Caitlin Whyte (Host): If you or someone you care about has experienced an accident, stroke or other condition that causes pain or disability, consider asking about occupational therapy. Today, we are talking to Nichole Federman at Upland Hills Health in Dodgeville, Wisconsin, about what you can expect when you are working with an occupational therapist.

This is the Inspire Health Podcast from Upland Hills Health. I'm Caitlin Whyte. So diving into the details of a home visit, how can someone request in-home services from an OT?

Nichole Federman: All services provided by OT do need to be referred by a doctor. We receive those referrals from the patient's primary care physician. We receive them from specialists like cardiology, rheumatology, Neurology, so sometimes a specialist will refer OT when maybe they're in an acute setting in the hospital. Then, we go in and we evaluate and treat right in the home, so we can really identify what their barriers and what supports they need in order to be home to meet their daily needs.

The person also needs to be, what's called homebound. So when a person's going home for home care, the person is not able to get out in the community, so they are able to take benefit of those services right in their home. But homebound can mean a lot of things, but that's looked at very closely on an individual basis on what justifies a person to be home, rather than going into an outpatient setting.

Host: So, what do you look for when you visit someone's home and you're doing that initial assessment?

Nichole Federman: When we walk into the person's home, everything is on alert. So, we're already observing their home, already observing the patient's conversation, how they're conversing, their family's conversation, so that we're really watching for signs of how that condition is affecting the person, has it improved, is it not improving, and then we want to make sure that we're really paying attention. That's when we start to document anything that might affect the person's safety and health. So through that, we're looking at the observations that we make, are definitely looking at cognition, like how is that person describing his or her condition to us? How do they know why we're there? Are they able to describe what happened in the past few days? So, that's kind of looking at that cognitive side. We want to make sure that they're alert and oriented. So, we can do really quick assessments that help determine, you know, that cognition level so we can individualize that plan of care so that later as we begin to treat, our strategies are client-centered and completely for that person and where they're at so we can optimize their level of independence to stay at home.

From looking around the home, we want to look at reducing the risk of falls. So, we assess lighting, we assess is there loose rugs, is there clutter that contributes to falls. Are there narrow doorways impeding like a safe passageway, especially if they have an assistive device, like a walker or a wheelchair. And then, if that person can't get in their office and they love working on the computer, that's a valued activity that they might be avoiding to reduce risk of falls and how can we make that available for them again?

Other areas that we look at right on that first visit are medication management. Medication is really important, obviously. We need to make sure we are taking our meds so that we can function every day. We want to know where it's stored. How do they manage it? Do they put it in a med box? Do they have someone helping them? Is there an actual routine established? So, if that person has low vision or any, memory loss, any sensory loss in their fingers or, you know, if they can't feel the pills or even decreased fine motor skills because of arthritis, all that stuff's going to affect that medication management. So, we're going to have to look at all those areas. So, how can we, make them as independent to manage those things?

And then, that leads in, like, when I talked about low vision, I mean, we need to make sure they can read the microwave. They can read the med bottle, the phone buttons. A lot of times these things, a person with low vision knows exactly how their home is and how the phone buttons are, but oh my gosh, if a microwave goes out and they have to change it, it changes everything, especially if they're legally blind. We have to come up with strategies so they can operate that microwave, for example.

I mean, this is just kind of a trickle down of when we're assessing, does that person use a cane? Are they using the walker or the wheelchair? Can they use it properly and safely? Are they locking the brakes? You know, is there a risk for falls? Does the wheelchair not get into the bathroom? Many, many times it doesn't. So, we have to come up with, do they have to transition to another device? So, you know, as we're walking through the home, we're looking at all those issues.

One thing that's really important when we're working with people in their home, we can tell, and they'll talk to us about if they're not sleeping well. We have to figure out why aren't they sleeping. Is it a pain issue? Is it shortness of breath? Is it that they need to get up to go to the bathroom five times in the night? So, we look at those areas too.

Going back to like that kitchen area and moving around the home with meal planning, we're not only looking at can they get up and access the kitchen, can they use the microwave and the stove safely if they've had some other kind of deficit that's affected their vision, their cognition, but we need to also look at that meal planning effort from like dietary restrictions and we work closely with a dieticians and the nurses as well for that. But it might be something, as simple as getting a dietician consult and then working on how can we make sure they have that support in the community to get those in the home.

Host: Great. Well, so you've done this really, really in depth assessment through this person's home, determined the capabilities and the limitations of their space. What comes after all of that?

Nichole Federman: So after we do the evaluation process, we set up a plan of care for how many days a week or what's our frequency to go in. And we really want to work with individuals, like I said, to continue to work with them with that plan of care, what is important to them in order to stay home. So, we do that. And while we're in the home, each visit that we're there, we're working on the goals that we set up.

