What Occupational Therapists See That No One Else Does

As a new grad, I thought home assessments were about grab bars and shower seats, but that was only the tip of the iceberg.

In the lead up to my first home assessment, almost 15 years ago, I was worried about the checklist of questions from the hospital team that would determine whether this person was able to go home or would move to a step-down facility for further rehab. Much like our inpatient work, there are goals that have to be met, milestones achieved, in order for someone to meet the criteria to discharge home.

What I encountered in that first assessment was the “rubber meets the road” moment of peaking behind the curtain into a patient’s world- home layout in an old New England home, adaptations for getting around that went from “problem solving” to a baseline level of function and every quick fix in between. None of this came up during their time in the hospital, moving around an ADA compliant and sterile mock apartment, with constant supervision and cueing from a therapist. I’ve seen people leave walkers in the middle of living rooms to default to “furniture walking” (using couches and countertops), muscle memory of moving around trip hazards, and the reintroduction of pets underfoot. When you’re home, it’s just different.

None of this can be replicated in the hospital and the “data” for an OT of watching someone live in their own environment is much richer than a standard set of assessment questions. This is where the real answer to the question “what do OTs do?” can be found- analyzing the environment, breaking down the activity with the person, troubleshooting in real time around environmental barriers and the level of support family caregivers (if they have one) are able to provide.

There’s a world of difference between what someone tells you they do at 1am when they get up to go to the bathroom and what that trip down the hall looks like in person. That gap is where Occupational Therapists thrive. Building a bridge between skill and requirement for success, figuring out which levers of function to pull (changing the furniture arrangement, adding lighting, adapting tech you can find at home depot), to maximize impact, is the bippity boppity boo of OT.

The one thing I was not prepared for: how, previously quiet, caregivers come alive with questions when they see how their loved one performs in their own environment. At this point in a hospitalization journey, this is often the first indication of what they will be navigating after discharge. It’s a time for education that’s overdue- safe transfer techniques, how to navigate new precautions, what their role will adapt to in order for this person to be able to discharge home. When you are in their space, there’s nothing hypothetical happening anymore.

In the last decade and a half of working with patients and families, conducting home assessments as an inpatient therapist and then as a consultant, there are three things OTs see that no chart captures:

The environment tells you everything

Whether it’s the mail pile, the fridge, the hearing aids on the counter, or the life alert hanging on the back of the bathroom door, none of it is in any record. The “oh yeah, I know we’re supposed to [standard recommendation] but […patient specific adaptation…]” adjustments I’ve seen- good, bad, and generally unsafe.. nothing surprises me. All of it is clinical data. None of it is judged. The worst thing that can happen in an assessment is for someone to omit information to save face.

People are adapting how they live in their home without the background or training that an Occupational Therapist has. We are here to help, to simplify, and to improve safety for you and your family. Ask the questions, nothing is off limits. We’d rather you have one million questions than smiling and nodding.

Family dynamics as a care variable

Families are a fundamental component of the care team. They are the ones tracking symptoms, helping with medications and mobility (as needed), narrating between doctors appointments, consults and helping fill in the blanks when an update doesn’t reach another provider before the appointment. How healthcare is delivered in the US has changed dramatically over the years, when I started working in inpatient rehab, someone with a single knee replacement would be admitted for about a week, now double knee replacements are performed as an outpatient procedure. That means that there is a family member or friend helping manage post-op recovery at home, usually for at least the rest of that day before home care comes in the following morning. A caregiver is being asked to do the work of nursing, therapy and case management, with very little, if any, training.

By the time OT reaches someone’s front door for a home assessment, we’re not treating just the patient, we’re also working with their family. We are entering their ecosystem, seeing how things have worked behind the scenes, done with love and grit. No two families are the same, there are different levels of comfort with care, available time for care, and navigating family relationships. In my private consulting work these conversations make up the bulk of a home assessment, from finding common ground, to everyone sharing their level of comfort with care, there are a multitude of family variables to consider. The OT role expands to include meditation, bringing up the hard and uncomfortable conversations.

Creating a plan for care, especially with a proactive lens, relieves the “what if” tension that results from avoided conversations, and ensures that the care recipients wishes are honored by all caregivers involved. When you, as an outside clinician, are invited into someone’s home, these conversations are held “on their turf,” which has led to more forthcoming of information and hands on opportunities to troubleshoot “this is how I usually do it” demonstrations that improve safety for patients and their caregivers.

No matter if there’s one person at the table or a whole table full of people offering to help, there is palpable relief at the end of these assessments because of opportunities for these conversations, whether or not the person is able to go home or moves to a step down facility, are no longer getting pushed off.

Dignity over survival

The medical system, as a whole optimizes for keeping people alive- testing, monitoring, surgery, interventions that improve or impact function. While working within this system, OT focuses on optimizing function and keeping people themselves alongside their medical journey. In the face of physical, cognitive, or mental health changes, Occupational Therapists strive to recognize the patient as an whole person, no matter their diagnosis or treatment trajectory, and help them maintain or regain as much function and independence as possible. This may look like different strategies for activities like dressing, or moving around at home or adapting their environment so they are able to participate in tasks that are important to them while navigating changes with their body.

Keeping the person at the center of their care, and creating opportunities or strategies for them to engage in activities is a core pillar of OT. The profession itself was created after soldiers returned home from WWI with injuries and needed to find a way to reintegrate into their communities and continue to live life post deployment. Client centered care is the forefront of treatment planning, which is why there is such an individual focus during initial evaluations through to home assessments and discharge.

Through it all

OTs working the continuum from acute care to outpatient rehab have seen, for years, what is now showing up increasingly in policy and care direction conversations- the care coordination gap filled by family caregivers, the invisible labor without infrastructure or support and the family systems that are expected to carry the weight of care alone. Building Dovetail has been rooted in addressing these systemic issues, ones that are difficult to see unless you’ve been a part of the healthcare side of the conversation, because otherwise it’s been “just what families do” for far too long.

If you’ve been a caregiver, what did you wish your care team actually knew about your home situation?

Dovetail is a care coordination platform for family caregivers- built to distribute the load, capture what no one else is tracking, and connect families to vetted support. Available on iOS and Android.

If you’re a family caregiver, build your care profile here and we’ll match you to resources built for your situation.

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