Editor's note: This text-based course is a transcript of the webinar, Seating Considerations in the Home Health Setting, presented by Sara Frye, MS, OTR/L, ATP.
Learning Outcomes
- After this course, participants will be able to identify at least two basic seating and positioning principles in order to identify postural supports for three common asymmetries.
- After this course, participants will be able to identify three areas that should be assessed in a seating evaluation based on client, occupation, and environmental factors.
- After this course, participants will be able to identify three logistical challenges and ethical considerations for seating and positioning in the home.
Introduction
I am happy to talk about seating considerations in the home health setting. I am an occupational therapist, have a broad inpatient rehabilitation background. One of the things that I noticed moving into the home health setting is the vast need for seating and positioning interventions, but clients or clinicians often do not feel they have the tools to address these complex cases. My goal is to give you some ideas for interventions to be a more effective clinician and a better advocate for your patients, knowing that there are so many different things that we are triaging and addressing in the home health setting.
Background
- Although there is a wealth of knowledge on seating and positioning, there is little evidence on seating and positioning in the home health setting.
- Specialized seating clinics exist but may be inaccessible to clients who are homebound.
- Conversely, clinicians working in home health may have limited knowledge and comfort in providing seating and positioning interventions.
There is a wealth of knowledge on seating and positioning; however, there is little evidence for seating and positioning in the home health setting. We are going to address this today. As I mentioned before, I have experience in inpatient rehabilitation and previously ran a seating clinic in a large inpatient rehabilitation hospital. As I transitioned to the home health setting, I needed to adapt those skills to the home health setting.
Specialized seating clinics exist, but often these clinics are inaccessible to our homebound clients. Even though we may not have the most advanced training or knowledge of the most advanced interventions, we are the clinician in the home with that patient. Therefore, we need to be prepared to address seating and positioning. As such, clinicians working in home health may feel that they have limited knowledge of providing seating and positioning interventions. Since we are the ones who are present in the home, we have to have a plan to address this.
Today, I hope to give you a plan of attack for how you might triage some of these more complex seating and positioning cases.
Homebound Status
- Criteria One (One of these must be met)
- Because of illness or injury, need the aid of supportive devices such as crutches, cane, wheelchairs, and walkers; the use of special transportation; or the assistance of another person to leave their residence.
- Have a condition such that leaving his or her home is medically contraindicated.
- Criteria Two (Both must be met)
- There must exist a normal inability to leave the home.
- Leaving the home must require a considerable and taxing effort.
(Loeffler & Simpson, 2015)
For a definition of homebound status, I will use the Medicare criteria because this is the basis of what we do in healthcare. Criteria one is that the client is homebound due to illness or injury and needs the aid of supportive devices, such as crutches, cane, wheelchair, walker, or the use of special transportation, or the assistance of another person to leave their residence. Or, they may also have a condition where leaving their home is medically contraindicated.
Second, there must be a normal inability to leave home, and leaving home must require a considerable and taxing effort for the patient. There are two different classes of clients in home health care that we work with when looking at seating and positioning intervention. We can work with homebound clients for a short period as they recover from surgery or when discharged from the hospital, but the time they are homebound is finite. Then, we have those homebound clients for a more extended period. A client may be immunocompromised and cannot travel into the community. Or, a client may have a severe physical disability and are functionally bedbound or chairbound and unable to access transportation. These clients may not be able to leave their homes in the near future.
It is essential to determine if the client requires home intervention or would best be served in a specialty clinic. Additionally, we need to consider how long the client will be homebound and their ability to travel to an outpatient clinic in the near or medium-term future.
Challenges of the Home Environment
- Accessibility Barriers
- Condition of Home
- Weather/Temperature
- Clutter
- Pets
- Pests
- People
- Distractions
There are many challenges of working in the home care environment, and if you have worked in-home care, you are probably familiar with many of these. There are accessibility barriers. You may have seen these barriers or have heard many stories about accessibility barriers or solutions. For example, many clients are wheelchair-bound or bedbound and cannot get out of their homes. They may have steps and require the assistance of caregivers to carry them in and out of the house. Or they do not have a very accessible home. Many clients live in urban areas where they are confined to one room because their doorways are not wide enough or they do not have a bedroom or bathroom on their first floor. They might be staying in a living room or dining room.
Second, the condition of the home can be a barrier. A house may be in disrepair with uneven floors or walkways that have not been maintained well.
