Why everyone needs an estate plan

When I was a kid and my dad would drop me off to meet friends he would always say "make good choices" as I was getting out of the car. 

When I was pregnant with our first child, my daughter, I had a- sit up in a panic, in the middle of the night, drenched in sweat, moment thinking about what would or could happen to her if my husband and I were no longer around. That "make good choices" phrase had suddenly taken on a whole new meaning. We met with an attorney shortly after that night and set about making plans should the unthinkable happen in our lives. 

What a terrible and uncomfortable conversation. Sitting in a lawyer's office talking about what we wanted for medical intervention, powers of attorney for medical, financial, where our kid(s) would go. What level of life insurance coverage we'd require to get our kids through college- the kid that was still hanging in hotel mama. I came into this conversation with a background working in hospitals, and seeing the horror shows firsthand that happen when these decisions aren't made by the person themselves. It was that little voice saying "who is going to know this stuff if you don't put it down" that nudged me along. We can make these decisions but they don't get you too far if no one knows or, worse, if they think they know and it's not what you want. 

I don't want my husband to have to make choices and wonder "what if" when it comes to medical decisions. I wanted the kids to be taken care of from all angles (care, medical, financial) because that's part of the b-side to parenting- making these decisions. In my career I have witnessed the mess that comes from lack of direction from parents. It creates conflict, aggressions, anger, and ultimately resentment. So while you're healthy (and of the right mind) make these choices- sit through the icky feeling meeting with an attorney to go through these documents. Set up your estate plan.

What is an estate plan? It sounds so daunting. At what point have you tipped the scales into having an "estate"? What are these documents?

[insert disclaimer: I'm not a lawyer so consult with one to figure out what the best option is for you and your family, it's worth the time and money]

I would highly recommend a trust. They are on the expensive side to set up but include the following: 

1. Will

2. Powers of attorney (POA)- healthcare, and financial

These documents are where you can be as broad or specific as you'd like in determining who has a say and (maybe more importantly) who doesn't. You decide who the beneficiary is/are and what that means for each person. There are clauses you can add- like if there is a substance abuse issue they lose access to funds, funds are specific to the individual recipient and cannot be considered as assets to divide in case of a divorce. Our lawyer explained it the best by saying, "it's like reaching back from beyond the grave and saying- this is exactly what I want to happen."

The other key component of this package is having a life insurance policy. There are different types of policies and it's best to discuss which is the best fit for your individual needs. You must, no matter which one you choose, have one that names the trust as the beneficiary in case something happens. The life insurance payout funds the trust and puts the financial wheels into motion, per your instructions.

An established trust is another way to avoid probate- the freezing of your assets while the estate is being settled. Once your trust is written and signed transferring your assets (bank accounts, vehicles, house, retirement accounts, etc) to the trust they are protected from the probate process. This is so the individuals you've named as trustees can access funds for your beneficiaries (ie. pay the utility bills, buy groceries, buy school supplies) instead of waiting months or years to access any funds. 

This is a very very brief example of some of the legal and financial considerations to make when planning for the future, whether it's for a new baby or simply making sure you have all your ducks in a row. Having these documents in place has given me piece of mind knowing that if something were to happen my wishes are explicitly known and not assumed. 

Connecting with a lawyer to discuss these documents is uncomfortable.

I get it.

These are big items to cross off your list.

Once they're done you can cross it off your list and not think about them unless some updating is necessary. 

Do this for your family.

Do this for you.

Changing seasons.. Not about the weather

I started to write this post thinking about the transition back to school, it's hard to think about it actually turning to fall when the weather is still in the 80's. With October right around the corner and winter coming quickly we're moving into "fall season." 

In acute rehab there are seasons, "joint replacements" at the end of September before golfer's move down to Florida for the winter, "fall season" usually a few days after the first hard frost, and "hip replacements" once the weather starts to get nicer and people plan trips. These seasons are not meant to make light of the injuries and events that happen, just showing some of the patterns that year round therapists typically encounter. 

As you can imagine by the work that I do as part of Home Field Advantage, individuals that come in after a fall (especially preventable ones) make me wince thinking about the "what ifs."

What if they had a grab bar in the shower to possibly prevent falling in the shower?

What if there was a handrail on the stairs in the garage?

What if the rug in the kitchen had been taped down?

