Disability and aging force most of us to recognize limitations created by declining physical, economic, and mental health. The curtailment of activity that usually accompanies declining health may lead to involuntary withdrawal from once familiar and comfortable activities, resulting in further decline and depression. It is in the patient's home that we as therapists can directly affect physical deterioration and function. Rehabilitation professionals can and should provide a key role in assisting those who are disabled to maintain the highest quality of life possible regardless of diagnosis. Home health agencies must consider treatment options that have traditionally been a part of therapist practice in hospitals, outpatient clinics, and skilled nursing facilities as well as the use of therapists in the role of case manager. By maximizing the practice of their therapists, agencies may reduce the cost of providing care to their patients by reducing unnecessary visits by other disciplines. Thus, agencies would provide more efficient care to their patients while maximizing their reimbursement.
The homebound elderly have multifaceted problems, and our culture will be challenged to make a tremendous shift to adapt to their needs. This population will require an increasing number of health care providers who distinguish between the normal and abnormal changes associated with aging. The model home care team would consist of practitioners who are skilled in just this manner. Team members would address the chronic illnesses associated with the elderly and function much as interdisciplinary teams do in other settings. Regular and effective care coordination and case communication do not have to be fantasies in the setting of home health care, as evidenced by the success of the Johns Hopkins Home Care Group Geriatric Team. To match its success, home care agencies must organize their teams to encourage regular, ongoing multidisciplinary meetings. These meetings increase immediate attention to current issues and ineffective portions of treatment plans, reducing the cost of providing high-quality care.
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