Shadow Day #1 - Hospital

I spent yesterday at a hospital in my area shadowing OTs as they worked with people receiving out-patient care within the hospital [I think I understood that correctly]. I also saw them work in the Intensive Care Unit, and I’ll come back to that at the end.

For the most part, the focus of the OTs work was very narrow. In the 20-30 minutes they spent with each patient, they mostly asked questions to get a sense of what ‘baseline’ was for the patients before they came to the hospital. These questions were about what their homes were like, whether they had stairs, whether they had equipment to make it easy to get in and out of the bathtub/shower, whether they were able to put on their socks and shoes by themselves.

In addition to the verbal questions, the OTs asked the out-patients to perform tasks like getting out of their beds, moving to the bathroom, washing their faces, brushing their teeth, in order to observe what each patient was capable of doing. This mode of functional ‘questioning’ probably didn’t seem like questioning to the patients. They might have thought the OT was just offering some help or support, but the OTs were observing.

From what I could surmise, all of the OT’s questions were asked so that they could make recommendations to the patient’s case manager about what kind of care the patient should receive after being discharged from the hospital. That’s notable because there wasn’t really much ‘therapy’ going on. The work seemed mostly diagnostic, and then mildly educational - for example, a handout with a list of community resources or an 8x11 about how to put a sling on for yourself.

Even though I didn’t get a chance to see the notes that the OTs made after their visits, I gathered from conversation that the OTs could make about 3 recommendations: either the patient would go to a skilled nursing facility [SNF, colloquially pronounced ‘sniff’] to do rehabilitation, or they would have home health visits from an Occupational Therapist, or they’d be deemed fine to go home without any further care.

My understanding was that once the OTs [and PTs and Speech Therapists] made their recommendations, the case manager would put together a report to send to each patient’s insurance provider, whereupon the insurance provider could either approve the hospital’s care recommendations or deny them. I don’t know anything about the insurance provider’s calculations, but I did get the sense that it was a fairly regular possibility the hospital’s recommendations for care would be denied by the insurance provider.

That’s about as much of the process as I saw. I could only guess about what happened to any of the patients after their meetings with the OTs and PTs, and the same is probably true for the OTs and PTs themselves. It didn’t seem unusual for an OT or a PT to see a patient once or twice before the patient was shunted into the next phase of their ‘care’ journey.

I did gather during my time at the hospital that one of the big initiatives for both the hospital and the insurance companies is to consistently bring down the average amount of time that each patient spends in the hospital, which, of course, makes sense financial sense, but which apparently also might make sense health-wise. I would intuitively think it best not to rush someone after a traumatic event or a health crisis, but a PT told me in the elevator after one visit that more time in the hospital doesn’t necessarily result in better outcomes. This left me with questions about how health outcomes are measured by hospitals and insurance companies, not because I think anything sinister would be going on, but just out of curiosity.

The most emotional I got during the day was when I went with an OT-PT team to visit a woman in the Intensive Care Unit. She had just suffered a spinal cord injury and was newly a quadriplegic. It was moving to see the support she was getting from her sister and her son, and it was also very moving to hear the OT tell the woman that based on what the team knew at this early point in her recovery, and based on the large amount of function that remained in the patient’s arms and hands, the patient would eventually be very independent again.

Now, the patient wanted to know if she’d be able to walk again, and the OT said, “I don’t know about that. But I can tell you that you’ll be able to move around for yourself, you’ll be able to drive, you’ll be able to go to the grocery store, you’ll be able to get yourself out of bed. You’ll be able to do pretty much everything on your own.” It was a powerful act of consolation, and who can say how much of that message got through to the patient struggling with her new embodied reality. But the OT and the PT helped the woman into a sling and got her from the bed into a power wheelchair and showed her how to tilt the seat so she could shift her own weight from her sits-bones to her back to prevent pressure sores, and it was clear that for this patient a new chapter of life was starting, and an OT and a PT were there to help.