Lakeview Rehab at Home

What we’ve learned so far

Third Thursday Presentation January 20, 2011

Lakeview Rehab at Home

• Welcome and introduction

• Technical issues

Goals for this session

Participants will have an understanding of the major elements of Rehab at home:

• program structure• staff • family participation• payor communications• outcomes

Home and Community Based Rehabilitation

• The Client’s own Home and community are backdrop for Rehab at Home

• Environment is ecologically valid• Behavioral results based on natural consequences• Relearning in own home is easier than in clinical

environment• Acute rehabilitation can be delivered in the home

and community

The Home and Community as a setting for rehabilitation

• Rehab is more real in the home and community• Community resources – health clubs, church, social

organizations, vocational and educational opportunities are an integral part of most clients’ programs

• Friends, family and persons from community organizations can be team members and help support the client in their rehabilitation

Goal setting

• Goals are determined by client, family, payer, and professional team input

• Goals are highly functional

• Goals are adaptable across clinical disciplines

Rehab at Home Team Members Client

Family members Primary Care Provider Payer representative Physical Therapist Occupational Therapist Speech and Language

therapist Nurse

• Social Worker• Clinical Coordinator• Cognitive Therapist• Behavioral Specialist• Community Integration• Specialist• Vocational Specialist• Personal Care Attendant

/Support staff

Individualized Client Teams

• All teams include a Clinical Coordinator• The Client is the focus of every team• The remaining members of a client’s team are

selected to meet the individual needs of each client – they may be clinicians, specialists, or support persons. All teams are individualized to reflect the needs of the client

Role of The Clinical Coordinator

• Communication – • - Client• - Family• - Payer• - Team• - Community resources• Quality outcomes

Community Medical Resources

• The role of the Primary Care Practitioner• Specialists included on the Lakeview Rehab at Home

team• Medical resources (Hospital, clinic, specialty services)

can be included, i.e. Balance Clinic, Vestibular training

• Outpatient services may be included in a client’s rehabilitation

Measuring outcomes

• As a results oriented model, Lakeview Rehab at Home monitors outcomes with every client

• Outcome goals are individually determined• Safety, self awareness and relative independence are

important for each client• Functional outcomes, such as the ability to be alone

at home safely for a period of time, are reviewed for each client

Diagnosis Served• Brain injury

• Stroke

• Spinal cord injury

• Other neurological impairments

• Multiple trauma

• Complex care issues

• Alzheimer's disease, including early onset

• Atypical developmental issues

• Autism, spectrum disorders• Dual diagnosis• Any complex diagnosis in

children, adolescents, and adults, including seniors

Payment structures

• Lakeview Rehab at Home can accept:• - Private pay• - Health insurance• - Worker’s Comp Insurance• - Medicaid• - Medicare (once the program is certified)• - State Brain Injury waiver funds

Licensure and Certification

• Lakeview Rehab at Home is Licensed in New Hampshire as a Home Care Agency

• Medicaid approval is being sought

• A Federal Medicare application for New Hampshire has been filed

• Accreditation by CARF and medical accreditation as a home care provider are being sought

How to refer

Individuals, family members, physicians, case managers and discharge planners may call:

1-800-473-4221To make a referral

Call also with your questions regarding LAKEVIEW REHAB AT HOME

Send your questions regarding this presentation to: emunson@lakeview.ws