5 Strategies for the Home Health OT Working with Stroke

If there is one area of practice that can be overwhelming (and massively rewarding), it is home health occupational therapy. And if there is one diagnosis that can make the home health OT feel buried in options or approaches, it is a stroke diagnosis.

This article is an attempt to pull back the layers of overwhelm and offer practical strategies to progress towards a more potent and sustainable approach for home health OTs serving the client after a stroke.

Below you will find five strategies to optimize your plan of care and streamline the approach of the home health OT serving stroke survivors.

Setting the Stage for Home Health OT Stroke Rehab

Before we jump into specific strategies, let’s pause to set the stage. It can be easy to assume that some basic questions are being asked and that rapport is being established, and so perhaps that is the place to begin. With each patient, as with each stroke, the presentation of symptoms is very different. Let’s be intentional in creating a safe and curious space to FIRST build rapport with the client and their family.

If nothing else, let’s pause for a gentle reminder to tune into and carefully build the relationship with the human being in front of you whose world has just been rocked by trauma. From this place of understanding and compassion, these other strategies can be much more helpful.

A quick trick I learned during job training a few years ago was to set the stage for what the client could expect during the appointment and that by doing this it would decrease anxiety. Start with a run through of the visit plan to set expectations for the session. It may sound like this:

“Today is the Occupational Therapy assessment. This will include an interview with you and your family to understand what life used to be like and how it is today, as well as what your top goals are; checking your vital signs; moving around to assess your movement and function in the home and safety overall; and then ending with a conversation about goals that I think I can help you achieve in the next 1-2 months based on all the information from you and this session.” (If you’d like more specific scripts, consider getting the e-book with more examples.)

Also, don’t forget the value of a thorough chart review. Taking a few extra minutes with the chart can help you do a little more research into the hemisphere of the brain affected and get a jumpstart on your observations during the OT evaluation.

Strategy #1: Look at the big 4 and how they impact function

Start with functional mobility

With falls at home as one of the major reasons for re-hospitalization, it’s important to establish how the patient will mobilize as part of their ADL routine.

Will a mobility device be used for particular ADLs?

Should the patient be encouraged to use the wheelchair for some activities of daily living and stand with assistance for others?

Pair with your PT counterparts and ensure clarity on mobility suggestions for ADL participation. Ask when the patient/family realistically wants to shift to using a different mobility device. The answers you receive may also gain you insights into the family’s level of understanding about the impact and implications of the stroke.

Address upper extremity assessment and positioning (mobility) early on

Choose a functional assessment to determine the baseline for upper extremity function. An assessment like the Fugl-Meyer is reliable and doesn’t require any additional equipment. The 9-Hole Peg Test (for fine motor coordination) can also be quick and easy to keep stored in your bag or car for patients with higher level function.

Check in with the patient and/or caregiver on any splints or slings and the wearing schedule that was established. Just because you don’t see it in the room does not mean it is not there. Ask the caregiver if a splint has been ordered. Initiate a positioning program for the upper extremity, as needed, to prevent pain, contracture and/or subluxation.

Lastly, build up your resources. For example, here is an evidence-based UE Toolkit that was found on Senior’s Flourish Learning Lab Clinical Resources page. Here is another assessment developed by the National Institute of Health found via use of OT Potential Club that highlights quality research and links to assessments used in the research.

Assess cognition and its impact on function

Use an assessment that is quick and easy like the MOCA or Short Blessed Test to determine the areas of cognitive deficit that might be impacting function. Keep these copies on hand in your bag or trunk.

Also, be sure to interview the caregiver to see what they’ve seen as the impact of cognitive deficits in the home and work together on strategies.

Follow up, as needed, with the use of the ACL Leather Lacing or other battery of tests to help determine the patient’s functional cognitive level. Knowing this will also help you grade your education strategies for more effective learning. For example, some people may benefit from checklists where others may need a different level of organization.

Lastly, set up supports like an ADL checklist or written instructions for activities that are difficult for the patient to sequence or recall. See the OT Toolkit for great handouts for ADL sequencing.

Don’t forget to check in on vision after CVA

Do a quick vision screen for all stroke patients including motricity, eye teaming and scanning in order to determine visual effects that may not have been previously identified. A simple vision screening kit can include a pencil and occluder (small piece of cardboard that can cover the eye). A simple clock drawing or scanning task like the star cancellation test can also help reveal neglect.