When someone comes in for a fall related injury one of the first questions they are asked is "what were you doing when you fell?" The answer 9/10 times is "it was the silliest thing, I went to reach for/pick up/do something I've done a thousand times.

The challenge is to work with individuals before a fall. To keep them out of the hospital-rehab-subacute rehab continuum for as long as safely possible. 

So while you or your loved ones are preparing the changing seasons with fall cleanup and last of the year house projects why not consider accessibility and safety within the home? 

Are there ways to improve safety as you move through rooms in your house? Are there a few small changes that could decrease the risk for falls? What does any of this mean? 

I can help with this. 

Before the frost. Before the snow. Before the black ice. 

Before "it was the silliest thing."

Check out the services offered by Home Field Advantage and how we are able to meet your home accessibility needs.

 

What is a Home Accessibility Consultant?

Great question!

A home accessibility consultant (HAC) can be someone with a few different backgrounds but typically includes- Occupational Therapists, Builders, and Architects. They have skills and training in working with individuals to modify their environment to optimize safety and accessibility. Occupational therapists have an added advantage when they combine this knowledge with experience in various hospital settings and the discharge planning process for each. Hospitals, acute rehabs, and skilled nursing facilities all have different "end points" and discharge procedures. 

When should you contact them?

Whenever you have noticed a change in your functioning at home or that of your loved one. Connecting with a HAC prior to an event or injury (ie. fall in the home), is one of the best ways to prevent potential accidents. Some examples of scenarios to "red flag" connecting with a home accessibility consultant:

A: You have noticed a change in how you are moving around at home or things around the house are feeling harder to do and you want to have someone help you troubleshoot

B: You have concerns about how your parent or loved on is functioning at home but don't know who to reach out to for answers

C: You are looking to make changes around the house and want the renovation to suit your needs now and as you age in your home

D: Your loved one has been in a facility but wants to return home and you know that changes need to be made to their home, or are unsure about the facility's determination of their fit for home and would like an independent professional opinion

This is the short list. Any situation revolving around questions of being able to age in your home are prime opportunities to bring in a home accessibility consultant. 

What do they do?

I can only speak to my process with my clients so the following is a typical three part series.

1. First, I meet with a client to learn about their background, current level of function, where they may be having difficulty, what has been going on medically/socially/physically/emotionally that has led them to reach out to a HAC to consider modifications. Then we walk through their home, having them do each activity they would in a typical day at home.

2. Following the interview and assessment piece, a report including suggested modifications, new equipment placement, and/or new services to be introduced are presented to the client and any pertinent family members.

3. A final meeting takes place after modifications have been made to discuss their effectiveness for the client and to go over any new concerns. 

Home accessibility consultants are an integral component of making informed decisions for yourself or a loved one when it comes to living arrangements and modifications. As an HAC my responsibility is to the client, to integrate their goals with their physical environment to promote safety and accessibility at home. In certain situations these assessments may indicate that staying home is not the safest option. In these instances, working with clients and their families to devise a plan, whether it be adding services or beginning the transition to an assisted living facility may be part of the long term strategy. 

If you have concerns regarding your loved ones, or your home set up please contact me to discuss your current situation and needs for the future. 

Most common mistakes people make when wanting to age in their home

I was asked at a meeting this afternoon what my "most frequent pieces of advice" were for clients. Here's a greatest hits list of encounters I've had in people's homes and what to do about it.

1. No bathroom or a half bath on the first floor- A half bath is a great idea for any house. The problem with them on the first floor is that they are usually either a design afterthought for new construction so they are tucked into a tight space, or they are in a location that makes it extremely difficult for them to expand if need be. No bathroom on the first level speaks for itself. The houses on the seacoast can range from new builds to 300+ years old so there is an incredible amount of variation. 

2. Handrails, or lack thereof- Have two steps down into the living room? Have a split level but you took the railings down when you moved in because of the furniture? Don't like the idea of having a handrail on your front steps for esthetic reasons? Whatever the reason, these are prime areas to improve safety when looking to stay in your home. There are a number of products that have come on the market over the years that improve the outward appearance of some of these bars. This is also an important consideration if you are in the market for joint replacement (think knee, hip, shoulder) to prepare for that discharge. The other half of the equation is having them installed correctly. Have a professional put them in. 

