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Journey of a DPT Student

Repeat Patients -- Same Approach?

Published February 24, 2014 4:54 PM by Lauren Rosso

For the first time ever, I'm treating a patient who returned for repeat therapy after being discharged a month or so ago. This patient, who is impaired following an anoxic brain injury and transfemoral amputation, has been through the medical ringer in the past six weeks.

His first course of care was very challenging, however we made some great progress prior to his discharge. Knowing that multiple medical complications occurred while he was away, I was honestly scared to see how he was functioning when he came into the clinic on Friday.

The evaluation was interesting. I knew what we had measured and worked toward in the past, so I collected similar outcomes. But I couldn't help but think that I needed to be doing more. Unfortunately, I correctly predicted that this patient would be well below his previous performance.

Bed mobility, contracture management and sitting balance were back to pre-PT days. In the middle of the evaluation, it occurred to me that I might have to take a very different treatment approach this time around rather than plugging away at the same old goals that we set last time. A new episode of care with a new focus.

I think it may be hard to phase out the old program and start a new one. It took so long to develop an effective and efficient treatment plan for this patient, and I fear that he and his family may not be interested in taking a step back to work on some basic functional skills that seem more important this time around.

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I have often heard the phrase when on clinicals that there are certain patients who are "repeat offenders." This means they are a regular and often comeback. I had not had an experience with a "repeat offender" of my own, but have treated them. Therapists often dismiss those who are regulars in my experience because no matter what they do, they believe it doesn't make a difference for long because the patient will be back. On this last clinical I had my first regular. The first week of my clinical there was an individual with a CVA. He was my CI's favorite patient and she often treated him or told me how to treat him. He discharged home with his family on my second week. On my 7th week of the rotation, he came back. He had been experiencing falls at home due to decreased safety awareness and balance problems. I fully expected my CI to be thrilled he was back, but the attitude was very different. I took over fully this time. My CI was not as invested in him as before. I told myself that I did not want any patient to feel like they were unwanted or felt like their treatment time wasn't being utilized. I think repeat patients should be treated like new patients each time. They should be evaluated to find where the problems with their function lies. They could be treated using the same treatment approach if the same functional problems exist, but these patients should be properly evaluated and treated despite being a regular. I think your point of repeated patients is important and on treatments, but I think this opens the door to look at our own bias with repeat patients and increased caregiver burden we feel when working with these individuals.

Caleb P March 20, 2016 7:54 AM

During my last clinical experience I had a number of patients who were repeat patients for the facility (although not for me during the clinical experience) and was faced with this same decision as to whether to take a similar or new approach.  I think it really comes down to the specifics of the patient and what has changed in their health status that caused them to need PT again.  For example, we had some patients who had undergone surgery and/or general health decline but continued with the parts of their HEP that they could still complete.  Their impairments may or may not have been slightly different than their previous episode of care.  For these patients I found it important to address any new impairments or limitations, adjust their HEP to suit their current level of function, and take a new approach to impairments that seem to have declined with no apparent cause.  On the other hand, we had some patients that I found a similar approach worked quite well: patients with cognitive impairments making learning new tasks challenging, patients who had a change in caregivers, and patients with recurring vestibular impairments.  For these patients, education for the patient and/or caregiver on how to perform ADLs, transfers, HEPs, etc was extremely important and highly emphasized but otherwise treatment was fairly similar to their last episode of care.  Of course not all interventions work equally well for each person, and yes, we need to consider alternatives to help patients achieve their best outcomes, but if something worked for a patient the first time, in certain situations I think it is okay to repeat it, too.

Caitlin March 26, 2015 7:32 PM

I'm sorry the above post was meant for a different blog.

jean March 24, 2014 11:52 PM

I find myself in the same situation, nearing the end of my education that is. However all I can think about is getting ready for my comprehensive final in a couple weeks, trying to figure out how to wrap up my research to present, and what my study schedule for boards will be. I think that most of these problems are because our class schedule was structured differently than yours was at the time. I feel like my life revolves around those things right now and it's hard to see the light at the end of the tunnel. I feel like I have to do all these things and start applying for jobs so that I can start supporting myself after I graduate. Maybe it is just for me, meaning I am just letting myself get wrapped up in the small details to allow me to enjoy everything I have accomplished at this point. Reading this has made me realize that I need to start enjoying this stage. At least find a happy medium between the two ideas, enjoying this time and being productive at the same time.  Thanks for this post because it was really eye opening as to how to handle all of this without getting overwhelmed.

Jean March 24, 2014 11:50 PM

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