Geriatric Physical Therapy 3rd edition

442 CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation outcome measures such as the Timed Up & Go, Timed reported to outpatient physical therapy using a wheel- Walk Tests, Barthel Index, and Functional Independence chair and was already walking with his prosthesis and Measure, and the amputee-specific tests included review a rolling walker; he had received his initial prosthesis of tests such as the Amputee Mobility Predictor, Func- 1 week earlier and was able to ambulate in parallel bars tional Measure for Amputees, and Houghton Scale. The at the prosthetic facility. authors note that there was no single measure that emerged as being universally appropriate for measuring Mr. J’s past medical history revealed multiple signifi- lower limb prosthetic success. cant medical conditions as follows: hypertension, pe- ripheral artery disease, coronary artery disease, status SUMMARY post coronary artery bypass graft 3 4, and type II diabe- tes mellitus. Medications included: metoprolol (Toprol Many factors influence the successful prosthetic use for XL), valsartan (Diovan), and insulin (Novolin 70/30). the older person who has experienced a lower limb am- The patient denied symptoms of recent episodes of chest putation. Careful examination of the person’s psychoso- pain or signs of claudication in the right lower extremity cial, socioeconomic, and physiological status assists the at the time of this initial outpatient evaluation. His his- clinician and entire prosthetic clinical team in formulat- tory also included use of alcohol (one to two drinks per ing a prognosis and designing appropriate interventions day) and moderate tobacco smoking (one pack per day). that lead to successful prosthetic functional outcomes. The patient lived in a ranch-style home with a significant Physical therapists may more often encounter older other; he worked as a welder in a machine shop and adults in the home setting who require prosthetic pre- enjoyed fishing (dock and boat). The patient and family scription and application, given the present trends in goals for rehabilitation were for him to receive training health care service delivery. The complexity and high ill- with his prosthesis, learn to walk, get back to fishing, ness burden of the typical older adult with amputation is and if possible return to work. The discharge plan was apparent, and recent evidence suggests that there is a for the patient to achieve independent community ambu- potential benefit of providing more intensive inpatient lation with his prosthesis, with the potential to return rehabilitation. In every rehabilitation setting, advocacy to work. and consultation with other members of the prosthetic team are essential to assist older adults to achieve their Systems Review maximum functional potential using a prosthesis. Based upon this patient’s extensive history and interview, Improvements in surgical techniques for amputation a brief review of all body systems was indicated. Impair- and advancements in prosthetic design occur each year. ments were grossly noted in the musculoskeletal, neuro- The effect that these scientific advances have on the qual- muscular, cardiovascular, integumentary, and endocrine ity of life and functional mobility of the older adult who systems. The patient did not present with any cognitive uses a lower limb prosthesis is only beginning to be elu- impairment; however, he was somewhat tearful during cidated and requires greater investigation. Moreover, the interview as he was deeply concerned about his abil- outside of the traditional standard physical therapy care ity to return to work and was worried about disability. being provided today, such as general strengthening, bal- He was not overweight; however, his reported diet was ance tasks, and progressive prosthetic gait training, there not optimal for diabetic control or his cardiac condition. appears to be limited, if any, evidence-based physical He reported having difficulty controlling his blood pres- therapy studies examining treatment strategies that pro- sure and blood glucose levels since the amputation; how- mote optimal prosthetic function for the older adult with ever, he was being carefully monitored by his cardiologist amputation. and medical physician, with changes to his medications ongoing. CASE STUDY Examination History and Interview The physical therapy examination focused on addressing Mr. J was a 62-year-old man who sought outpatient all impairments and functional limitations related to physical therapy 3 months following a left transfemoral Mr. J’s goals to return to community ambulation and amputation, secondary to vascular insufficiency and work. Functional ability with and without the prosthe- gangrene. He had a failed femoral popliteal bypass graft sis, lower extremity and core trunk strength, gait and on the left (autograft was from the right lower limb), balance, and education about correctly managing the which resulted in poor restoration of blood flow and prosthesis were emphasized. necessitated amputation. Although not commonly used in older adults, the surgical technique for the above-knee • Cognitive status/emotional behavior/education: Intact amputation included myoplasty, muscle-to-muscle at- cognition. Although tearful at times, it appeared that tachment of his abductors/adductors. The patient his emotional status was consistent with significance

CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation 443 of illness; he felt that he was coping effectively at that pin suspension, a multiaxial safety knee, and dynamic time. Education regarding prosthetic use was indi- response foot. cated—patient required verbal cues for prosthetic management and limb care. • Prosthetic checkout: At the first outpatient physical • Pain: He reported 2/10 pain (“soreness”) in the re- therapy visit, a well-fitted prosthesis was noted with sidual limb, which occurred during attempts to in- no areas of excessive pressure, proper alignment, and crease walking distance or with decreased use of an patient report of comfort in sitting and standing; the assistive device; he had symptoms of tingling sensa- patient required verbal cues for management of pros- tion in his missing foot consistent with phantom thesis and correct donning and doffing techniques. sensation and did not report any symptoms of phan- tom pain. Evaluation, Diagnosis, and Prognosis • Range of motion: Remarkable for hip flexion con- tractures of 210 degrees left (residual side), 25 de- Mr. J came to outpatient physical therapy highly moti- grees right using the Thomas test. vated to begin physical therapy. Of primary concern to • Motor performance: Grossly 31/5 left lower extrem- him was his inability to ambulate safely with or without ity, 42/5 right lower extremity; bilateral upper ex- a device and difficulty performing instrumental activities tremities 5/5; trunk extensors/abdominals 42/5. of daily living, such as grocery shopping or doing house- • Integument integrity: The left residuum healed effec- work. His two children did not live within the state, and tively; the scar was pliable and not adhered, there although he discussed a significant other he did not seem was no evidence of any skin lesions. Observation of to indicate she helped him with everyday activities in his the skin of the right lower leg was noted to have a home. He was also unable to work, which created tre- shiny appearance, “patchy” hair growth, and evi- mendous financial hardship to him, as he was often un- dence of healed graft wounds. able to make copayments for therapy. He was given • Bed mobility/transfers (without and with prosthesis): guidance on ways to apply for “indigent care” through Independent. the outpatient hospital system and received indigent care • Cardiovascular response to ambulation (initial): services within 1 month into physical therapy treatment. • Resting vitals (sitting): heart rate 5 82 bpm; blood The