Case Study
Admitting Diagnosis: Polyneuropathy; Charcot Joints; History of Falls
Specialty Program: Neurology
Discharge Location: Home
A 69-year-old gentleman was admitted to Blueberry Hill Rehabilitation and Healthcare Center from Beverly Hospital for rehabilitation and skilled nursing with the goal to safely return home. Upon admission, Mr. F. was evaluated by and participated in skilled occupational and physical therapy where he was found to require maximum assistance for all self-care tasks, minimum assistance to transfer and contact guard assistance to ambulate 15 feet with the use of a rolling walker. He was found to have decreased balance and activity tolerance which increased his risk for falling and had a right lower extremity walking boot due to his Charcot foot making his challenge all the more compelling. He had a strong determination to return home and as he progressed with his therapy goals, he was able to participate in higher level functional activities. Upon discharge, Mr. F. was able to improve his ability to perform self-care tasks with between minimum and moderate assistance and was able to transfer and ambulate independently. We also started the process for him to obtain a new walking boot which he will receive when at home. He made some great gains toward his therapy goals and was able to return home with strong family support and Home Health Services. Great work, Mr. F.!
10.0 – Complete Independent – No assist, no equipment
9.0 – Modified Independent – No Assist, but equipment or extra time
8.0 – S/u – No physical assist other than set-up; supervision for safety/technique; and/or single cue to initiate
7.0 – Supervision-No physical assist; supervision for safety/technique; and/or single cue to initiate
6.0 – SBA-Pt. performs task with close supervision and or visual/verbal cues for task completion
5.0 – CGA – Contact Guard Assist
4.0 – Min – Occasional assist (25% or less time or effort to complete)
3.0 – Mod – Frequent assist (40-50% of the time or effort involved to complete task
2.0 – Max – Constant assist (75-90% of the time or effort involved to complete task
1.0 – CD – Complete Dependence: No contribution from pt; task done by others or not assessed
Case Study
Admitting Diagnosis: Covid-19
Specialty Program: Pulmonary
Discharge Location: Home
A 71-year-old woman was admitted to Blueberry Hill Rehabilitation and Healthcare Center from North Shore Medical Center for rehabilitation and skilled nursing with the goal to safely return home. Upon admission, she was evaluated by and participated in skilled physical and occupational therapy where she was noted to require contact guard assistance to transfer and ambulate 25 feet with a rolling walker, standby assistance to perform toileting tasks and contact guard assistance to perform bathing and lower body dressing tasks. She was also noted to have decreased balance and activity tolerance which increased her risk for falling. She had a strong determination to return home and as she progressed with her therapy goals, she was able to participate in higher level functional activities. Upon discharge, B.C. was able to independently transfer and ambulate 150 feet and was able to perform all self-care tasks independently. She made great gains toward her therapy goals and was able to return home with VNA services. Great work, B.C.!
10.0 – Complete Independent – No assist, no equipment
9.0 – Modified Independent – No Assist, but equipment or extra time
8.0 – S/u – No physical assist other than set-up; supervision for safety/technique; and/or single cue to initiate
7.0 – Supervision-No physical assist; supervision for safety/technique; and/or single cue to initiate
6.0 – SBA-Pt. performs task with close supervision and or visual/verbal cues for task completion
5.0 – CGA – Contact Guard Assist
4.0 – Min – Occasional assist (25% or less time or effort to complete)
3.0 – Mod – Frequent assist (40-50% of the time or effort involved to complete task
2.0 – Max – Constant assist (75-90% of the time or effort involved to complete task
1.0 – CD – Complete Dependence: No contribution from pt; task done by others or not assessed
