By Sarah Schmelling
Liz Thompson, OT, occupational therapy supervisor for stroke service, helps patient Pat Burton (right) relearn kitchen skills at a model kitchen in the Helen Hayes Hospital’s stroke unit.
In the aftermath of a stroke, rehabilitation is not just about getting a patient back to a functioning level. The goal should be to return the patient, as much as possible, to the life they were living before the event. For the staff of the stroke rehabilitation unit at Helen Hayes Hospital in West Haverstraw, NY, these words are more than a good philosophy. Everything they do seems to stem from this patient-centered approach. "We're treating the patient as a whole," says Nicole Dean, PT, physical therapy supervisor for stroke service.
This means providing multiple treatment options, from daily physical, occupational, and speech therapy to cognitive and respiratory therapy, psychiatry and psychology services, nutrition education, and aquatic and recreational therapy.
The department also features dysphagia therapy, an on-site prosthetic and orthotic department, and a Center for Rehabilitation Technology that provides everything from augmentative communication devices to seating. And all of these services are conducted with a staff that works closely together to know exactly how—and what—the patient is doing at all times. "I think I'm spoiled," says Dean. "Anything we need to work with a patient is right here."
But integral to this approach to care is also an effort to give the patient as much one-on-one time as possible. "We emphasize individual therapy, as opposed to group therapy," says Laura Lennihan, MD, a neurologist and director of the stroke unit.
Through this method of working individually with patients, looking carefully at their previous lifestyles, and determining the most appropriate treatments to return them to those lifestyles, Lennihan and her staff believe they can provide the best stroke rehabilitation possible.
TREATING THE OLDER PATIENT
Laura Tenteromano, RN, CCRC (left), and Nicole Dean, PT (far right), help patient Daniel Chirrell improve his balance. Classes and real-world situations are used at Helen Hayes Hospital’s stroke unit to help patients regain physical and life skills.
Because a high percentage of these stroke patients are elderly, the staff of the stroke unit must continually keep in mind special considerations for working with the geriatric population, who often have a host of medical issues, says Liz Thompson, OT, occupational therapy supervisor for stroke service. "You have to find out, for example, are they diabetic? Do they have cataracts, and is that what's impacting their vision, or is it stroke related?" she explains. "These are all things the staff needs to be aware of."
Lennihan says that an in-depth evaluation process is conducted upon admission that looks at all aspects of a patient's medical history, what their functional disabilities are, what their living situation was prior to the stroke, and what their social supports are in preparation for discharge. "We want to get them back to what their life was like before the stroke as much as possible," she says.
And though this approach of personalizing the rehabilitation for the patient is the same, regardless of age, Lennihan says, what differentiates many of the geriatric patients are their social circumstances. "They may be living alone because their spouse is deceased. They may have more health problems that contribute to the challenge of physical rehabilitation, and they might be more likely to have preexisting memory problems," she says. "All of these things contribute to the level of independence they will reach in the hospital before discharge and what kind of assistance they will need after discharge, and this will determine the likelihood that they can return home living independently, as opposed to having to move in with a family member or go to assisted living or even have a time after discharge in a skilled nursing facility. The younger patients are more likely to be employed, have a living spouse, and generally be in better health."
Eileen Szysh, OT, the occupational therapy supervisor for the outpatient day hospital at Helen Hayes, says the staff knows it must be accommodating when it comes to treatment of geriatric patients. "Some of our clients can't tolerate an hour of therapy at a time here, so we have to be flexible as far as the time of the day clients can come," she says. "We try to rearrange schedules to meet their needs best."
Activities selected for a patient also have to be age-appropriate, Thompson adds. "You're not going to give a child's letter board to a stroke patient even though they're aphasic," she says. "There are certainly other ways you can go about treating that patient."
According to Nicole Dean, PT, physical therapy supervisor for stroke service at Helen Hayes Rehabilitation Hospital, a typical day for patients in the stroke rehabilitation unit starts early, "probably earlier than they're used to [about 8 am]," she says. They wake up and immediately begin a variety of activities of daily living (ADLs), which include showering, dressing, and grooming—all actions that should be considered therapy in themselves, says Laura Lennihan, MD, a neurologist and director of the stroke unit.
"These things might be looked at as getting ready for therapy, but I actually think they're a crucial part of the therapy," she says. "The nurses and nurse's aides are really crucial for reinforcing transfer techniques and grooming techniques...and getting the patients to dress themselves as much as possible. It's a collaborative effort between the nursing staff and the patient to help to foster increasing independence."
At about 8:30, patients eat breakfast, with their eating and swallowing being closely monitored by the nursing and therapy staff. Following this, patients have at least 3 hours of individual and group therapy, which is divided into half-hour sessions.
