By Mary Clark Green
No sick person is cured until enabled to fill the same, or equally as good a place in the community as before sickness… often where the work of the surgeon, the trained nurse, the physiotherapist ends, our hardest work begins…
— Occupational therapist Edith Griffin, Winnipeg, 1923
Occupational therapists in Manitoba today share this same conviction and work diligently with their clients to ensure that they can remain in their own communities. The role of the occupational therapist in community and home care is essential in assisting people to continue to do what’s important to them. Community Therapy Services Inc. (CTS), has provided occupational therapy to Manitoba’s communities since 1961, initially as part of the home therapy program of the Manitoba Division of the Canadian Arthritis and Rheumatism Society.
“Working in the client’s home is a privilege and very reality-based,” explains CTS senior occupational therapist Deena Dyck. “There is no guessing. When you are trying to see how someone can manage cooking for herself and her pet dog is biting at her ankles…you can’t ignore the factors involved! I also see the family dynamics and the support they are able to provide to keep the client at home.”
At least 65% of Deena’s clients are over 65 years of age and generally want to stay at home. Many of the people have complex health care needs and are struggling with decreased function due to illness, aging or injuries. Home care case managers, general practitioners or families who ask for an occupational therapy visit want to know whether the person can function not only independently but also safely. When visiting the client in his home, Deena is able to look at how the person functions in various tasks, where his strengths lie and where he needs help. For example, if the person needs assistance bathing, Deena may recommend alternate methods or equipment such as a bath bench or a powered bath lift. She might also educate the caregiver on how best to help the client use the equipment. This would prevent undue stress on the caregiver but may also allow for private and independent bathing by the client. If the person needs assistance beyond their own or a spouse’s abilities then Deena would recommend a home care assessment for attendant services.
“Each client is different so what I do each day varies,” says Deena. “It’s very rewarding when you can make a positive difference in the person’s home.” She recalls a former client with cerebral palsy who had little involvement with home care services until Deena arrived.
He had declined services in the past because he was worried about being institutionalized or losing his independence. One of the reasons for the referral was that he had fallen and spent six hours on the floor unable to reach the phone to call for help. Over time Deena worked out safer transfers from his wheelchair to other seating in the kitchen and bathroom. His speech was difficult to understand but with time and patience he was able to communicate his needs. In addition to acquiring a more suitable wheelchair and cushion to prevent pressure sores, Deena also recommended inexpensive yet helpful aids such as an electric can opener, a special cutting board to help cut vegetables and a thermo mug to prevent burns as he had decreased sensation in his hands.
Kristine MacDonald is also an occupational therapist with CTS and works in southwestern Manitoba. She and another part-time therapist cover a rural area with a population of 34,000. Kristine covers eight communities and surrounding areas. Luckily Kristine lives in Killarney, which is close to the centre of her area so most of her driving time is limited to 45 minutes or less.
Kristine agrees with Deena, that seeing people in their homes gives her a more accurate picture. “Most of my work is either assessing safety or recommending equipment to help clients maintain function and independence or ease the workload of the caregiver,” explains Kristine.
She is a wealth of information for her clients. Kristine is able to connect her clients with various agencies that offer permanent equipment loan programs or other assistance. One of her clients is receiving Employment and Income Assistance and living in provincial housing. He uses a wheelchair and needed a ramp installed to be able to get in and out of his home. Kristine believes that her advocacy and knowledge of “who to call” facilitated the ramp’s installation.
She also helps clients make appropriate equipment purchases. “Sometimes I see a client who has a sore back or trouble with her shoulders and it’s due to the incorrect adjustment of the height of her walker. Just by raising the handle slightly the client feels much better and can participate in more activities,” explains Kristine. The most frequent comment she receives regarding her services is… “It’s so much easier for me now.”
Kristine wishes there were more funding for occupational therapists for health promotion in order to prevent falls or unnecessary dependence. She feels they miss a number of seniors who are not currently using home care services who are starting to be at risk in their homes. They are just getting by and not wanting to bother anyone. Kristine is convinced that a few practical, occupational therapy suggestions and equipment would make a world of difference to them and save health care costs in the future.