patient’s tearfulness and expressed sadness were also of concern when he was asked how he was coping. pressure 5 154/92 mmHg The physical therapist discussed options to address these • Peak vitals postambulation with rolling walker issues by asking if he would like to seek counseling, re- ceive peer visits (amputee volunteer), or attend an ampu- 500 feet (not timed): heart rate 5 98 bpm; blood tee support group. Mr. J really liked the idea of having a pressure 5 188/98 mmHg; O2 saturation 5 97%; peer visit, so this activity was set up in consultation with he did not show any signs of shortness of breath his prosthetist. during activity. • Function/balance/gait: Mr. J was independent in bed Based upon examination findings and the Guide to mobility and transfers with and without the pros- Physical Therapist Practice,72 this patient’s primary thetic and in all aspects of wheelchair mobility and diagnosis fell under Pattern 4J: Impaired Motor Func- ADL abilities at home. The patient required contact tion, Muscle Performance, Range of Motion, Gait guard to maintain standing balance with the prosthe- Locomotion, and Balance Associated With Amputa- sis and without upper extremity support but had tion. Because of the severity of his cardiac condition, a difficulty reaching outside of his base of support— second pattern was used: Pattern 6D: Impaired Aerobic indicating fair dynamic standing balance. He ambu- Capacity/Endurance Associated with Cardiovascular lated with the prosthesis independently more than Pump Dysfunction or Failure. 200 feet with a rolling walker with minor gait devia- tions in the home and community; contact guard to Mr. J’s prognosis was considered good to excellent for minimum assistance was required to ascend/descend his goal for independent community ambulation, but it four steps with railing, and to safely ambulate on was not clear if he could return to work because of the ramps or curbs. high physical intensity of his job. There were some con- cerns regarding his cardiovascular signs at rest and with Prosthetic Clinic Assessment ambulation; therefore, referral to his cardiologist and consistent vital sign monitoring during all physical ther- Mr. J. was evaluated in the prosthetic clinic 10 weeks apy activities were warranted. His vital signs may be after amputation and was measured for his initial pros- indicative of more significant disease and could delay thesis. Even though the patient had multiple medical is- progress. Although he had a complex medical history, sues, he was progressing well at home with functional the examination findings illustrated that this patient had tasks and was very motivated to walk. At approximately the potential to achieve his goals and the functional de- 12 weeks, the patient received his prosthesis with a left mands of a transfemoral community ambulator.62 Mr. J’s flexible brim ischial containment socket, gel liner with ability to return to work, however, would depend upon

444 CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation modifications to his job, as standing long hours and recovery. The patient also had a history of smoking and heavy lifting are difficult tasks for a person with trans- did not have optimal eating habits, placing him at risk femoral amputation. for worsening of his arterial disease. Yet, the patient continued to make steady progress in all aspects of Plan of Care physical therapy as he was highly motivated and willing to work with the entire rehabilitation team to achieve his Mr. J’s postsurgical inpatient rehabilitation and home goals and the highest level of success. physical therapy program involved mat activities that emphasized lower extremity stretching and strengthen- After 3 and 6 months of physical therapy on average ing exercises. He also reported working on dynamic sit- of two times per week, the patient required prosthetic ting balance activities with a balloon or ball toss and socket changes and adjustments, secondary to residual performed cardiovascular training on an arm ergometer, limb shrinkage/shaping and advancements in all aspects with vital signs monitored as appropriate. The patient of function with the prosthesis. At 9 months, in consul- was instructed in skin monitoring and the use of a tation with the prosthetist, we recommended that he shrinker garment for edema management and shaping of receive a new prosthesis that included components re- the residual limb. All aspects of functional mobility were quired for a K3 level so that he could achieve his com- addressed, including performance of ADLs, wheelchair munity-level goals. To better determine his Medicare mobility, and hopping with a walker. functional “potential” level, the Amputee Mobility Pre- dictor86 was completed. Mr. J scored a 38/47, which was Once his prosthesis was received, Mr. J was referred indicative of the patient’s ability to meet the criteria of a for outpatient prosthetic phase physical therapy training. K3 level, so we began discussing use of the C-leg. In view Education regarding skin care, management of limb of the significance of his problems, some would argue shaping, gentle massage, tapping continued—he was now that he also had relative contraindications for an ad- also able to use the roll-on gel liner as a means of shaping vanced prosthetic fit, especially at the K3 level. However, throughout the day, which is what he preferred. Mr. J providing him with a permanent transfemoral prosthesis was able to learn to ambulate with a rolling walker inde- would allow for more intimate fit and control through pendently during the week from referral to his first suction suspension and for greater ease of ambulation physical therapy session; he had little fear of falling and with reduced fall risk by using the C-leg microprocessor was actually quite safe. Physical therapy began prosthetic knee.26,28 gait training in parallel bars with emphasis on weight ac- ceptance on the prosthesis, dynamic weight shifting and Although it was clear that Mr. J would achieve his limb advancement, and immediately progressed the assis- goal for prosthetic ambulation, he was unable to return tive device to a rolling walker. Progression of therapeutic to work because of the high demand of his welding job, exercise, core training, balance and gait training was which required standing for long hours and heavy lift- conducted using a treatment approach that is well ing. His cardiac condition also would not allow for this described by others and beyond the scope of this case type of work, and at the cardiologist’s recommendation report.21,106,109,112 Patient education for prosthetic man- he applied for disability. This patient also had issues re- agement was also addressed throughout treatments. lated to limited insurance coverage from his work (would not cover the K3 recommended components) Cardiovascular endurance training was also performed and difficulties in filing for disability after amputation, using single-limb bicycling and arm ergometry. Using the which resulted in a delay in prosthetic fitting with the Karvonen formula, the patient’s target heart rate for ex- C-leg. In addition, his “inability to work” greatly com- ercise was calculated at 113 bpm {[(220 2 62) 2 68] 3 promised his financial status and further delayed healing t0r.a5in1in6g8}e,ffwechtischcawnasbbeasaecdhioenvelditearat tu5r0e%sugV·g oes2timngaxth.1a08t recovery, emotionally and socially. Written letters of re- Within 2 months of attendance at outpatient physical quest to receive disability were submitted by the physical therapy two to three times per week for endurance train- therapist and cardiologist. After two attempts, his re- ing, the patient’s ambulation on a treadmill progressed to quest for disability benefits was finally approved 1 year 1.0, 1.2, and 1.4 mph with bilateral upper extremity sup- following his surgical amputation. While awaiting his port for 2- to 3-minute bouts, as tolerated. The physical disability status and benefits, many physical therapy vis- therapist remained in close contact with the medical team its were provided pro bono so that he could continue to ensure safe progression of exercise and activity, consid- with therapy and attain his optimal potential for func- ering his complex cardiac status and diabetes. tional recovery. Once he was granted Medicare disabil- ity, he received an ischial containment, flexible-brim Goals and Outcome Measures suction socket with a C-leg microprocessor knee and dynamic response foot as recommended. Mr. J had multiple medical problems with a significant history of diabetes and cardiovascular disease, which At the time of discharge from outpatient rehabilita- could have prevented his progress at any stage of his tion, approximately 18 months after the initial outpa- tient clinic visit, the patient achieved independent com- munity ambulation on all surfaces without an assistive

