As rehabilitation professionals, we often miss that it takes focus to solve multi-factorial patient problems and a discipline alone cannot solve 24 hour impairments without continuous reinforcement on core issues. We each build on one another’s success, as long as there is no slippage in between. By understanding the resources available to the patient and the real road blocks or barriers in placing patients back to their previous lifestyle, a focus must be on solving barriers to discharge. An interdisciplinary team is more effective when they understand identified barriers and work 24/7 on common solutions. We are each other’s hands as we pass the patient between us. This is the “aha moment” for a team to be cohesively successful.
Rehabilitation skills must continuously assess variance from the intended response. Solve the problem. Why can’t this patient go home?
When are the needs for focus defined? From the first contact the clinician must discuss pre-morbid to present status, particularly as the new status will relate to available resources and expectations to returning home. What will it take from the patient’s perspective? The key to establishing the discharge plan begins the moment insurmountable issues are identified by the patient/family, these issues will require resolution to enable a successful discharge to the community. If it’s inpatient or outpatient, the truth is the same. The initial assessment holds the key to areas of focus in meeting barriers to discharge success.
Prioritize absolute barriers (impairments), so that you can establish the exact criteria to meet successful outcomes. Create the plan of care relentlessly focused in accomplishing the goal. Be honest and earnest toward your abilities and then focus on the areas requiring the greatest needs as a team and you will find it difficult not to succeed. Learning from experience is also helpful. Every facility is its own ecosystem of successes and failures. Know and build on previous knowledge whenever possible. Although no two patients are alike, solution sets are similar.
Sounds simple doesn’t it? Discovering the core problem and then applying rehabilitation methodology and resources to dispel issues. Isn’t this really what managing a rehabilitation level of care all is about? If you become disparate and lack cohesiveness, it is a disservice to the patient and mediocre outcomes can result. Veer from the plan and time is lost. It happens, take-backs rest in the inability to display the patient story as a series of skillful goals achieved to enable successful discharge because the team lacked focus.
If, as disciplines, we exercise the practices required to meet areas of greatest barrier and focus specifically on training carryover, barriers are defeated and continuous quality is deeply seated into your program. Focus is as powerful as the love and reward gained in returning a patient home with as many skill sets as possible to do as much of their own care as is feasible.
How potent is your focus? Outcomes are tell-tale!