Be sure to set up supports in the home to encourage visual scanning in the case of a neglect or field cut (i.e. red tape on the door ways).

Lastly, get a referral to a neuro or functional optometrist if there’s a concern about neuro related visual challenges. NORA is a great resource to look up a provider in the patient’s area.

Strategy #2: Complete a home safety assessment or walk through of ADLs in the home environment

With the changing landscape of healthcare, it’s less likely that a patient that has had an in-person home safety assessment. Observe what you can on day one in the home especially of the shower, toilet set up, sleeping location and entrance/exit, and set a goal for a more thorough home safety assessment.

Have the patient move through their ADL routine using the Modified Barthel Index or another assessment that can quantify their ADL performance.

Be sure to understand how much assistance a patient wants to have for each of his or her ADL activities. Just because the patient CAN perform a task, doesn’t mean that completing it independently is important. Many patients over the years chose to have assistance for certain ADLs to allow them the energy to focus on the routines that are most important and meaningful to them.

If there is an opportunity to leave a self-rated assessment with the patient and their caregiver, the Stroke Impact Scale can be helpful in determining what the patient is able to do since their stroke and how it has impacted their life.

Strategy #3: Have a small stash of adaptive equipment that can be trialed with stroke survivors

Some items you might find particularly useful:

• Dycem—for a variety of one handed activities
• Long handled devices—including sponges for bathing, wiping aides, a reacher and/or a dressing stick
• Elastic shoe lace—for easier shoe management.
• Built up handles—especially helpful for eating and toothbrushing.
• Other ADL equipment for trial—such as a sock aide and button hook for starters

Strategy #4: Encourage your patients to do what they can with their affected side consistently

Determine 2-3 activities that a patient can do with their affected side to increase the number of organic repetitions and attention to their affected extremity.

The tasks can be simple and should be repeatable. Some examples might include repositioning their arm on their lap, turning on and off lights, flushing the toilet as well as using the affected side as a stabilizer for opening containers or involvement in other meaningful ADLs.

Strategy #5: Teach and train family on a simple home exercise program for UE function

This includes positioning for safety and protection of joints! Don’t forget that a foundational part of the UE HEP is positioning. Many caregivers and patients do not fully understand the immense value of correctly positioning the arm when it is at rest. Help assess how the arm, wrist and hand are resting and recommend adjustments as needed. (The OT Toolkit is another great resource for positioning handouts.)

There are several online programs like the GRASP program that get patients moving in a fun and functional way. The program can be graded based on patient abilities and use household objects.

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We’ve given you five effective strategies for working with CVA clients in the home health setting, but remember that part of the beauty of being an OT practitioner is that we are continually honing our skills to reflect our clients’ needs (as well as our own treatment philosophies). As you grow and gain experience in the home health setting—and as you work with more and more post-stroke clients—you will develop your own strategies that work best for you.

As long as you remain passionate about helping your clients progress, and you commit to continually learning and improving your practice, you’ll do right by your clients and help them live their lives in the ways that matter most to them!

About the Authors

Monika Lukasiewicz, OTR/L has loved writing since she started making greeting cards at age 10 and was partially pre-taught occupational therapy hacks after school by her grandpa at about the same time. What drives her professionally today is a vision for sustainable and higher quality healthcare and relationships, especially in home health. She’ll celebrate a 10-year OT anniversary this year, with 6 years in home health. You can check out an experimental podcast called Home Health Occupational Therapy Explorer. She has written a few items for the home health OT already that are currently available here. Email her monika@homehealthOTexplorer.com. She also enjoys long walks, laughing especially with loved ones, air conditioning (as a new kid to Arizona) and unexpected wit. She likes to stir creativity with community.

Lauren Sheehan, OTD, OTR/L, has been an occupational therapist for 10-plus years in a neuro-rehabilitation clinical setting, working with individuals with neurologic injuries and illnesses. She also spent a handful of years in clinic administration and director of rehab roles for small community hospitals as well as facilities in large, urban areas. She has spent the last two years of her career working for rehabilitation technology companies to assist with product and process development for products that serve stroke patients. She’s currently the Field Clinical Manager for NeuroLutions, a device company committed to developing quality products for patients through innovation such as BCI (Brain Computer Interface) stroke rehabilitation technology. She has a passion for supporting individuals with neurologic injury and illness through greater accessibility to technologies that can be used at home to increase function and improve quality of life. Outside of work, Lauren enjoys singing, cycling, and traveling.