CHAPTER 23  Prosthetic Management for the Older Adult with Lower Limb Amputation 445 device; he felt safe and comfortable doing instrumental the outpatient physical therapist and the prosthetic activities of living, such as grocery shopping, and was clinic team included support and encouragement, also able to return to fishing on the dock and by boating which allowed him to achieve his goals as quickly as with friends (he did carry a cane when he went boating possible. “just in case”). REFERENCES Mr. J’s case continued to be followed by the prosthetic clinic, as needed, for monitoring fit, align- To enhance this text and add value for the reader, all ment, and wear. If prosthetic adjustments were made references are included on the companion Evolve site he was referred, by the prosthetist, for a physical that accompanies this text book. The reader can view the therapy assessment. Early rehabilitation and coordi- reference source and access it online whenever possible. nated efforts of the entire prosthetic clinic team played There are a total of 112 cited references and other gen- a significant role in promoting this patient’s maximum eral references for this chapter. functional potential. The coordinated efforts of

VP A R T Special Populations and the Continuum of Care 446

24C H A P T E R Wellness for the Aging Adult Marybeth Brown PT, PhD, FAPTA, Dale Avers, PT, DPT, PhD, Rita A. Wong, EdD, PT The World Health Organization defines health as “a diseases and medical conditions, and avoidance of iatro- state of complete physical, mental, and social well-being genic complications.2,4,6 Exercise and nutrition are dis- and not merely the absence of disease or infirmity.”1 cussed later in this chapter. Wellness is often described in terms of these three inter- connected domains of physical, psychological (mental), Sleeping well is important for physical health and and social well-being. Wellness is viewed by some as a emotional well-being, especially if there is a history of process,2,3 and by others as an outcome achieved through prior depression.7 A good night’s sleep is especially health promotion and disease prevention processes.4 important with age because it improves concentration Regardless of whether wellness is viewed as a process or and memory formation, allows the body to repair any an outcome, wellness programs give participants tools to cell damage that occurred during the day, and refreshes approach life and activities in ways that promote opti- the immune system, which helps to prevent disease.8 mal health and maximize personal potential. Conversely, a lack of sleep is linked with the risk of de- pression.9 Older adults’ sleep habits change with aging, Health promotion and disease prevention programs with having increased periods of wakefulness and less typically focus on enhancing wellness within one or REM sleep.10 Chronic diseases are associated with poor more of these three health domains.5 Wellness becomes sleep habits, complaints of poor sleep quality, and inter- a philosophy of life that utilizes health promotion and ruptions in sleep patterns.11 Specific sleep habits such as disease prevention strategies to achieve the goal of opti- engagement in physical exercise, one nap in the middle mal aging. Optimal aging implies maximizing one’s abil- of the day, avoidance of caffeine and snacks in the eve- ity to function across physical, psychological, and social ning, relaxation techniques, and a consistent sleep sched- domains to one’s satisfaction and despite one’s medical ule can promote healthful sleep. conditions. The three overarching domains of physical, psychological, and social health are often further divided Cigarette smoking is a major public health concern. into dimensions (Table 24-1). Hettler, the founder of Conservative estimates are that 30% of deaths from lung the Wellness Institute, is frequently quoted for his cancer, and 80% of deaths from chronic obstructive pul- view of wellness as a process with six interconnected monary disease are linked to cigarette smoking.12 Smok- wellness dimensions: physical, emotional, spiritual, social, ing is also a factor in cardiovascular disease. It is never occupational/vocational, and intellectual (Figure 24-1).3 too late to quit smoking, with benefits occurring in as Although these dimensions are frequently described in the little as 1 year in those with cardiovascular disease.13 wellness literature, there is little scientific evidence to con- firm or reject these dimensions as the primary underlying Few studies have been conducted regarding the value of factors making up the broad construct “wellness.” De- participating in preventive medicine services after the age spite the lack of a clear understanding of the various of 75 years. However, common sense might dictate that components of the construct of wellness, wellness is gen- getting regular checkups to identify problems before they erally accepted as a multidimensional entity, with inclu- impact wellness, maintaining a healthy weight, engaging in sion of factors associated with physical, psychological, physical activity, and getting enough physical exercise pro- and social health making intuitive sense. motes physical wellness. These habits may make it less likely for hospitalization and medications that often have PHYSICAL HEALTH DOMAIN associated iatrogenic complications.6 The physical dimension of wellness is primarily influenced Physical therapists can promote the goal of optimal by such factors as exercise, nutrition, sleep, avoidance aging through the accommodation of the primary, second- of disease-causing agents, early detection and treatment of ary, or tertiary prevention needs for those whose health conditions span the range of minor physical impairments and sedentary lifestyle to major disability. Similarly, physical therapists possess the requisite knowledge of the Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc. 447