Kristine’s rural territory is farming country and many of the people she sees are retired farmers. For many of them, the most important occupation is chatting with their friends at the local coffee shop. They keep up-to-date and it’s a routine they had even when working. Kristine’s job is to make sure they can get there!
Kristine describes the ease of working in small rural communities. “They are very resourceful. In one community, there is an independent taxi service; three dollars gets you anywhere in town. I sometimes do pre-discharge home visits while the person is still in hospital. There is always a family member or neighbour willing to take the client to and from their home so we can complete the assessment.”
Both Kristine and Deena see many clients who are in their 90s. They may have the “four-time-a-day home care” where an attendant comes in at each meal and bedtime to assist with meals, toiletting and medications but this is still less costly than personal care homes. However, occupational therapists also play a role in improving the quality of life for residents in these personal care homes. Again, they assess, make recommendations and assist in obtaining equipment to meet seating and mobility needs, and make suggestions regarding activities and the resident care plans.
Mental illness, especially schizophrenia, often hits people in their late teens just as they are acquiring advanced life skills for independent living. Once settled and discharged from hospital, they may move to a supportive living environment as a first step to living on their own. Whether living in a boarding home, with supportive family members or on their own, occupational therapists work with the clients to identify what is important to them and work out a plan to get there!
Merri-Lou Paterson, a CTS occupational therapist working in the mental health rehabilitation program, recalls one client who was able to move into an apartment on her own in a short period of time. “She was divorced and her former husband had taken care of everything. She didn’t know how to bank, budget, look or apply for apartments, etc. But we made lists and she learned new skills. In three months time she was on her own and three months after that she told me she didn’t need me anymore. That felt so good!”
Some older adults with mental illness reside in boarding homes on a permanent basis. Merri-Lou works with community rehabilitation workers and the residents to plan group and individual activities to make life more enjoyable. “They love bingo but they also like to get outside, go for coffee or to the local park,” says Merri-Lou.
CTS also runs four programs at Freight House, a Winnipeg community centre. The Snack and Chat Program alternates weekly with a meal program where people learn to cook easy and affordable meals. These community run programs are open to all clients, however, further linking to other resources is frequently necessary. Merri-Lou facilitates discussion regarding what they would like to do and helps them to discover the community resources, transportation to and from the facility and may even go with them the first couple of times until it becomes a familiar environment.
Funding for the mental health rehabilitation program was initially received in the late 1980s and has since expanded. “It would be a great loss to these people if it was ever cut. Other mental health professionals look at the person’s cognitive or emotional status but not necessarily at how it affects their functioning in the community,” explains Merri-Lou. “Due to heavy caseloads, clients often don’t see other community support workers as frequently as they would wish. We are fortunate to be able to see our clients two to four times a month if needed.”
Often clients’ needs fluctuate and they require both acute and community care. Merri-Lou would like to see further development in the continuity of care between hospital and community mental health services. This would ease the transition between hospital and home.
CTS is a private, non-profit agency that provides services throughout Manitoba. “We employ about 40 occupational therapists although presently there are vacancies in some rural settings due to the nation-wide shortage of occupational therapists,” comments occupational therapy profession leader, Barbara Siemens.
The demand for occupational therapy is growing as Canada’s population ages. People wish to remain in their homes for as long as possible and this is less costly than personal care homes and other residential care.
The recognition of the value and role of occupational therapy in enabling an individual to remain at home with family and home care supports is resulting in increased referrals from palliative care programs. The functional analysis that the occupational therapist does with the client is best done right in the home where both the problems and solutions can be found.
Deena, Kristine, Merri-Lou and the other occupational therapists working in community and home care across Canada have continued to demonstrate what Edith Griffin proposed in 1923. They are not only helping people stay in their communities but also helping them to navigate complex systems that may be anything but enabling.
The author would like to thank the occupational therapists at CTS as well as Barbara Siemens for their assistance with this article.
This article first appeared in the September/ October 2002 issue of Occupational Therapy Now magazine published by the Canadian Association of Occupational Therapists.