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PCHC Collaborates With Jefferson


Philadelphia Coordinated Health Care (PCHC), the Southeast Region Health Care Quality Unit (HCQU) is available to assist teams that are struggling to support someone with complex physical and behavioral health conditions. PCHC requires that a Team Agreement Form (TAF) be submitted to begin the process of requesting clinical supports.

A request (TAF) was received from a Supports Coordinator needing assistance finding resources for a family supporting their brother, Tony (not his real name) who was experiencing some

challenging behaviors associated with his diagnosis of dementia. Tony is a sweet, gentle and compassionate man who loves being around his family. At the time of this request, Tony’s team was reporting a progressive decline in his physical and behavioral health, worsening over the past six months. Tony’s family was overwhelmed and looking for solutions.

With the goal focused on improving the quality of life for Tony and his family, the team assessed the problem using an interprofessional approach. The family worked on clarifying Tony’s medication with his health care providers. The Supports Coordinator worked on obtaining additional staffing supports, while PCHC looked into resources within Tony’s community. A resource which provided a positive outcome for him and his team was Jefferson Elder Care.

Jefferson Elder Care is committed to improving the lives of elders and their caregivers by providing services and training grounded in research and real world experience. Occupational therapists specializing in elder care and trained in an innovative caregiver skill building program, Skills2Care®, evaluates the needs of the client and his/her caregiver. An individually tailored program is developed and implemented to address those specific needs.

The occupational therapist evaluated Tony and met with his family to determine their concerns.

Tony needed help with dressing, toileting and washing, which he often refused. He was anxious about moving through his home, going up and down the steps to the second floor apartment where he lived with his family, and going into the community. He seemed to have limited leisure interests and his family felt he was bored at times. A treatment plan was developed to address all of these areas.

During the service, the occupational therapist worked directly with Tony, his family and caregivers, who provided assistance while his sister was at work. Using the Skills2Care®, program, the occupational therapist collaborated with caregivers to develop Actions Plans with specific strategies to help Tony participate more in his daily activities with fewer behaviors. The caregivers better understood his capabilities and created a busy box with appropriate activities, which was used at home and in the community. In addition, caregivers learned to change the way they communicate and set up the environment for self-care.

The occupational therapist provided seven visits over a 70-day period. At the end of the service, Tony was dressing himself with less help, toileting and washing with less resistance, engaging in a variety of activities during the day, and going out into the community for short trips. Tony also began attending a local day program three days a week.

Through the interprofessional team effort of primary care physician, PCHC staff, the Supports Coordinator, the occupational therapist and (most importantly) family and staff caregivers, Tony has made incredible changes in his participation.

E. Adel Herge, OTD, OTR/L, FAOTA
Catherine Verrier Piersol, PhD, OTR/L, FAOTA

Originally published in the Fall 2016 Philadelphia Coordinated Health Care Southeast Region Health Care Quality Unit Health Care Alert