Teamwork is a big part of senior transitions

Making sure your house or apartment is a “home,” not an obstacle course, is a mission that rehabilitation therapists take very seriously when dealing with seniors.

When you go home after spending time in a rehabilitation facility following an injury or illness, health care providers work to make that transfer as seamless and safe as possible, said Dr. Ralph Wang. And that process begins the moment you enter the health center.

Wang is a physiatrist at Wynscape Health and Rehabilitation Center — part of the Wyndemere Senior Living Community in Wheaton. A physiatrist is a doctor who specializes in rehabilitation medicine.

The physical, occupational and speech therapists at Wynscape collaborate with Wang and other doctors, making it possible for patients to return home or to transfer to the most independent living situation possible following their rehabilitation.

“Using an interdisciplinary approach, we treat the whole patient and work to improve their quality of life through innovative treatment approaches and goal-oriented therapies,” said Amanda Aaron, RehabCare area director of operations.

Physical therapists work on balance, gait and large movement mobility. Occupational therapists work on fine motor movements and activities of daily living like dressing and grooming. Speech therapists concentrate on speech, swallowing and cognitive training to support independence in function such as taking their medicines correctly.

“If you think of it as a continuum, the physical therapist concentrates on the legs, the occupational therapist on the arms and the speech therapist on the brain,” Wang said.

Wang has a daily presence at Wynscape and is fully engaged in the plan of care for each resident. He leads a weekly meeting with the care team during which the progress, needs and discharge goals of each patient is discussed.

“Our goal is that therapy program will help take away the patient’s fear about how they will function in their own environment because they will have practiced and will be prepared,” he said. “We work to send them home with a greater sense of confidence.”

Barriers to healing such as pain, emotional or psychosocial issues and physical issues affecting the functioning of the heart, lungs or circulatory system are also systematically addressed and dealt with during the 26-day average stay in “rehab.” Wang works collaboratively with primary care physicians on medical barriers to rehabilitation. And as the patient heals, the achievement of milestones is noted, such as the ability to transfer from the bed to a wheelchair without assistance, the ability to walk with a walker or cane, and the ability to carry on the tasks of daily living like dressing, bathing and eating independently.

“Everything to restore lost abilities is addressed,” Aaron said. “Our aim is to restore their function and well-being and return them to their normal life as soon as possible. The trust that develops between patient, therapist and doctor is wonderful to watch.”

“We also put a lot of emphasis on prevention of complications and further injuries, by trying to determine the underlying medical issues that might have caused the injury in the first place — like lightheadedness or problems with sight or hearing. If we find something like that, we immediately address it,” Wang said.

Wynscape’s team also educates its patients about fall prevention and fall recovery strategies (how to fall without injuring themselves and how to get up safely after they have fallen) and also works with them to improve and maintain their mobility.

The nurse case managers and social service team begin planning a patient’s discharge upon admission to Wynscape. The need for home care, specialized equipment and other support services are identified and coordinated prior to discharge. The team creates a post-discharge plan of care that supports the patient for the month following their discharge home. This is a unique and important part of a successful transition back home.

Prior to returning home, a patient-family visit and a home assessment are arranged. A family member comes to pick up the patient, successfully getting him or her into the car and then a therapist follows them to their residence, said Michelle Pytel, rehabilitation program director at Wynscape.

Once at the home, barriers to safe movement are evaluated from room to room, starting with the entrance to the home. Are there steps? Does a railing need to be installed? Can the recovering patient safely open the door to get inside?

Once inside, can the person easily get into and out of their favorite chair or couch? What are the bathrooms like? Does the tub or shower need to be altered? Do grab bars and transfer benches need to be added? Can the kitchen be used safely, reaching the cabinets and using the appliances? Are there any trip risks that need to be removed? Can the patient safely access a telephone and does he or she know how to access help? Is a Life Alert button needed?

Finally, what extra assistance is necessary — help with laundry, housecleaning, meal preparation?

“Going to the home with the patient and a family member offers us additional insights to help them make a successful and safe transition back home,” Aaron said.

Wynscape is located at 2180 Manchester Road in Wheaton. For more information, call (630) 665-4330.