448 CHAPTER 24  Wellness for the Aging Adult TA B L E 2 4 - 1 Wellness Domains life. Maintaining a healthy body weight promotes opti- mal aging. Effect size for the relationship between opti- Health Wellness mal aging and having a normal body weight ranges from Domain Dimension Description 1.58 to 3.05.16 Weight loss in obese individuals is associ- ated with improved functional status and amelioration Physical Physical Physical functioning to the degree of frailty in older adults.17 Dietary interventions may Mental Emotional that allows one to perform roles decrease the risk or progression of macular degenera- Spiritual in family and society tion, stroke, heart attacks, and lipid abnormalities, Social osteoarthritis and osteoporosis, and a number of can- Intellectual Sense of well-being and the ability cers.18-20 There is growing evidence that older adults can to cope effectively with life’s benefit from regular use of a daily multivitamin contain- Social “ups and downs” ing age-appropriate recommended amounts of folic acid Occupational/ and vitamins B6, B12, D, and E, as older adults are often Aspect of life that provides deficient through dietary intake.21-23 Subopitmal vitamin Vocational meaning and direction that D levels have been associated with poor balance, weak- connects to something greater ness, and increased risk of hip fracture.24-26 Table 24-2 than one’s self provides a summary of the key nutritional consider- ations outlined in the USDA-approved modified nutri- Ability to learn and use information tional guidelines for older adults, advocated by many effectively; to reason and use gerontologists.6 Physical therapists should be ready to self-efficacy in wellness advise older adults on basic nutrition principles to man- endeavors age weight or accommodate high levels of physical activ- ity.27 The physical therapist will also work with nutrition Meaningful relationships and specialists who can provide individualized assessment of presence of a social support nutritional needs and recommendations for nutritional structure modifications in managing special diets (e.g., control of diabetes or morbid obesity). Purpose in life, a reason to get up in the morning Exercise Physical Intellectua Exercise is the single most important health-promoting activity for older adults.28 Current recommendations for Social physical activity to achieve health benefits are a mini- l mum of 150 minutes per week of moderate to intense aerobic activity and strengthening of the major muscle Spiritual groups 2 or more days per week (Table 24-3). However, Personal Wellness the Centers for Disease Control and Prevention reports Vocational Emotional FIGURE 24-1  S​ ix dimensions of wellness.  (Courtesy of Lifetime TABLE 24-2 Recommendations from the Modified USDA Food Pyramid for Wellness, Ltd., Longview, Tex.) Older Adults consequences of poor health behaviors and strategies to 1 . Whole, enriched, and fortified grains and cereals such as brown promote more positive behaviors through patient educa- tion.14 Wellness is a way of life that often requires behav- rice and 100% whole wheat bread ioral and lifestyle changes to accomplish, changes only 2. Bright-colored vegetables such as carrots and broccoli accomplished when individuals are educated in behaviors 3 . Deep-colored fruit such as berries and melon and conditions that limit or enhance wellness.5 4 . Low- and nonfat dairy products such as yogurt and low-lactose Nutrition milk 5 . Dry beans and nuts, fish, poultry, lean meat, and eggs Poor nutrition and excessive weight loss in older adults,15 6. Liquid vegetable oils and soft spreads low in saturated and as well as excessive weight gain (obesity),16 are associ- ated with excess mortality, frailty, and lower quality of trans fat 7 . Fluid intake (water is best) 8 . Physical activity such as walking, housework and yard work (Adapted from Lichtenstein AH, Rasmussen H, Yu WW, et al: Modified MyPyramid for older adults. J Nutr 138(1):5-11, 2008.)

CHAPTER 24  Wellness for the Aging Adult 449 TA B L E 2 4 - 3 2008 Physical Activity Guidelines for Older Adults 2 h and 30 min (150 min) of moderate–intense aerobic activity (i.e., brisk walking) every week AND muscle strengthening exercise on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms) OR 1 h and 15 min (75 min) of vigorous–intense aerobic activity (i.e., jogging or running) every week AND muscle strengthening exercise on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms) OR An equivalent mix of moderate- and vigorous-intensity aerobic activity AND muscle strengthening exercise on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms) For generally fit older adults the guidelines listed in Table 24-3 apply. Otherwise, obtaining a health clearance from the individual’s physical therapist or physician is advisable to set appropriate physical activity goals. (Data from Centers for Disease Control, Division of Nutrition, Physical Activity and Obesity, National Center for Chronic Disease Prevention and Health Promotion. Physical activity for everyone: guidelines: older adults. http:// www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html. Accessed April 4, 2010.) that only 34% of individuals between ages 65 and because of increased time to reflect about their role in the 74 years, and 17% of individuals aged 75 years and universe and the meaning of life.32 older, exercise regularly.29 This is consistent with Fiatarone Singh’s findings that only 30% of older adults Ryff and Keyes33 in a confirmatory factor analysis of a are physically active.30 Physical therapists are uniquely large group of adults across a wide age range compiled qualified to guide older adults to improve physical well- six distinct dimensions associated with psychological ness through individualized fitness and physical activity wellness that integrate elements from several theorists programs. Physical therapists, as movement specialists, such as Erikson, Maslow, and Rogers. Taken together, can provide information, guidance, and help that is par- these six dimensions encompass a breadth of wellness ticularly relevant to older adults striving to optimize that includes positive evaluations of one’s self and one’s their aging—by maintaining and enhancing function and life, a sense of continued growth and development as a adapting physical activity and exercise programs to ac- person, the belief that life is purposeful and meaningful, commodate pain or other disability that challenges the possession of good relationships with other people, movement ability. Communicating and marketing the the capacity to manage one’s life and the surrounding value of physical therapist–designed and –led wellness world effectively, and a sense of self-determination. A programs are key to promoting the functional abilities healthy psychological outlook can reduce the intensity and wellness of aging adults. and duration of illnesses, creating the so-called mind– body interaction. Although the absence of mental distress PSYCHOLOGICAL WELLNESS or illness does not equate to psychological well-being, attention to these six domains can promote a sense of Psychological wellness includes the emotional, cogni- well-being and hope that encompasses psychological tive, and spiritual dimensions of wellness. Emotional health.34 wellness emphasizes control of stress and effective cop- ing with life situations. High stress levels with poor SOCIAL WELLNESS coping can lead to negative physiological (e.g., cardio- vascular, musculoskeletal), emotional (e.g., depression, Social wellness includes the social and occupational anxiety, anger), and behavioral (e.g., inability to work, dimensions of wellness. In general, social well-being inefficiency) responses. Cognitive wellness emphasizes involves the ability to develop and maintain healthy the skills, self-efficacy (a person’s confidence in his or relationships with others, to feel connected to a commu- her ability to accomplish a task or achieve a goal), and nity or group, to interact well with other people, and to interest in engaging intellectually in the world. Strate- have a support structure to call on during difficult times. gies to promote cognitive health are contained in Social supports significantly influence the ability to cope Chapter 8 on cognition. with life’s stressors. Social networks also help to protect older people against harm and promote emotional and Spiritual health includes the values, morals, and ethics physical well-being. For older adults, social connected- that guide an individual’s search for a state of harmony ness is often a priority need and helps people find a bal- and inner balance. Spirituality is about a person’s exis- ance between quality of life and compromised health. tence and relationships with self, others, and the universe. People considered socially well are usually involved with Spirituality does not necessarily connote religiosity.31 The others, rather than isolated, and they report satisfactory spirituality dimension may increase with age, perhaps levels of perceived social support.