3. Laundry in the basement- When we moved in to our house a few years ago the washer and dryer was in the kitchen. An elderly couple had lived in the home two owners before and had brought the hook ups up from the basement. From a professional standpoint I dragged my feet moving them back to the basement knowing that they would move upstairs decades from now. At least we know where to put them. The #1 reason people cannot live on one level is having laundry in the basement. It's not the most pleasing to look at if there's no option to box them in, but it beats 12 stairs up and down with a laundry basket. 

4. Delaying bringing services in- I think there's a misconception that once you have one person into your home it will inevitably and quickly turn into a tsunami of help that will result in you being swept out to assisted living or a skilled nursing facility. The truth of the matter is there are a number of opportunities along the way to bring services into your home that probably won't affect your ability to stay there. Some example services include:

- cleaning service- once a month, every other week, heavy cleaning, total house clean. You pick the level and adjust as need be over time.

- meal delivery- meals on wheels, take out on fridays, grocery delivery (where available), meal prep delivered. You pick the level of assistance. Maybe grocery shopping isn't your thing but you still have no problems cooking. 

- money management- need help paying bills or staying on top of your checkbook? There are trained professionals to assist you with keeping your accounts in order. There is a checks and balances system in place to protect you as well

- respite- this is not an in home service typically. If you are the caregiver for an aging spouse there are respite programs in the area that will take over care for them to give you a "break" or the opportunity to not be responsible for them. I've seen this most commonly for individuals going into the hospital to have an elective procedure. Usually respite in a few weeks to a month, which gives the caregiver the chance to have surgery (joint replacements, etc), recovery, and return to caregiving when they are healthy and able.

5. Not having a plan in place- wanting to stay in your home is typically a polarizing decision. If you want to stay home, you need to have a plan in place. Mapping out your potential problems along the way as you age creates the opportunity for you to say "I want to stay until ..... happens" or "even if ..... happens, here's my plan to address it". The more clarity you have with these decisions and the more open you are with your family about them, the more likely they will be carried out. 

The more clarity you have the greater chance your family will continue to work collaboratively to support your choices. Starting early, before you are confronted with the immediate need to make changes will save stress, time, money, and aggravation in the long run. Working with professionals trained to help individuals age in place will also ease the burden of these decisions. 

If you are looking down the road and have questions about setting your home up for optimal accessibility and comfort to support aging- give me a call. I will help.

When going home is no longer an option

Let me be the first one to say that my goal- in life, as a therapist, as the child or the grandchild, is to always be able to help people get home after illness or injury or to age successfully in their home. 

So what happens when home isn't the safest place for you or your loved one to be? How do you know? Who can you ask? What are the next steps?

The answers to these questions are simple and complicated.

When home is no longer an option it depends on where you are when the decision is made. If you are in the hospital or rehab, you'll continue along in the system, progressively to a less acute facility, until an assisted living or skilled nursing facility bed opens up. Usually the continuum is: hospital- acute/subacute rehab- skilled nursing (potentially while you wait for a room to open)- finally to assisted living or skilled depending on the level of assistance required. 

If you are at home, the next steps would be to contact a home care company if you currently do not have services coming to the home, either privately funded or through your insurance. People will usually try to increase services to see if that helps push off the decision. You can also refer yourself to a facility. It's not common practice to self-refer, in my experience it is usually done by the care giver once they've seen a marked decline or if they have tried to discharge home unsuccessfully from a hospitalization. It is not the easiest route and you run the risk of the facility being full and being left with minimal options. 

Figuring out the "right time" to make this choice is the hardest part. Hospitalizations provide concrete data to support a decision either way. They also provide the opportunity to connect with Occupational, Physical, and Speech Therapists to weigh in with their expertise. So what happens if your parent is in the hospital and you know that home is not an option, regardless of the modifications or level of assistance that can be provided? And all these health professionals are affirming your decision- but your parent is steadfast in their decision to go home.

Have a home assessment

In my experience, no amount of professional jargon, data, or opinion is going to come through for someone wanting to go home, until they have a chance to try on their own. 

These assessments are opportunities to allow individuals to try for themselves, to help them make their own decision about being safe at home. These are vulnerable moments, being confronted with the reality that the safety of home is not what it used to be. But they are incredibly valuable to that individual. Instead of being told, they are able to make the decision on their own. It eliminates the "what if" and releases the burden of that guilt on families. And in the end, will hopefully ease the transition to a safer environment. 

