Providing therapy in the home can be challenging and rewarding. The therapist has the opportunity to use his/her creativity with what is available in the home. It requires that the therapist discover who the patient is and what the person's support systems are. With the appropriate support, the therapist is able to facilitate the highest safety and function with the ability to see the carry-over of teaching (of the patient and/or the caregiver) in the home environment. The initial evaluation is crucial for determining the level of assistance the person requires, for creating an environment that will facilitate the patient's best abilities and engagement in valued activities, and for Medicare reimbursement.
As always, the initial evaluation must begin with assessing cognition. Does this person have the cognitive abilities to make decisions that will result in an ability to function safely in the home? Remember that a person with a physical deficit can learn compensatory techniques to remain safe and independent; however, the person with cognitive deficits may be unable to learn. Often, it is crucial to discover this information on the first visit, as the patient may need immediate assistance in the home.
In home health, the initial evaluator must score the patients on their ability to perform basic skills. This information is recorded on the OASIS evaluation and the scores result in the HERG score which determines the amount of money the home health agency will receive for each episode (60-day period). Obviously, it is paramount that these scores are accurate. There is a five-day window from initial evaluation until these scores must be "locked." During that time it is essential that all disciplines have input into the scores and just as importantly, that they understand how to score accurately.
How can the evaluator assess cognition and discover the Allen level or stage of dementia on the first visit? The therapist needs only to observe the client performing familiar, routine, procedural activities, as well as new activities that require the use of the working memory. The OASIS requires that the client is observed performing the components for grooming, dressing and bathing, preparing a light meal, doing laundry, housekeeping, shopping, using the telephone, and managing medications. If these activities are observed, a therapist can use the scoring of the Routine Task Inventory to determine a patient's cognitive level. Or the evaluator might use the FAST scale to determine the patient's stage of dementia.
Frequently, it is not possible to actually observe all the above mentioned activities. If the client appears independent and safe in basic care activities, it is important to observe activities that require working memory. This is often easily accessed in the client's home.
Often the client has appliances in the home that are relatively new. I just evaluated a client who was an accountant and highly valued balancing his checkbook. His checkbook was accurate (he only pays 3 to 4 bills a month), but he was unable to show me how to use the microwave, or the remote control for his TV. Using the microwave or the remote control was not in his procedural memory; balancing his checkbook was. The caregiver reported that he had been instructed on the use of these many times, but he was unable to retain that information. One can assume that he has significant difficulties retaining new information. This is indicative of Early Stage dementia and Allen Cognitive Level 4 performance.
Communicate With Family and Caregivers
Communication with the family and caregivers is a vital component for obtaining an accurate assessment of the person's abilities and deficits. The person performing at Low 4 Allen Level is usually unaware of his or her deficits. This patient will often tell the evaluator that his/her memory is good and that he/she is paying the bills and strictly following the diabetic diet. Yet, when the evaluator talks with the caregivers, it is reported that the son has been handling the finances for a year, and when the evaluator looks in the refrigerator, just muffins and cookies are found. Remember, this patient is not lying or in denial; the patient is telling the evaluator what he/she believes to be true. The patient is no longer aware of deficits, but will fool the person who bases assessment solely on the patient's report.
Remember that the person who is performing at Low 4 Allen Level will continue to perform well in activities that are highly familiar for that individual. This means, if the person always used power tools, or a sewing machine, or had advanced knowledge concerning gardening or electronics, the person performing at Low 4 Allen Level may perform these familiar, complex tasks with only minor errors. Therefore, to make an accurate assessment based on functional performance, one must know the person's history and interests. The evaluator may need to interview family or a caregiver to discover this information. With this knowledge, the evaluator can feel confident in his/her ability to make recommendations that will allow the patient to be safe, functional, and feel productive.
It is usually easier to determine deficits and the stage of dementia when we visit persons who are requiring consistent assistance from caregivers for basic care tasks. A person who is using his/her hands to manipulate objects or assist with steps of basic tasks, but is unable to sequence through basic ADL tasks due to cognitive deficits, is performing in the middle stage of dementia, Allen Cognitive Level 3. As part of the evaluation, it still remains essential that the therapist discover the valued interests, likes, and dislikes of the patient.
Establish Plan of Care
Once the evaluator has established the cognitive abilities (and deficits) of the patient, a plan of care is established which may include recommendations for caregiver assistance. If the patient is performing with very early signs of dementia, we know the client may require just daily checks in their familiar environment, to ensure safety and performance of basic daily tasks. If the patient is demonstrating further deficits and low 4 or level 3 Allen behaviors, then the evaluator must recommend 24-hour care for this patient, in order to ensure the patient's safety. The treatment plan should include environmental adaptations and caregiver education, always with an emphasis on maintaining the patient's engagement in valued activities.
In my opinion, the patient's home is the best place to complete an accurate assessment. Evaluation is a powerful task; it begins the process of improving safety and quality of life for the patient and the caregiver.
Additional Thoughts from Kim Warchol
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This is a wonderful article describing the critical need that exists to evaluate and treat cognition for patients in home care. Thank you, Chris, for sharing your knowledge and advice based upon much experience working with individuals with dementia in home care.
Each discipline, OT, PT, ST, and nursing, must be able to evaluate the patient's cognition as it impacts the patient's function and safety, related to the scope of treatment.
Also, I very much agree that speaking with families, both to gather information to assist with the assessment and treatment plan and to provide education to the family, is often very necessary. Please be sure to consider and honor all HIPPA regulations.