouraged to build more spontaneity into the process to avoid the risk of exchanging one kind of rigid schedule for another. Instead of saying "this patient could fit in with the group that is going to the beach Monday," therapists are encouraged to think about what a specific patient needs to work on and plan a trip around that.

"If you're trying to slot a particular patient into a preconceived group schedule, you may not be meeting his needs," Staveley says.

For example, in the case of a student, a lot of her therapy took place in her dormitory and classroom, where the staff helped her work on compensatory techniques so she could resume her studies. In this case, much of the therapy was one-on-one.

Community-based rehab takes a lot of commitment and effort on the part of therapists, who have to cope with the logistics of getting all the schedules to work. It's been difficult for some therapists to shift away from the old way of routinely scheduling patients at 45-minute intervals for treatment in the hospital, but others are enjoying the challenge of coming up with ways to treat the patients in the community, Staveley says.

"They are really motivated by patient successes and progress and positive outcomes," she says.

The rehab institute started the transdisciplinary approach to community-based rehab in the past year. It's too soon to have any hard data on how the change has affected outcomes, Staveley says. The move toward community-based therapy, however, has forced the administrative staff to look at productivity standards in a different way, she adds.

"We no longer look at productive or nonproductive time, but we talk about direct and indirect time, knowing a certain amount of indirect time is necessary for the planning, which in turn produces positive, enduring outcomes," Staveley explains.

[For more information, contact Melinda Staveley at (805) 683-3788.]