Lunch breaks up the day, but, again, patients are watched and worked with to ensure proper eating and swallowing. Then the afternoon therapy sessions start up, again divided by the type of therapy into 30-minute sessions. In all, patients should get about 6 hours of therapy per day, partitioned fairly equally between physical, occupational, and speech therapy, and other kinds of specialists may be seen and therapies used as needed. "With some of the geriatric patients, we also may modify the schedule to include a nap during the day, depending on whether they did that before the stroke," says Liz Thompson, OT, occupational therapy supervisor for stroke service. "Again, we are trying to accommodate the patient and facilitate them being able to participate at their highest level of functioning."
Dinner begins by late afternoon, and patients are again supervised, and then some patients may participate in recreational therapy, or spend time with visitors. Then, following more ADLs, "we try to wrap it up" and get patients to bed before 9 pm, Thompson says.
So is it a full day? "It's huge," she says. But only by going through all of it, the staff believes, can the patients reach their rehab potential.
—S.S.
If a patient was a homemaker, Thompson explains, the OT staff will focus more on home activities in the department's kitchen. If a patient played golf for recreation, they will try adapted golfing. "It's all about what that patient's main interests were," she says.
Even with more fundamental training, such as gait and balance, the therapists try to make treatment practical. "We often use functional activities since the goal is to maximize the independence of our patients," says Dean. "We try to walk outdoors, in the cafeteria, in the gift shop, in home and food management, etc, to challenge our patients in more open environments like they would most likely encounter in their everyday lives as opposed to only walking them up and down the hallways."
Dean and her team also use modalities, such as gait trainers, to help patients regain their ability to walk with little or no assistance. "We will use a gait and balance trainer for those patients who need a lot of help to achieve an upright position," says Dean. "Occasionally, we will put these patients in the pool. We also will break down the components of gait and focus on exercises that will help to improve the quality of a patient's gait pattern."
Balance training is handled with classes that have patients engage in a number of activities to improve balance and coordination. "Our inpatients attend a balance class, if appropriate, where therapists challenge their balance through various activities such as kicking or tossing a ball, indoor golf, bowling," says Dean. "The primary therapists will also use rocker boards, therapy balls, obstacle courses, or a ladder that we put on the floor to focus on step length or challenge their balance. They will also challenge their balance through simple activities such as sidestepping, walking backwards, and tandem and single leg stance."
Both Dean and Thompson say a key to the department's successful treatment is its team focus on care. "It is a very holistic approach to the patient," says Thompson. "There's a lot of communication. We have team rounds for stroke alone three times a week to discuss the patient. And we all work on the same floor in the same therapy area, so you could be working with one patient, and you could be watching another one of your patients walk up and down the stairs [with a PT] across the therapy gym. So you really know what your patient is doing in other therapies."
She thinks this differentiates Helen Hayes from other facilities, where PT and OT treatment are often kept separate. "Here, we do a lot of co-treating. For example, if you wanted to work on ambulation with a patient while doing functional activities, you may have a physical therapist come with [the OT staff] down to our home apartment and do a cooking activity with us. Or say you have someone with communication deficits and you want to go out in the community; you might bring a speech therapist along to help them facilitate more functional communication when they're out in public. We all work together this way."
In the outpatient unit as well, OTs and PTs are "constantly talking," says Szysh. "We're always there to help each other out as need be."
She says there is also strong communication between the inpatient and outpatient staff. "They'll often bring a patient down and introduce us before they are discharged. That way, the patient can get the orientation ahead of time so they're not nervous when they come back to the day hospital," she says. "That kind of rapport is always a good thing."
A WEALTH OF RESEARCH
Neurologist Laura Lennihan, MD (right), meets with patient Pat Burton. Lennihan, director of the stroke unit, emphasizes the importance of individualized therapy.
Most of the studies are multi-center trials and are done in conjunction with the National Institutes of Health. About five studies are being conducted at any given time, Tenteromano says, and they range from pharmacological methods of preventing a second stroke, to looking into the effects of constraint-induced therapy.
Tenteromano, who has worked in the department for 10 years, says a large percentage of the patients in the stroke department participate in the studies, which are approved by Lennihan, as well as an institutional review board.
ONE KIND OF SERVICE Thompson says that among its many special features, Helen Hayes is known for its strong commitment to staff education, as well as its student training program. Lennihan adds that the senior staff continues to advance themselves by teaching these students. "I think teaching is a challenge that improves the knowledge and expertise of the teacher," she says.
The continuum of care—for example, from the inpatient hospital to the day hospital—is also a differentiator, Thompson says. And Lennihan touts the physical environment of the facility, which has stunning views of the river valley.
But across the board, the staff within the stroke unit says the primary way that Helen Hayes differs from other facilities is its sheer concentration on the individual.
And this idea of working individually with one patient coincides directly with the hospital's overall theory of looking at the "whole patient" as a specific person with specific needs and interests, who requires personalized treatment.
"It gets instilled in us," says Dean. "It's not just about whether a patient can do an activity, but that they can go back and do what they used to do and live their lives the way they want to."
Sarah Schmelling is a contributing writer for Rehab Management.