I could write endlessly about prevention and the importance of planning for the future when it comes to aging and health. Maybe it means downsizing to a smaller and more manageable home. A first floor bedroom and full bathroom. One with an option to install on overhead lift. Maybe it means knowing the end point before starting to look for an assisted living facility.

Whatever lengths you are comfortable with, these decisions are yours.

The earlier and more explicit these choices are made, the greater chance for success in implementation. 

 

We are all trying to do our best..

It's been a while since I've put up a post so I wanted to start by thanking everyone for their support and kind words about the article in the Portsmouth Herald (click the link to read- http://www.seacoastonline.com/news/20170430/home-field-advantage-helps-elders-age-in-place). It's a surreal and exciting feeling to see your name in the paper and the idea you've been cultivating into a business come to life. 

The idea for HFA came from my own experience trying to do the right thing for my family. Trying to use my skill set to help the people I love be safe and comfortable in their home.

This past week I met with a client and she told me about her family- they sound absolutely wonderful. They are supportive, check in on her, help with any errands or help with appointments- everyone is trying to do the right thing. With all that in mind, she still needed someone to help problem solve a few ways to safely get around at home and perform some daily activities independently. She found my article online and called. 

When we met last week she asked me questions about myself, my background, the business- but one question stood out for me. She asked what the hardest part of starting this company was. My answer was/is that our healthcare system is not set up to focus on prevention. Insurance payments are dictated based on diagnoses codes, pre-approval, referrals. Annual visits are covered but there has to be a medical "reason" for an appointment to be covered for the other 364 days left in the year. 

I have worked in this industry for enough years to know the juggernauts in the health insurance business are not going to focus on prevention anytime soon. There is less money in people not getting sick. What a terrible idea. 

So instead of going along with the system I decided to try and do what I could to help as many as I could. Help people avoid entering the health care roller coaster after a preventable injury or fall. Help people maximize function and safety in their home. Trying to do my best. 

To share my experiences and the knowledge I've gained as a therapist and family member of those navigating the healthcare system.

To help answer questions people didn't know they should or could ask.

To empower individuals to make decisions based on facts and not feelings or fear. 

If you have questions, contact me to set up a time to talk. I want to help as many people as I can.

- Ashley

 

What happens when you can't speak for yourself?

It went like this..

me: "hey dad, thanks for having us over for dinner"

my dad: "just putting it out there for you, I'd like to be buried (...) and here (...) is where all the documents you may need are. What can I get you to drink?"

at another time with my mother..

me: "hey mom, glad the kids and I got a chance to come visit"

my mother: "good thing you're here. I just had copies of our wills made for you and your brother to have just in case."

This may not be normal dinner conversation for most families. I credit the openness in talking about death and planning to having a mother that has been a nurse for 40+ years. People are going to get sick and some may not make it through that illness. It may not even need to be that black or white. What if you went into the hospital and were unable to make decisions for yourself regarding your care? Who would you want to step in for you and do they truly know what you are OK, and more importantly, not OK with when it comes to medical intervention?

Before my daughter was born my husband and I took a series of "baby classes," ones that talked about labor and delivery, caring for a newborn, etc. The class that I was most interested was the c-section class. Purely because I knew relatively nothing about that procedure other than it resulted in a newborn baby. In that class they talked about different types of medications during labor and their relative effectiveness. During this class my husband leaned over and asked "do you want any of this stuff?"

I had no idea.

I was well on my way with this pregnancy and knew that I was going to deliver in a hospital, but hadn't thought about all the options or possibilities and what I was on board with. A few long months later- after a night and most of the day in labor, I literally could not make the decision for myself regarding medications. I remember mid contraction the midwife talking to my husband and asking him questions but I couldn't concentrate on what they were saying. Long story short- I woke up an hour later from a nap, with a clear head and the ability to continue (I did believe for a moment that I had somehow lucked into a 1950's birth and they just knocked me out and she was born... no such luck). That birthing class turned out to be invaluable. It sparked the conversation about what I wanted for myself at a time when I was able to clearly consider my options and decide what worked for me. It also created an opportunity for me to discuss these decisions with the person that was going to step in and make them. 

So what do newborn babies have to do with end of life planning? Lots, actually. Nothing helps address the elephant in the room (ie. mortality) like a new baby. It creates another link in the chain of generations, a glaring reminder that time is passing. You may have no idea what you're comfortable with medically in case of an emergency or you may know exactly where the line in the sand is. 