450 CHAPTER 24  Wellness for the Aging Adult wellness, familiarity with the other domains of wellness will enhance the physical therapist’s ability to promote Five major factors make up the construct of social optimal aging. wellness.35 These five factors are: PHYSICAL ACTIVITY AND 1. Social integration (“I feel close to other people in my EXERCISE–FOCUSED WELLNESS community”) PROGRAMS 2. Social contribution (“My daily activities are worth- In the past decade, there has been an explosion in the while to my community”) literature to support the efficacy of purposeful activity for the older adult, whether community, clinic, or home 3 . Social coherence (“I can make sense of what’s going based. The essence of this work demonstrates that fun- on in the world”) damental and meaningful change in strength, balance, flexibility, function, and community participation is pos- 4. Social actualization (“Society is improving for people sible with exercise regardless of age.30,39,40 Therefore, the like me”) inclusion of activity promotion, purposeful physical engagement, and/or exercise should be a goal of any 5. Social acceptance (“People care about the social wellness program for individuals between the ages of 50 issues that are important to me”) and 1001 years. In a large-scale set of two studies that included adult PHYSICAL THERAPISTS’ SCOPE subjects between 18 and 74 years of age, Keyes found OF PRACTICE that social well-being increased with age (although more slowly with increasing age) in all categories ex- Providing health promotion and wellness services in the cept for social coherence, which decreased with in- area of physical fitness and patient education in healthy creasing age. lifestyle principles is identified in both the Guide to Physi- cal Therapist Professional Practice and in the Normative Social supports and caregiving can be both formal Model of Physical Therapist Professional Education41,42 as and informal. Formal caregiving involves paid services, practice expectations of physical therapists. However, usually from agencies and organizations that address wellness is not generally viewed as a health care service basic needs of individuals such as personal care, meals, within the traditional medical model oriented around ill- and transportation. Informal (unpaid) caregiving, typi- ness. Most insurance companies do not reimburse health cally provided by family, friends, and significant others, care providers for delivery of wellness interventions. As often is the main source of emotional and psychosocial such, there are few regulations on who can deliver wellness support for the older adult. A healthy social network services. Thus, many wellness practitioners are not li- provides a safety net for older adults. Older adults who censed within any health profession. In seeking wellness lack adequate social supports are more vulnerable to services, older adults should carefully scrutinize the back- safety risks such as older person abuse and substance ground of the provider to determine their comfort level misuse and are at risk for depression, impaired decision with the practitioners educational background. making, isolation, loneliness, poor health, and de- creased life expectancy.36 However, when licensed health professionals such as physical therapists deliver wellness services they must Occupational/vocational wellness is closely linked to function within the scope of practice allowed by their social wellness. A basic tenet of occupational/vocational state licensing laws. Each state has its own laws regard- wellness is a balance between work, home, and leisure ing the practice of physical therapists. Some states allow activities, with the opportunity to engage in meaningful full and direct access to patients; other states require a activity.37 Occupational wellness refers to one’s attitude physician referral for any access to a patient. Most states about one’s work and to having an occupational or vo- allow physical therapists to evaluate and screen individ- cational interest in life. An occupationally well person is uals without physician referral but then have varying one who is involved in paid and nonpaid activities that provisions regulating the implementation of an interven- are personally rewarding and make a contribution to the tion. For several states, the language of the state physical well-being of the community at large. As older individu- therapy practice act makes a clear statement allowing als leave paid work, purposeful employment (occupa- physical therapists to provide wellness and fitness pro- tion) can be replaced with purposeful and meaningful grams without physician referral when the purpose is for activity such as volunteer activities (vocation). Vocational prevention of illness or improved functional ability (in wellness occurs through matching core values with inter- the absence of an acute illness or injury). However, other ests, hobbies, employment, and volunteer work. Retire- state practice acts do not provide this option. Thus, ment can bring opportunities for vocational wellness. physical therapists must be familiar with the licensing Employment or vocational endeavors can provide a sense of purpose, enrichment enhanced mental health indices, and overall wellness in older adults.38 The dimensions of wellness described earlier demon- strate the capacity of aging adults to live optimally throughout their days. Wellness is a concept to strive for regardless of health conditions. Although physical therapists deal primarily with the domain of physical

CHAPTER 24  Wellness for the Aging Adult 451 regulations in their state and organize wellness services a total joint replacement or arthritis. Asking a few to comply with these regulations. questions about their pain can often determine if a physical activity modification is needed, thus promot- The ability to legally evaluate and provide wellness ing confidence that exercise may improve the clients’ services to older adults is a separate consideration from symptoms. the ability to be reimbursed by health care insurers. Fre- quently, patients’ rehabilitative needs far exceed their In response to the limitations of the Par-Q, the Ex- Medicare benefits. For example, older individuals with ercise Assessment and Screening for You (EASY) tool fractured hips or stroke frequently show the greatest was developed.47 This six-question online screening trajectory of improvement between 2 and 6 months; tool48 (Table 24-4) identifies potential health problems after that time, most patients have completed their reim- that require health care provider clearance before ex- bursable rehabilitation.43,44 Other clients with chronic ercising, provides education about each problem and conditions may be ineligible for traditional physical the value of exercise, and helps older adults choose therapy because they require “maintenance,” an area appropriate exercises that may not first require a phy- Medicare benefits do not currently cover. General decon- sician’s approval. The EASY tool emphasizes the ben- ditioning (e.g., following treatment for cancer or even efits of exercise and physical activity for all individuals severe flu), neurologic disease such as Parkinson’s while educating the older adult about how to exercise disease and dizziness are examples of chronic conditions within the individuals’ limitations. The EASY tool pro- that fall into the cracks of our health care system. These vides instant recommendations regarding the safety of patient groups are given as examples of older adult cli- exercise or the need for the client to see a physician ents who may benefit substantively from follow-up care before exercising. or wellness for which the expertise of a physical thera- pist could be particularly useful. Regardless of which screening tool is used, addi- tional questions about the presence of osteoporosis and Screening for Physical Activity falls history are helpful in an older clientele. Certain and Wellness Programs movements such as excessive thoracic flexion, common in the presence of osteoporosis, have been linked to Screening is an essential part of a physical activity/ thoracic fractures,49 and fractures result more easily exercise-focused wellness program to determine the with falls.50 In addition, fear of falling may be more appropriateness of individuals to participate and