goal-setting

Having worked for the army I see access visits as a form of reconnaissance to inform my goal setting and treatment planning in physical rehabilitation settings. I therefore like to do them as early as possible if my initial assessments indicate that the home environment may present specific rehabilitation or adaptation needs. I have however worked with other occupational therapists that prefer to wait until a patient is fit for a home visit instead. I have only worked as an occupational therapist for 2 months so far, so I am reluctant to disagree with more experienced therapists. I am therefore posting this blog entry in the hope that you will share your experiences and opinions on the issue. Assuming whichever occupational therapy department I work for lacks the human-resources to undertake both access visits and home visits and therefore must choose between the two, this is my current perception of the choice:

Advantages home visits when a patient is fit enough:
1. This is the most valid test of a service-user’s function in his or her home environment. It may reveal unpredicted behavioural risks.

2. This method avoids wasted time for patients who end up never going home (e.g. due to placement or death).

Disadvantages of waiting until a patient is fit for a home visit:
1. This significantly increases the risk of discharges being delayed by occupational therapy, and therefore has an impact on the entire patient journey from A&E admissions or elective waiting lists onwards (the functioning of the whole NHS is adversely affected).

2. This allows less time for equipment orders. Urgent equipment orders cost more, as does an OT or OTA going out to fit equipment (considering rates of pay, transport etc). This impacts on PCT budgets.

3. Urgency of referrals for unforeseen problems is then offloaded onto social-workers and other agencies giving them less time to react.

4. Specific environmental factors are not used to inform the rehabilitation process and it may therefore not be as service-user centred as it could be.

5. We risk being seen as a profession of discharge facilitators that follows the directions of the rest of the multi-disciplinary team (e.g. doctors, nurses and physiotherapists tell us it is time for us to facilitate a person’s discharge).

6. If you have not done an access visit first, you may find yourself taking a patient into a dangerous home environment.

Advantages of early access visits:
1. Reconnaissance informs goal setting for the rehabilitation process. We tell the rest of the multi-disciplinary team the level of function required for a person to go home, and they set their goals based on the information we provide (e.g. telling the physiotherapists a person needs to be able to mobilise distance-x with a walking aid no more than y-wide and sit-to-stand from surfaces z-high).

2. We can replicate the service-user’s home environment for hospital treatments, thus making them more client-centred, realistic and valid.

3. We can order equipment early at the cheapest delivery rates, thus making the best use of our budgets and minimising the risks of delayed discharge.

4. We can provide social-workers and external agencies with a heads-up on likely needs, giving them a reasonable time to prepare for discharge (e.g. identifying a patient with crush fractures of the vertebrae will not be able to reach her oven, freezer or washing machine and may therefore need help for cooking and laundry on discharge).

5. This way we will be viewed as rehabilitation directors instead of discharge facilitators.

6. An access visit involves less clinical risk than a home visit.

Disadvantages of early access visits:
1. Access visits will not reveal unpredictable behaviours a service-user may exhibit in his or her home environment.

2. If the patient never gets home, the access visit may have been a wasted exercise.

The text above is a generalisation. In specific circumstances one option would be indicated as opposed to the other, but overall which option do you think is preferable?

V