That's step one.

Step two, usually the hardest one- you have to tell someone.

Specifically, the person you want to step into that role should you need them to. We don't like to talk about these things because they are scary and overwhelming. Consider the alternative though- your family standing outside the hospital room trying to figure out what's right for you. Think about the burden of that position. What if you had four kids and they all thought they were doing what's best for you? These choices have a lasting impact on families, regardless of the outcome.  

These conversations don't have to be stiff and formal, sitting around a table at a lawyer's office. If you are not the type to discuss this consider writing a letter with your wishes in it. Tell the person who may need it where it is. Or better yet, go one step further and use an online template to create a will, sign it, and keep it in a safe place. 

While you have the time and ability to make these decisions for yourself- do it. Take the burden off your loved ones. 

"What if".... the silent killer

How many major decisions- which college to attend, beginning or ending a relationship, taking a new job, moving to a new city- have you looked back at and thought "what if I made the other choice?"

Take that feeling and think about what it would mean to make a major decision on someone else's behalf. Should your parent go home? Can your spouse be home alone during the day while you're at work? Does your grandmother need to move to an assisted living facility? 

Ick. 

Decisions made with (or for) a loved one are packed full of guilt. Did you make the right choice? Did you get all the information about what the discharge plan was going to mean for them? For you? Will they be safe?

In a time of google, WebMD, and numerous chat sites, it seems as though the internet has the answer. If you search for "is my parent safe to stay home" the results include tips for talking with your parents not about staying in their home, signs it's time to move to assisted living, and the dangers of leaving parents home alone. These websites do not inspire a lot of confidence, maybe rightfully so, but every house is different and every person is different. There is no formula to be applied or googled to let you know that the right choice has been made. This is why home assessments used to be a more prominent component of discharge planning for patients while in acute rehab. 

As you (or your loved one) progresses through a hospitalization they will inevitably come to this fork in the road- home or not. So now that a home evaluation by the hospital therapist is a less likely option, how can therapists gather information to inform their recommendation? In the hospital therapists ask family members to take measurements of areas in their home- height of furniture, bathroom dimensions, stair height, to try and piece together information. This could work for a simple question (can they get in or out of the house for example), not the “whole person” approach to deciding whether or not someone can continue to stay in their home or how best to adapt it.

Going through a home with a trained therapist yields much more information, how that person moves in their own space, what tricks they've been using to get by if their health has declined, how to adapt areas in their home to suit them. Living in New England and going in and out of dozens of homes has honed my troubleshooting skills when it comes to making a 100+ year old house work for clients.  

My goal as an acute rehab therapist was to get as many people home as safely possible. Home Field Advantage is an extension of that goal in a collaborative model with clients and family. Not every person will end up at home though. It is my hope for these individuals and their families to not have these lingering "what if" feelings. If you are unsure if you or your loved one will be safe in your home, I would like to help. To make an informed decision, one that you can be at peace with, knowing you’ve considered all options, you need all sides to the story. If home is no longer an option following an illness or injury helping a family know that they made the right choice, is paramount to the discharge location. 

If you are struggling with whether your loved one can return home after a hospitalization, or ways to troubleshoot their safety and function at home, I would love the opportunity to help.

 

Navigating healthcare and the transition home

The idea for Home Field Advantage came from an astounding realization I experienced over and over again while working as an Occupational Therapist in an acute rehab hospital:

People don't know they have a choice. 

The unfortunate reality in our country is that healthcare revolves around profit. Reimbursement levels have changed drastically in the last 20 years, especially in the last ten. Medical technology and research has created advancements in treatment and rehabilitation but no advancement can alter the fact that some patients just need more time. 

Over and over I saw patients that could have discharged home had they been given extra days or maybe a week, discharged to a subacute facility. On the surface it sounds logical, they aren’t ready to go home so a next level down will give them time. The reality is the longer a person spends in the healthcare continuum, the longer they are likely to stay there. What about their home setup informed the therapists’ recommendation? Was it the stairs to enter the home? or their ability to access their first floor bathroom?