may acute in individuals who know they have a heightened help to stratify individuals to the appropriate program risk of fracture.51 The physical therapist can provide or level within a program. Screening is a precursor to valuable information and exercise cueing to avoid po- baseline and outcomes assessment, which will be dis- tential problems if awareness of osteoporosis is present. cussed in the next section. Table 24-5 describes screening questions for osteoporo- sis. Although no tool exists as a criterion standard Although validated screening tools for adults older of fall risk,52 the American Geriatrics Society recom- than age 70 years do not exist, several tools are widely mends asking about a history of falls in the previous used in the general population. The Physical Activity 12 months and conducting the Timed Up and Go Readiness Questionnaire (Par-Q) is a popular screen- (TUG) test when screening for fall risk.53 Others would ing form to identify contraindications to exercise. suggest a positive history of falls is sufficient to deter- However, the Par-Q has several limitations, such as mine fall risk.53 unnecessary elimination of individuals.45 The Par-Q is accompanied by a MED PAR-X form that can be used TABLE 24-4 Exercise and Screening to communicate with the client’s medical team. The for You (EASY) Par-Q consists of seven questions that address possible contraindications to exercise and is freely available.46 1 . Do you have pains, tightness, or pressure in your chest during A positive answer on any of these seven items indi- cates a need to further investigate the individual’s physical activity (walking, climbing stairs, household chores, readiness for more intense physical activity. For ex- ample, the Par-Q question “Is your doctor currently similar activities)? prescribing drugs (for example, water pills) for your 2. Do you currently experience dizziness or lightheadedness? blood pressure or heart condition?” can help identify 3 . Have you ever been told you have high blood pressure? medications such as b-blockers that can blunt the 4. Do you have pain, stiffness, or swelling that limits or prevents physiological exercise response. The Par-Q question of “Do you have a bone or joint problem (for exam- you from doing what you want or need to do? ple, back, knee or hip) that could be made worse by a 5 . Do you fall, feel unsteady, or use assistive device while change in your physical activity?” is often answered yes because clients have experienced increased pain standing or walking? and/or discomfort with physical activity as a result of 6 . Is there a health reason not mentioned why you would be concerned about starting an exercise program? (Adapted from Exercise and Screening for You. http://www.easyforyou.info/ index.asp. Accessed July 3, 2010.)

452 CHAPTER 24  Wellness for the Aging Adult Outcome measures for program evaluation can be used to provide individual feedback on progress, to TA B L E 2 4 - 5 Screening for Osteoporosis evaluate and determine whether the class has met its purpose, and to provide data on the program’s effective- The physical therapist can ask for: ness. Individual client feedback focused on the clients’ The results of previous dual-energy x-ray (DEXA), heel scan wellness goals can be provided at the end of the pro- gram. Consideration should be made for the time it takes indicating (T-Score of 22.5 or more) to realize a change in the desired outcome. For example, Family history of osteoporosis (mother, sisters, grandmother) 12 months or more may be needed to achieve weight loss Low body mass index goals, to increase physical activity to recommended History of vertebral or wrist fractures135 wellness levels, or realize quality-of-life changes.62-64 Observe presence of kyphosis135 However, specific strength and endurance gains may Loss of height of .4 cm135 occur in as little as 12 to 15 weeks.65-67 Recognizing that several months may be required to achieve functionally Baseline and Outcomes Assessment important physical changes, it is important to provide feedback that highlights the short-term successes the Baseline measures for physical activity/exercise-focused patient is achieving along the longer-term path to more wellness programs can help establish program goals and functionally visible outcomes, for example, sticking with identify specific areas to target, such as flexibility, a commitment for regular attendance and participation strength, and aerobic fitness. Baseline measures can also in physical activity, lower perceived exertion with the be used to stratify clients to an appropriate exertional same workload, and additional repetitions of exercises and skill level. Ideally, baseline information should be or distance walked without a rest. Early success in gathered that determines health issues, prior exercise his- physical activity endeavors positively reinforces commit- tory, functional deficits, impairments such as poor car- ment to pursuit of long-term physical activity goals. In- diovascular endurance, strength deficits, and balance dividual results can be provided in terms of age-based issues. In addition, clients’ adherence and self-efficacy norms for additional value to the client. can improve when regular feedback is given about their progress.54-56 Program evaluation can also be determined by factors such as class attendance, clients’ adherence, and satisfac- Many objective and responsive tools are available to tion with the various components of the program, such measure different aspects of physical ability, and many as self-perception of health and lifestyle changes. Sum- of these tools have age-based normative data. The spe- mary scores of performance-based outcome tools can cific measurements or assessments used depend on the provide an indication of general strength gains, weight amount of time available, the condition of the client, and loss, and balance improvement in the group. Program the focus of the program. For example, if a walking evaluation outcomes should relate to the purpose and program is the focus of the wellness activity, then the focus of the program. assessment may be heart rate response to walking in a 6-minute walk test, gait speed, 1-mile walk, or a 24-hour Types of Physical Activity and Exercise pedometer reading. If the intended outcome is improved Programs balance, then baseline measures of balance capacity should be used. Several tests that range from well- There are literally hundreds of opportunities for physi- validated and reliable tests with normative data to timed cal therapists to promote wellness for the older adult tests such as stair climb,57 time to put on a jacket,58,59 client. Fortunately, there are resources available, some and floor rise60 are listed in Table 24-6. in book or monograph form, many on the Internet, and numerous video-based protocols that may be used to Knowledge of the clients’ physical activity history can assist in the design of an activity program. Several types provide valuable baseline information if a goal is to of programs are presented here. Utilizing preexisting improve physical activity. Knowledge of clients’ physical resources is encouraged when a specialty wellness activ- activity history can help determine a starting point for ity program is chosen. Physical activity/exercise–focused the physical activity/exercise class. A detailed history of wellness programs can be developed in any venue such prior training is likely important if preparing older as health clubs, outpatient offices, older adult resi- adults for an intense exercise activity such as a competi- dences, senior centers, health-related clinics, nursing tive senior Olympic sport. If working with a group of homes, rehab hospital gyms, religious facilities, or indi- frail seniors in an assisted living facility, the only ques- vidually. Wellness programs can also take the form of tion that may be needed is, “Have you ever been consultant-type services. active?” Then follow up with an inquiry about fre- Balance and Fall Prevention Programs.  ​Many older quency and intensity of the activity. Several valid, self- adults are justifiably afraid of falling as their balance is report physical activity tools exist.61 Several of the more beginning to fail and reaction times are slower than they reliable and valid measures of routine activity are listed in Table 24-7.

