Focus on mobility.

Everyone knows that mobility issues in post-acute care settings, including home care, are crucial to a patient's recovery and/or sustained function. But they are the issues that receive the least attention, especially in relation to persons who are chronically ill.

Whether a loss of mobility is caused by injury or illness, the need to evaluate and restore function is crucial to recovery. Mobility can be explained as the ability to move through space, going from point "A" to point "B" by, for example, walking or by moving the hand from one's plate to one's mouth. Mobility has a significant impact on independence, and independence directly affects quality of life.

The lack of application of mobility programs in chronic care has come as a bit of a surprise to me. Some years ago I was involved in developing a mobility program for a large health care organization which proved to be very successful both for the patients and the organization. Yet, as I was researching data for this column, I found only a few mobility-oriented programs available.

To be precise about this, programs that are specifically directed at improving or sustaining mobility are somewhat different from traditional rehabilitation programs. They can either stand alone or be incorporated into rehabilitation programs. The goal is not necessarily to teach the individual to "ambulate" per se, but rather to improve or sustain health.

For example, brain injury patients may need to learn to turn themselves to prevent development of decubiti. Or a patient with upper extremity contractures will require treatment to relieve the spasticity so that feeding can be accomplished independently. In any case, mobility programs require that the treatment team design therapies that address such functional activities in small increments.

These therapies may nevertheless be multifaceted. Mobility programs always involve in their development the patient, the primary caregiver(s) and therapists, in addition to others such as dietary and nurses' aides.

There is no question that the nurses' aide who spends time in direct care of a patient plays an integral role in facilitating mobility goals. But in a time of shrinking reimbursement, downsizing and reorganization, there are increased pressures placed on nursing. Specifically, as health care is forced to redesign its delivery systems to limit costs, nursing is faced with the challenge of adapting to a balancing of time and money. As responsibilities for nurses' aides increase, there is less time for them to complete specific tasks. In many instances, they may find it faster to just simply feed the patient than to take the time to teach the patient to self-feed. Thus does the pressure to decrease resources often act in opposition to treatment goals. The challenge is to find strategies that promote the treatment goals and simultaneously encourage efficiency. Mobility programs can provide one such solution.

The development of the Movement and Mobility Center at Ballard in Des Plaines, IL, is one such program. Eli Pick, CNHA, CAS, Executive Director, explains, "stroke, traumatic brain injury, dystonia, multiple sclerosis and cerebral palsy are some of the primary conditions that we see. The use of new medications to reduce spasticity and contractures is a major focus of our program. One treatment example is the drug Botox, which is administered by a specially trained physician and is used to reduce spasticity.

"Dementia patients also experience mobility problems," says Pick. "Their mobility needs are frequently overlooked in our society because of the chronic nature of their cognitive status. Dementia patients who undergo surgical procedures are often not given rehabilitation because it is determined to be inappropriate due to their cognitive status. A medical event that results in hospitalization can thus be the greatest threat to the dementia client's successful return to the community. The inability of the medical establishment to adequately address the functional needs of the dementia patient increases the probability of premature or unnecessary institutionalization. Focusing on a dementia patient's mobility needs starts with the process of evaluating the uniqueness of that patient and what it would take to meet that patient's specific functional needs."

Conceptualized in this way, mobility programs can only help in improving outcomes and thus getting "more bang for the buck." A sharpened focus on patients' mobility issues should be the goal of all post-acute programs.

Laura Hyatt is President of Hyatt & Associates, 2956 Kelton, Los Angeles, CA 90064.