For example- Say a patient entered the hospital after a fall at home on the ice in their driveway and broke their hip. Prior to the fall they had been living independently, or with a minimal amount of services. Now they transition to acute rehab and work on improving strength and safety with the goal of going home. At the end of their rehab stay that person is still having trouble using the stairs. Instead of a home visit, because those are few and far between, they are discharged to a subacute facility (skilled nursing) to continue rehab and probably stay between 30-90 days there before heading home. If they stay the entire 90 days, plus the few weeks in rehab and the hospital, this person hasn’t been home for 4-5 months. In those 4-5 months the patient’s family has been educated on assisted living facilities (ALF) and begins to push for their parent to transition to an ALF after discharge. 

Sometimes this is a necessary outcome. But what if someone had gone through and assessed the patient’s home while they were in the hospital or rehab? If the patient wanted to go home, how would the family know what changes to make to facilitate a home discharge? Time and time again I had patient’s family members bring in pictures of their homes to ask for advice. It’s a start, but you can’t truly judge the space unless you are in it or unless you have a background in rehab. 

The term “home field advantage” refers to the advantage anyone enjoys from familiar surroundings or circumstances. We spend our lives making our home a safe and comfortable place. Our ability to safely access this space should not be hindered by a change in function if we are able to adapt the environment. 

I started Home Field Advantage to work with families. 

To help people stay in their homes longer and in a safe capacity. 

To empower families to make fully informed decisions about discharge planning.

To help people plan for the future. 

We are all going to age. 

It is never too early or late to make changes. 

 

* The picture with this blog is me and my grandparents. They were the first HFA assessment and the push to help me understand the impact this could have on other families.

The 5 people you need to know in Acute Rehab

Being admitted to the hospital is incredibly scary. There is a transition in an acute facility from independence to (potentially complete) dependence. When you've been medically stabilized but are not quite back to your starting point the next step is usually admission to an acute rehab facility. Here they have medical and nursing coverage 24/7 as well as three hours of therapy 5-7 days of the week. You may have entered the hospital for an elective procedure and this is a planned step, or something traumatic happened and this is another part of your journey back home. The people listed below are the heavy hitters in the acute rehab realm, ones that you will definitely have contact with and will play an integral role in helping you get back to your baseline (ie. back to your old self). 

1. Case manager- Think of this person as the travel agent for your life. They are the access point for services when you leave the hospital and play an integral part during your stay. All information from physicians, nurses, and therapists are compiled by your case manager. When a recommendation or decision is made about your discharge destination, this is the person that will make it all happen. If you go home, they will set up home services (OT, PT, speech, nursing) or if you are going on to another facility they will help you and your family find the right one for you. Case managers usually have a social work background, so they can help connect with other services in the community- meals on wheels, adult day programs, respite care for caregivers, oxygen and medical equipment delivery. They are also the people to talk to about power of attorney requests, medical proxies, short term disability and worker's comp. Case managers do varying levels of this, for every single patient, at the same time. Oh, and they also interact with your insurance company. When you've been extended 5 days so you can get home instead of going to a skilled facility- thank these guys. 

2. Therapy team- As an OT I'd love to put my discipline in its own category but that's not the reality of how rehab works. Physical, Occupational, and Speech therapy all work closely and in somewhat overlapping fashion at times to improve safety, strength, and function as quickly as possible after an injury. These are the individuals that can break down problems you may encounter when returning home after rehab. I'll break down the different disciplines and how we impact patient care in an upcoming blog.

3. Nurse- Your (or your family member's) nurse is an invaluable resource in the continuum of care. They typically work in 8 or 12 hour shifts and hand off information to one another at shift change. This is the person that will talk with you about pain management, dressing changes, discharge instructions. They also have a wealth of knowledge for family members about how the patient has been sleeping, eating, etc. Nurses are a special breed. My mom is a nurse. Their greatest skill is that element of calmness they bring to a stressful situation. The dynamic between nursing and therapy is important for patients to learn to push themselves and to take care of themselves. Also helpful to know, every shift has a nursing supervisor, so should you feel like there's an issue not being addressed- that's your person.

4. Doctor- DO, MD, (put PAs in the mix too), typically from internal medicine and physiatry (rehabilitation medicine). If everything is going well in rehab you won't see your doctor a lot- It's a good sign. They typically come in early in the morning for rounds and to see new patients on their first "official" day in rehab. I explain the difference between internal medicine and physiatry as- internal medicine keeps everything going, physiatry helps you get back to where you were.