There is also weather and temperature to consider, particularly during COVID. Many of us wear PPE, which can get very hot, making it more difficult for both the clinician and the client. Outside weather conditions like rain, snow, and ice may make it challenging to complete equipment demonstrations or get equipment in and out of the home.
Some of our clients have clutter in the home, making it hard to assess a client. For example, if they work on wheelchair propulsion, they may not have sufficient space to maneuver. We may need to help them identify pathways to travel through the home. We may even have to help them reorganize the space.
They may have pets in the home. The best practice, in my opinion, is that we ask pets to be constrained out of the area while we are providing therapy, as they can be a distraction. Some people may also have pests or bugs in their homes as well.
There may be other people in the home, which can be positive or negative. People who are not direct stakeholders in the client's care may provide input and ideas during your assessment which can be distracting. However, access to the caregiver or multiple caregivers invested in the client's care may be beneficial.
Finally, there can be many distractions like the television, kids coming home from school, et cetera. I like to preserve this time for us to work together during the session if I am going to be doing more advanced seating and positioning intervention. I want the client and the caregiver's full attention.
Who Needs a Wheelchair?
- Unable to ambulate
- Chairbound
- Bedbound
- Unable to ambulate functionally
- Needs assistance
- Fatigue
- Unsafe/falls
There are two categories of people who need a wheelchair. Some clients are unable to ambulate or are bedbound or chairbound. Or, the person needs a wheelchair to mobilize from one point to another in these situations.
The second category is those who are unable to ambulate functionally. This category is critical to consider because this is an opportunity for intervention. This could be a person who is discharged from an acute or subacute rehabilitation facility, unable to ambulate without assistance and has to have a caregiver available upon discharge. However, they still require assistance and cannot ambulate independently and safely as time goes on. They may not have sufficient endurance to walk throughout the day or are unsafe and incur falls. This type of client would benefit from having a wheelchair to move from one place to the other in the house without assistance. It also may preserve their endurance and reduce their risk of falling. These could be clients that were thought to be able to reach independent ambulation at home and were not ordered a wheelchair because of this. However, they cannot do so for whatever reason and are safer and more functional using a wheelchair.
Benefits of Completing a Seating Assessment in the Home
- The clinician has the opportunity to serve clients who are homebound and unable to travel to an outpatient seating clinic.
- The clinician can see the client's home environment to address accessibility challenges.
- The clinician is able to understand what activities are most meaningful to the client and/or their caregivers.
There are some benefits to completing a seating assessment in the home. One of the most significant benefits from my perspective is that the clinician has the opportunity to serve clients who are homebound and unable to travel to an outpatient seating clinic. We can see people who otherwise would not have access to service, which is the most powerful point in the presentation. I will provide some case examples that illustrate how important this can be for our clients.
The second is that the clinician can see the client's home environment to address accessibility challenges. Many times, there is an insufficient area for the patient to maneuver. We can address some of those issues and help them problem-solve to develop a functional solution to make them independent within their home.
Finally, we can interact with that whole family system and understand what activities are the most meaningful to the client and their caregiver(s). We can get a good idea of what the client likes to do and how and where they want to spend their time. A home assessment allows us to make informed decisions about what type of equipment will be the most effective.
Mobility-Related Activities of Daily Living (MRADLs)
- Toileting
- Dressing
- Grooming
- Bathing
- Feeding
*Justification centers on the need for the wheelchair to complete MRADLs in the home
Finally, I want to talk about mobility-related activities of daily living or MRADLs. These are toileting, dressing, grooming, bathing, and feeding. Mobility-related activities of daily living are essential because our justification for any seating and positioning intervention centers on the need for the wheelchair to do things like getting to the bathroom to use their toilet, being able to access clothes from the closet to get dressed, being able to get in front of the sink for grooming, being able to get to the tub for bathing, or being able to sit with appropriate trunk support to feed themselves independently and reduce the risk of aspiration. I always include these daily tasks with my seating and positioning interventions in the home.
Case Examples
George
- George is an 85-year-old man who lives alone. He was having pain and swelling in his joints and had a fall at home. After the fall, he had so much joint pain that he was bedbound. His family did not want to take George to the hospital, so his primary care provider referred home services. When home health started, George was unable to get out of bed, and his daughters were providing 24-hour care.
George was dependent on care from his daughters. They bathed him, and he used a brief to go to the bathroom. George is an example of someone who is considered fully bedbound. He needs a seating and positioning intervention to be more mobile within his home.