CHAPTER 24  Wellness for the Aging Adult 453 TA B L E 2 4 - 6 Baseline Measures for Physical Activity/Exercise–Focused Wellness Programs Measure Description Normative Values Short Physical Performance Quick, easy to perform test consisting of Individuals scoring 9 or less reflects mobility disability.136 Battery (SPPB) timed 53 chair stands, usual gait speed, and balance tests. 1.2 m/s is approximate time it takes to cross the street. Gait speed137 Norms for community-based older adults138: Scored on an ordinal scale with a total Single limb stance test.35 This possible score of 12. 60-69 y: males 1.59 m/s (usual); 2.05 m/s (fast) test is self-explanatory 60-69 y: females 1.44 m/s (usual); 1.87 m/s (fast) although a few rules do apply Test is free and instructions are available at 70-79 y: males 1.39 m/s (usual); 1.83 m/s (fast) such as not being able to put www.grc.nia.nih.gov/branches/ledb/sppb/ 70-79 y: females 1.33 m/s (usual); 1.71 m/s (fast) the free limb against the download_sppb.doc 80-89 y: males 1.21 m/s (usual), 1.65 m/s (fast) stance limb or wiggling in 80-89 y: females 1.15 m/s (usual); 1.59 m/s (fast) place. It is up to the therapist Can use any distance of 4 m or more. Usual 10 s eyes open is the recommended minimal standard for (dictated by safety) whether (customary) and fast gait speeds can be adults older than age 60 y139 or not to assist the client into recorded. Age-based means140: the test position and then let 60-69 y: mean 26.9 s (eyes open); 2.8 s (eyes closed) go when they are ready or Ability to stand on one leg is associated with 70-79 y: mean 15.0 s (eyes open); 2.0 s (eyes closed) have them do the entire balance and normal gait and is known 80-99 y: mean 6.2 s (eyes open); 1.3 s (eyes closed) activity unassisted. Make to decrease with age.139 Time of stance note of the choice. should be measured with arms folded TUG times can be considered worse than average if they across chest and one leg lifted from exceed141: Tandem and semitandem stance floor, not touching the other leg. 60-69 y: 9.0 s Timed Up and Go test 70-79 y: 10.2 s Can be used in addition to single leg stance 80-99 y: 12.7 s Activities-Specific Balance and is included in the SPPB. Confidence Scale, or ABC142 None available Demonstrates ability to get up from a chair, Chair stand test walk, and turn and sit down again. 8 or fewer repetitions indicate risk for mobility disability.143 Norms for 30-s chair rise143: Distance walk test May be too low level for higher-functioning older adults. 60-69 y: women 11-17; men 12-19 70-79 y: women 10-15; men 11-17 Measures balance confidence during common 80-89 y: women 8-14; men 8-15 community-based tasks and is known to $90 y: women 4-11; men 7-12 be responsive to improved balance.142 Taking more than 5 min 30 s to complete 400-m test is indicative of risk of developing functional limitations.144 Is a self-report, paper-based test. Mean time of 5 min 11 s was recorded in healthy older 30-s chair stand test or timed 5-repetition adults.145 6-min walk test norms138: chair stand test have been used as proxies 60-69 y: men 572 m; women 538 m for leg strength and power. Arms cannot 70-79 y: men 527 m; women 471 m be used. 80-89 y: men 417 m; women 392 m Time taken to walk 400 m (approximately ¼ mile) or distance walked in 6 min can be used as proxies for endurance tests. The rate of perceived exertion can be used as a measure of effort.88 Continuted

454 CHAPTER 24  Wellness for the Aging Adult TA B L E 2 4 - 6 Baseline Measures for Physical Activity/Exercise–Focused Wellness Programs—cont’d Measure Description Normative Values Flexibility: Back Scratch (Apley’s) tests shoulder Norms for Back Scratch test146: Back Scratch mobility while the Modified Sit and Reach 60-69 y: women 23.5 to 11.5 in.; men 27.5 to 0.0 in. tests hamstring and lumbar mobility. 70-79 y: women 25.0 to 11.0 in.; men 29.0 to 1.0 in. Modified Sit and Reach 80-89 y: women 27.0 to 21.0 in.; men 29.5 to 23.0 in. $901 y: women 28.0 to 21.0 in.; men 210.5 to 24.0 in. Modified Sit and Reach norms146,147: 60-69 y: women 20.5 to 15 in.; men 23 to 14 in. 70-79 y: women 21.5 to 14 in.; men 24 to 12.5 in. 80-89 y: women 22.5 to 13.0 in.; men 25.5 to 11.5 in. $901 y: women 24.5 to 11.0 in.; men 26.5 to 20.5 in. TA B L E 2 4 - 7 Measurements of Physical Activity Physical Activity Scale Description Comments Physical Activity Scale for PASE comprises self-reported occupational, household, and Correlates with 6-min walk and other physical the Elderly (PASE)148 leisure activities during a 1-wk period providing performance measures.61 May not be prompts with examples of specific activities. responsive to change following physical Pedometer activity/exercise interventions.149 Can be administered by phone, mail, or personal interview. Focus on activities commonly performed by older Requires a license and purchase150 adults by giving more weight to these activities instead of sports. In people walking slower than 0.8 m/s, may not be accurate or register steps.151 Simple, inexpensive tool to record steps and/or minutes of activity. Generally, 10,000 steps per day is considered Individuals who used a pedometer were more to afford a health benefit.133 likely to achieve the recommended amount of activity as compared with those without a Accelerometer Computerized measures of step count and movement that pedometer.132 may be more applicable for research.152 Can be attached at the ankle. Requires a computer to interpret number of steps. were in younger years. Balance programs are quite excellent Web-based resource.77 The Falls Free Missouri valued, particularly if they capitalize on popular pro- Web site provides information such as risk factors and grams such as Tai Chi. Tai Chi is known to be effective statistics on falling but more importantly, includes action in improving balance and reducing fall risk, and its steps that may be taken to reduce falls. Falls prevention movements and principles can be incorporated into any programs are relatively easy to provide with minimal balance activity.68-70 Tai Chi was also shown to reduce allocation of financial and human resources. In addition, symptoms of knee osteoarthritis71 and reduce blood this approach is an excellent way to enhance public pressure.72 awareness and foster community loyalty to the facility. Strength Training.  