Continuing Care - Rehabilitation

Continuing Care

The home care nurse may visit the patient in the hospital, interview the patient and family, and review the ADL sheet to learn which activities the patient can perform. This helps ensure continuity of care and that the patient does not regress but instead maintains the independence gained while in the hospital or rehabilitation setting. The family may need to purchase, borrow, or improvise needed equipment, such as safety rails, a raised toilet seat or commode, or a tub bench. Ramps may need to be built or doorways widened to achieve full access.

Family members are taught how to use equipment and are given a copy of the equipment manufacturer’s instruction book-let, the names of resource people, lists of equipment-related sup-plies, and locations where they may be obtained. A written summary of the care plan is included in family teaching.

A network of support services and communication systems may be required to enhance opportunities for independent living. The nurse uses collaborative, administrative skills to coordinate these activities and to pull together the network of care. The nurse also provides skilled care, initiates additional referrals when indicated, and serves as the patient’s advocate and counselor when obstacles are encountered. The nurse continues to reinforce prior teaching and helps the patient to set and achieve attainable goals. The de-gree to which the patient adapts to the home and community en-vironment depends on the confidence and self-esteem developed during the rehabilitation process and on the acceptance, support, and reactions of the family, employer, and community members.

There is a growing trend toward independent living by people with severe disabilities, either alone or in groups that share resources. Preparation for independent living should include training in man-aging a household and working with personal care attendants as well as training in mobility. The goal is integration into the commu-nity—living and working in the community with accessible hous-ing, employment, public buildings, transportation, and recreation.

State rehabilitation administration agencies provide services to assist people with disability in obtaining the help they need to en-gage in gainful employment. These services include diagnostic, medical, and mental health services. Counseling, training, place-ment, and follow-up services are available to help people with dis-abilities select and attain jobs.

If the patient is transferred to an extended care facility, the tran-sition is planned to promote continued progress. Independence gained continues to be supported, and progress is fostered. Ad-justment to the extended care facility is facilitated through com-munication. The family is encouraged to visit, to be involved, and to take the patient home on weekends and holidays if possible.