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How to Ease Your Patients' Transition from Hospital

Jennifer George

 

I was fortunate to find my passion in inpatient rehabilitation five years ago.  As a physiotherapist, I believe in a progressive-oriented approach to care; as a human being, I live for growth and in deep gratitude for my independence every day. 
 

I have discovered that regardless of the level of medical complexity, one of the most vulnerable experiences in my patient’s journey is when they are to returning home from hospital.  Their diagnoses are not just what happened to them but have ultimately changed their lives.
 

Imagine your new patient: a middle-aged father who is diagnosed with Guillain-Barré syndrome (GBS).  He was working full-time, raising a daughter with special needs, and was otherwise healthy.  Prior to meeting with him, you begin to review his medical record to understand as much of his story as possible. 
 

You read that he experienced a sudden onset of weakness at home and was unable to stand from the sofa.  EMS was called, and he was brought to the ER but upon assessment, was discharged. You further read that as his weakness persisted, he was finally admitted to acute care and diagnosed with GBS.
 

After a couple of weeks in acute care, his medical status stabilized, and the team decided he was ready for more intense therapy on an inpatient restorative rehab program.   
 

So, now, here is your patient, medically stable and recommended to participate in more intense therapy to prepare for a safe transition home.  There are essentially three stages to guide your patient to confidently prepare for the next chapter of his life.

 

The First Impression

As his physiotherapist, you recognize how significant this initial session is in your patient’s ability to determine if he can trust you to guide him towards independence again.  You recognize that without establishing a trusted therapeutic rapport, all assessment findings and subsequent treatment approaches will fall short.  In fact, you know that this is precisely the moment when you will begin to ease your patient’s transition from hospital to home.
 

Upon approaching your patient, you ask for permission and consent to assess him.  He agrees, but is overtly uneasy, uncertain, and overwhelmed.  You understand that there are so many processes happening around him and that he may feel like he has lost his sense of independent identity.  You do your best to make him feel comfortable – you may orient him to the unit, offer to plug in his cellphone charger into the outlet by his bedside and explain the nature of the rehab program to him and his family.
 

This first impression is the time to empower your patient to tell his full story, share his history prior to falling ill, express his concerns or feelings, and convey his goals.  You are curious here - you ask many questions and listen in for every verbal and non-verbal response so that you can absorb what will help you deliver the best care possible. 
 

You sense his frustration with the system as a whole – the lack of thorough follow-up on his initial admission to ER, the lack of communication among his team members, and expressed frustration with his current state of debility. You recognize that transparency, integrity, and competency are important to him.
 

When you ask him what his goals of therapy are, he says “to go home and be well again.”  This is exactly why your patients come to you – although they really do not want to be in hospital – they consent to participate because they believe you have the expertise and experience to help them return home. 
 

Although he is clear and adamant on returning home, the goal itself is vague.  Your follow-up question to his goals include asking, “Would you be okay with returning home independently using a walker or cane?”  You find he becomes open to discussion about his goals as you are meeting him somewhere between where he is at and where he hopes to be. 

 

The Collaboration

Up until his admission into rehab, your patient may show challenges in overcoming a sense of institutionalization.  His acute care stay may have been more sheltered in nature – encouraging him to spend most of his time in bed or in a wheelchair until he was more medically stable. 
 

As you can imagine, in explaining the nature of the rehab program, one in which independence in a controlled setting is safely encouraged, you may find he is unable to imagine himself remotely independent again.  As his treatment sessions occur, you may find that you become one of the first people he expresses such concerns or feedback to as you have demonstrated from the onset that you have his best interests at heart. 
 

The collaboration stage is an ongoing dialogue and continuity of care between you, your patient, and his team of health care providers.  By following-up on his needs and referring to other team members to provide comprehensive care, you will further gain his trust in you, his team, the system, and he will look to you more as a collaborative partner in his health outcomes. 
 

During this stage, you encourage your patient to become more engaged in his care and objectives as his treatment sessions with you are functionally focused - integrating a plan of care that simulates his activities of daily living, hobbies, interests, and work-related postures and positions.  It is during these moments that your patient naturally becomes more open to discussing foreseeable needs and services. This will help shift your patient’s focus from perceived barriers and loss towards progress and hopeful solutions.
 

Eventually, your patient will be more forthcoming with information around his health concerns and goals, rather than withholding it.  This is the only way you can fully address his concerns and help meet his goals.  Eventually, the one big goal of going home is broken down into smaller, successive goals, initiated by your patient and guided by your expertise and communication.  His focus shifts from what he could not do to what he currently can do independently and what he wants or needs to be able to do to return safely home again. 

 

The Transition

In this stage, you have been functionally guiding and preparing your patient for return to home.  Here, you may find you are continuously reviewing safe mobility and thorough education on the risks and benefits of returning home and recommendations to minimize risks. 
 

You realize this is a good time to offer education to your patient and his trusted family members or friends.  Many patients do not realize that their family or caregivers can be a vital part of their progress.  Often, it is their family members who recognize the significant improvements in their function since the initial injury.  Such recognition gives your patient more insight into his abilities and may help to minimize fear of returning home.
 

In this stage, you are also doing your best to ensure there are no loose ends when your patient returns home.  Through education and appropriate referrals to outpatient service providers, you are ensuring his chronic condition is not overseen and that he receives the necessary treatment.  This will further enhance your patients’ understanding of the nature of his condition, the duration of healing, and the need to continue with follow-up care.
 

By the time your patient is expected to leave the hospital and return home, he will understandably have some anxiety and worry, but he will feel empowered to self-manage his care needs and abilities.  He will begin to feel he is ready to step into the next chapter of his life, one that is filled with hope, courage, and independence. 

 

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