So, whether it's including, you know, a wide range of services that we include into looking at everything I explained, was someone that needs work simplification or energy conservation, depending on what-- again, I can explain that a little more in detail in a minute, but for example, like heart failure, the person, or a COPD, which is someone's emphysema or on oxygen and they just tire out really quickly. So, in order for them to do those activities, we need to dive in and figure out what interventions do we need to teach so that they can continue these activities. It might be a joint protection for someone with severe arthritis, along with stress management. And then, I already talked a lot about the low vision adaptations, there's so much more to that, but those were some simple adaptations of like we got to figure out lighting in the home, adapting new appliances, phones, things like that.

And then also, when we're in the home, too, one thing that, along with the safety part that I didn't mention, is caring for pets because they're at someone's feet all the time. So on each visit, we don't look at all those things. We kind of pick something that we're working on, because it's not all those things are on everybody's plan of care. But if we're looking at meal prep, how can we protect their joints as they're stirring? We may have them use a hand mixer versus a skinny little spoon to stir if the person loves to bake and they want to continue baking. Just kind of looking at all those different areas.

Host: Well, to close out our episode today, Nichole, I know preparing meals and bathing are two areas that are really, really important that help keep people in their homes. So, how can OT be helpful in regarding these two skills?

Nichole Federman: okay. So if I take meal prep in a home, I love being able to be in someone's home to do the meal prep because I have tried. I've worked in all settings, and when you try to set up in a rehab gym, "Okay. Let's see, how is your kitchen," you know, and we're trying to set this up so the person can mobilize around and learn how to move with their walker and move a plate down the counter to get to their table. And then, you get in their home and they're like, "Oh my gosh, it wasn't anything like what I just did with you."

So, to be in their home, It's just like the best place to be able to assess that in that setting. So, we get in there and we want to really make sure that kitchen mobility, they can get around that kitchen. We make environmental modifications like just something as simple as moving a table. If it's in the middle of the kitchen, we may push it against the wall. If they can't get the walker by, we may move a microwave even to the table so the person doesn't have to take their bowl of soup or their plate of food from the counter to the microwave. Even if it's on a walker tray, it may be unsafe to do that.

So, those are some of the environmental modifications that we'll make. And then, of course, we're assessing safety with whatever's going on with them, with getting things in those ovens and microwaves, especially those overhead microwaves, if they can't be moved down. Can they open up a jar and a can? I mean, we take all those things so much for granted. But pouring hot liquid, if coffee is something they got to have in the morning and they cannot handle that coffee pot anymore, is it something that we're looking at a single-cup device? And then, making sure that we're labeling or changing the texture of a button, like I said earlier, for that person to be able to operate it if they have that low vision. So, in the kitchen, that's really important that we're looking at mobility first, because they've got to be able to mobilize around and sometimes they're using a walker and they've never used a walker before or a wheelchair and teaching them how to do that.

I've even been in and we've looked at their fridge and just something as simple as like that safety of changing the fridge door, because they're usually interchangeable, opening from the other side so that they can open and it's opening to the countertop to get something out safely versus opening and then having to turn all the way around and come back into the kitchen. So, there's just all kinds of little things that, I think, we all just take for granted each day because we can do it. And then, we kind of really dive in, I always say, "I'm going to take this task, and I'm going to break it down to 100 pieces, and we're going to get this safe for you." That's kind of how I go about that way.

When it comes to bathing, we spend most of our time in kitchens and bathrooms. That's where we spend our times from OTs. It just depends on the person's setup. So, some people have walk in showers, some people still have tubs, some people have the cut-out tub systems, and sometimes we'll recommend those things. So, we're going in and we're literally just assessing those areas and maybe it's a matter of just adding a few grab bars in the bathroom. But it might be, "Okay. They need to be able to get up and down from the toilet safely too," so it may be adding rails over the toilet or a higher toilet type of setting. Can they even access the bathroom, or do we need to look at a different area for bathing and those things? Yeah, the bathrooms are many, many, many times too small to use their primary device. So, we have to decide, "Okay, when we get to the bathroom, how do we set the walker aside and where are we going to have the cane if they're safe to use the cane to go into the bathroom? Or is it a grab bar on the wall so we're safe to go in and use the bathroom?" So, those are a couple of examples.

Host: Well, it was great to have you back on the show, Nichole. Thank you so much for all you do. Find out more about Upland Hills Health and occupational therapy online at uplandhillshealth.org. And thank you for listening. I'm Caitlin Whyte. And this has been the Inspire Health Podcast from Upland Hills Health.