Many older folks are able to live independently at home—until they reach a turning point. For some, it’s a sudden event like a fall. For others, it’s a decline in function until they can no longer perform routine activities like bathing or going outside. At that point, a person who has declined significantly often enters a cycle of increased doctor visits or repeat ER visits.
“Let’s stop that process,” says Dave Shefte, CEO of HealthSouth Rehabilitation Hospital of Denver. “Let’s get them intensive rehab and medical services, and put them back on track.”
That’s the purpose of the “direct admit from home” program at HealthSouth, which aims to improve quality of life and preserve independence. In a nutshell, a patient referred to the HealthSouth is admitted directly from home, where he or she undergoes a thorough evaluation. Problems that have become barriers to independence are identified and addressed, and the patient discharges home with new strength, knowledge and resources.
A team approach is key to the success HealthSouth is having with this type of patient, Shefte says. Typically, 75-80 percent of patients return to independent living after a stay of about two weeks.
An interdisciplinary team approach is the core of that success, says Dr. Jill Castro, a Board -Certified Physical Medicine and Rehabilitation physician and medical director of HealthSouth.
A prospective patient receives a visit at home from a rehabilitation liaison, who evaluates the patient and looks for anything about the home setting that might be limiting the patient’s function.
During the first day or so after admission, “everybody from the team visits with the patient and talks about what they would like to accomplish,” Dr. Castro says. “Then we get together as a team to share the clinical assessment and determine the patient’s goals. Falls, for example, are a fairly common reason for admission. The cause can be something neurological, an inner-ear problem, a cardiac issue, peripheral neuropathy or a generalized balance problem. Sometimes it’s a simple as finding an electrolyte abnormality or a urinary tract infection.”
The patient’s team is headed by a physician and includes a case manager; physical, occupational, speech or respiratory therapist; nurse; psychologist; and dietitian, depending on the patient’s needs. Case Managers help patients find resources they will need when they are discharged, such as oxygen, home modifications or support groups.
Education is an important part of the process.
“Patients go home with large binders of educational materials and resources,” Dr. Castro says.
“They’ve seen the value of our “direct admit from home” program,” Shefte says. “We want to provide intensive services for a short time and get patients out of the health care system, rather than having them continue to utilize services.”
HealthSouth Rehabilitation Hospital of Denver is located at 1001 W Mineral Avenue, Littleton, CO and offers comprehensive inpatient rehabilitation services. For more information about the direct admit from home program, please call 303-334-1111 or visit www.healthsouthdenver.com
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