5. Patient services/patient experience/ombudsman- Ideally a rehab stay goes according to the following schedule- patient admitted, patient evaluated, rehab program with gains over length of stay, patient discharged to disposition of choice with follow-up services and transition to outpatient. So what happens if things aren't going well? If there is an issue at any point during your stay, someone needs to know about it. Healthcare professionals are entrusted with patients safety and dignity while they work to improve their level of function. If there is an issue a Patient Services representative should be notified right away. Contrary to popular belief, it's best to do this while you are still in the facility. Once you've left it's harder to track people down, especially if you are in a rehab with a high turnover rate. 

Going through this is difficult for patients and families. At the end of many stays we, as therapists, used to have the opportunity to conduct home assessments for patients we were unsure about discharging home. These visits are becoming less and less frequent with healthcare reimbursement changes and increasing demands on therapists. The need for these home assessments haven't decreased. Pictures and measurements of your "problem areas" at home are a good start, but it is not possible to conduct a thorough assessment without walking through the home. 

If you or a loved one are currently in this acute care-rehab transition period and would like to have additional resources to inform your decisions, give me a call. I would love the opportunity to help put a person or their family member's mind at ease about the next step.

Why I would not recommend a home discharge

I've spent seven years working in various acute care and acute rehab settings. I've had the responsibility of saying to family members, patients, and case managers that I don't think the patient should leave our facility and go home. It sounds like a thumbs up/ thumbs down decision but it's more than that. This recommendation may mean that an individual doesn't go home, now or potentially in the future. 

This may be the first in a series of facilities an individual transitions through during their rehabilitation process but the ultimate ending could be an assisted living facility. Not home. Not the comfort of their own pillow, coffee cup, breakfast table, favorite pet. Yikes. 

What leads up to this decision? 

There are a number of factors at play, the two most important are home set up and family support. Let's talk about the top 4 categories.

1. Home setup- This is the most important. First question- can you get into your house? For example, what if you have 5 stairs to get in with no railing and you are leaving the hospital in a wheelchair? How's that going to work.. Then, once inside, can you maneuver your wheelchair around? Get in and out of the bathroom? Cook? Get dressed?

2. Family support- I use the term "family" to categorize any support a patient will have once they leave. I've had patients that have lived in the same neighborhood for 50 years and now that their children have grown and moved away their neighbors have become the closest support system. Can your family stay in town for a few weeks? Do you need someone to check in everyday? If you are going to be set up with lifeline (or similar products), who will get your notification?

3. Impact of illness- Is the diagnosis acute (will get better), chronic (will get worse over time), or terminal? Acute illnesses or injuries may only require temporary changes, like renting a ramp to get into your one level home, whereas a chronic condition will continue to impact function. Chronic conditions necessitate planning for future issues, this is where a home assessment and renovation planning has the greatest potential to impact safety and accessibility. Discharge planning for patients with terminal illness, is generally a different category because the focus is not on rehabilitation. Whatever that person wants, 100%.

4. Personal factors- This is the "what are you made of" category. Some people strive for independence and will only see a home discharge as the end result. Some are happy to be in the hospital as long as they can. Most people fall somewhere in between. Where you go at the end of your rehab stay, is ultimately up to you. Put in the work, take in the information, learn new safety techniques. Do you want to go home? Is this hospitalization a tipping point?

No two people are alike and no two patients are alike. Each person is a mixed bag of these four categories. What may be a simple diagnosis to one may be an overwhelming roadblock to another. This is why home visits are a key component for these patients on the edge.

Why aren't they happening as often anymore?

When I started working as an OT, we had more flexibility with scheduling that allowed for more home visits to occur. Changes in healthcare reimbursement over the last few years has almost eliminated this as a possibility for patients prior to leaving. These home assessments were often the deciding factor for the therapy team (PT, OT, Speech) for discharge recommendation. Limiting access to this has created a gap for patients and their families, unsure about what types of modifications are available and what their family member may need to be safe at home. 

What can you do? 

Call me.

My goal is to help as many people as possible stay in their home as long as they chose to. If you have recently been diagnosed with a progressive illness. If your family member has been hospitalized and you want to help prepare their home for their discharge. If you are living in your "dream home" and are thinking about renovating to make it the "forever home." 

Whether you're planning for now or 10, 20, 40 years from now, it's never too early to start.