Transitions to Independent Living & Opportunities for Community-based OT

Life Juggling Act
The man in the linked Washington Post article struggled to meet his many needs with few independent living skills.

I just read a Washington Post article titled “In transition to independent living, the ‘dignity of risk’ for the mentally ill,” which focused on the experiences of a man named Kelvin who has mental illness and cerebral palsy. He had just moved from an assisted living facility to a small apartment near Charlotte, NC, and he was working with a team of “clinicians and social workers” who were helping him organize his life and transition to living on his own.

It was a lengthy article, but as soon as I began reading it I instantly felt as if there was a place for occupational therapy in this man’s life. After reading the article, I was both sad for the difficult situation in which Kelvin found himself after leaving the assisted living home and frustrated that the services he was receiving might not actually have been making it easier for him to accomplish his goals and live independently. As a future OT, I saw several areas in which an occupational therapist could intervene to improve the services Kelvin was receiving.

One of the main problems that I noticed with Kelvin’s intervention in the article was the lack of communication between the client and his support team. In order to support client success, it’s crucial that the treatment team work in coordination to organize the services being provided and share information about the client. Unfortunately, it didn’t seem like Kelvin’s team was coordinating with him or among themselves to provide services most effectively. For example, the author writes: “As organized as Kelvin’s transition plan was to the people who created it, how it all felt to Kelvin was random, even down to who would show up when. Sometimes Corey stopped by…sometimes Valerie…there was L’Oreal and Ericka, Julie, Marilyn, and Chad…” Although all of these team members may have made contributions to Kelvin’s transition plan, the sheer number of people involved did not appear to be helpful to Kelvin, as he reported being confused about who was coming when, and why.

If I had been a member of the team, I would have suggested changing several things to limit Kelvin’s confusion and provide better service to him. First, I would have suggested that if the 8+ person team could not be downsized, then they should provide a written schedule of the dates and times when providers would see him, and stick to it. This would have helped Kelvin build a routine, which can be helpful for people with mental illness. Additionally, having a regular schedule in place could have helped circumvent a recurrent problem with his phone not having minutes, because the providers would only have to contact him in emergencies or if they were unable to come (which hopefully wouldn’t happen very often). Another solution to the “too many people” problem would be having the providers use a transdisciplinary treatment model in which one or two providers compiled the recommendations from the other providers and served as the liaisons between the pharmacist, nurse, dietician, social worker, etc. and Kelvin. This would cut down on the number of visitors he had to keep track of, while still allowing each person to provide their expertise on his case.

Even with these other issues, I think that the thing that bothered me the most about the article was how little Kelvin actually appears to be being equipped to do for himself. Although his situation was described as independent living, much of the article described how his support worker “Corey” completed a variety of tasks “with” Kelvin, but without Kelvin’s help.

For example, the author described how Kelvin was late paying his rent, was out of his medications, did not have groceries at home, and needed to go to the store to purchase more minutes for his phone. All of these tasks could be classified as “activities of daily living” (ADLs), and broken down into goals that an OT could help Kelvin accomplish. However, in the article Corey does not appear to be equipping Kelvin with such independent living skills as money management, budgeting, or meal planning during their outing to complete all of the aforementioned tasks. Rather, he simply “took over” all of these activities for Kelvin and makes broad suggestions about how Kelvin can improve his handling of daily tasks.

Regarding paying his multiple bills, Corey told Kelvin, “You got to think, man. You got to write things down. Remember you still got to pay rent, you got a late fee, you got groceries…” While this is all very true, as an OT I would have helped Kelvin begin managing his money and budgeting by having him list out his bills, and then helping him write them down on a whiteboard in his apartment or within an app so he could better keep track of them, to support Kelvin’s independence with the financial management ADL.

After the bill-paying conversation, Corey drove Kelvin around town to the pharmacy and social services office to help him out – which I can’t exactly fault, because at that time the bills were due and the medication had run out, and it wasn’t a particularly opportune moment to teach him about how to use public transportation. But after Corey dropped Kelvin off at home again, more of his problems with independent living skills were revealed.

Upon returning home, an apartment employee named Cornelius came to see Kelvin. During his brief visit, Kelvin asked Cornelius about the state of his fridge’s contents and how to cook some collard greens he had. As a future OT, I saw an opportune moment to teach Kelvin about multiple aspects of the occupations of eating and cooking, like judging whether or not food was safe to eat, and how to cook food he enjoyed. However, Cornelius simply told him that the onion in question needed to be tossed and that he would cook the greens for Kelvin. I was disappointed that this was the outcome of the exchange, and while again, not every moment can be a teaching moment, this was just another example of a way in which things were being done for him that he needed to learn how to do for himself – and that he could have been taught with help from an OT!

Ultimately, I think that this article provided an important understanding of the challenges that people who are transitioning to independent living face. In addition to learning how to manage their time effectively, they must learn how to navigate their communities, purchase and prepare food, adhere to medication schedules, and manage their finances. Many people are doing these things for the first time in years, or for the first times in their lives. I believe that occupational therapists can and should be part of community-based treatment teams that work with people who are transitioning to independent living situations, because they can help provide more holistic and client-centered care to their clients, improve collaboration between clients and their care teams, and support the goals and skill development of the people with whom they work.

NOTE: This article provided a brief snapshot of several days in the life of a man struggling to live with mental illness and live a life of independence. The commentary, critiques, and recommendations I make are based on my own ideas about how occupational therapy services could have been a part of a treatment plan. I’m sure that Kelvin’s providers are doing their best, and I commend them for working in areas of practice – mental health, community reintegration, and transitioning to independence – that are challenging for seasoned providers, much less fledgling OTs!

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