T​ he efficacy of strength training for Tai Chi is not the only approach to enhancing balance older adults has been demonstrated by numerous inves- in older adults. Literature has demonstrated that balance tigators. From the seminal article by Fiatarone et al.78 in will improve if multimodal programs are used.73,74 The 1990 to more contemporary issues of power versus veloc- programs should include challenge to static and dynamic ity versus traditional weights, a multitude of evidence balance provided two to three times a week for at least overwhelmingly supports the inclusion of strength train- 8 weeks, environmental assessment and remediation, ing for all older adults, including those who are frail, visual assessment and remediation (if needed), vestibular have multiple comorbidities, and have never done any assessment, and promotion of strength, particularly of type of resistance activity.75,79-87 Indeed, resistance train- the muscles controlling the ankle.73,75,76 ing is endorsed, even encouraged by the American Asso- ciation for Retired Persons (AARP) and the American Missouri has the dubious distinction as the state with College of Sports Medicine.88,89 the highest falls-related death rate in the country. It also ranks in the top three states for recorded falls in the Strength training can be done in a myriad of ways, older adult population. Consequently, the state govern- including traditional free weights, isotonic-type ma- ment has grown alarmed and a coalition of practitioners chines, elastic bands, functional activities (e.g., weighted was formed to create Falls Free Missouri, which is an

CHAPTER 24  Wellness for the Aging Adult 455 chair stands, stair climbing), incorporating high- for abdominals and back extensors, possible use of a velocity training and emphasizing power-based training weighted vest (if there is no kyphosis), strengthening into class-type activity or individual exercises. Because exercises for the scapular retractors and upward rota- resistance training is so strongly recommended tors, and lower-extremity loading.111,112 A summary of for older adults, it should be incorporated into most activity- and exercise-based strategies to improve the activity programs.28,40,90 Strength training in dose- quantity and quality of bone include the following: specific recommendations known to increase strength should be followed as described in Chapter 5 on 1 . Exercises must include weight-bearing activity; exercise.40,91 weight-bearing that is over and above what is done in Exercise for Frail Older Adults.  ​Eighty-plus-year-old a typical day.113-115 individuals are the fastest growing group in the United States and are at greatest risk for loss of independence.92 2. Resistance exercise will increase bone mineral density A large proportion of this population is highly decondi- if exercise adherence is maintained for 6 months or tioned, with poor muscular and cardiovascular endur- longer.115,116 ance as well as muscle weakness, associated with seden- tary lifestyle and periodic bouts of bed rest from illnesses 3. Weighted vests do work, but evidence suggests a and hospitalizations. More than 50% of individuals minimum of a 2-year commitment to wearing the older than age 80 years are physically inactive; at least vest.113 For gains to be maintained, vest use must be 60% have difficulty with functional activities such continued.114 as stooping, crouching, kneeling, lifting or carrying 10 pounds, and standing from an armless chair; and 30% 4. Back extensor and core strengthening to reduce the have difficulty with very basic activities of daily living risk for vertebral fractures.112,117 such as dressing and bathing.93 Individuals who have low physical activity levels, need help with daily activities, Aerobic Training.  ​The vast majority of older adults fatigue easily, are weak, have slow motor performance have cardiovascular deconditioning, most of which is and balance abnormalities are likely to be classified as the consequence of sedentary lifestyle.118,119 The pres- frail.94 Many frail older women test poorly on measures ence of cardiovascular disease does not preclude aero- of function and balance.95 bic training; to the contrary, the presence of disease makes aerobic training even more important.120-122 Wellness classes are greatly needed for frail and near- There is no evidence indicating a worsening of cardio- frail older adults. However, this is the most challenging vascular disease with exercise123,124; in fact, exercise group to tackle given preexisting medical conditions, actually improves the disease state (e.g., congestive the lack of endurance, low physical activity levels, and heart failure, post–myocardial infarction) and raises generalized weakness.96 Nonetheless, developing and the level of conditioning.125 The only time exercise is implementing programs for the frail is interesting, grat- contraindicated for heart disease is if a client is in the ifying, and wonderfully challenging. Exercise focused midst of an acute crisis.88 One thing that should be on remediating frailty and improving function in frail borne in mind is that because so many older adults are older adults can be task specific, as research has shown so very deconditioned, nearly all exercise constitutes an that task-specific exercise is equivalent to resistance aerobic challenge. It is not necessary to consider aero- training.97-103 Task-specific exercise has the advantage of bic exercise within the narrow framework of running, being relevant to the frail older adult, which may pro- cycling, Nordic track, elliptical trainer, or stair stepper. mote participation. Musical chairs, dance, Tai Chi, brisk walking, and re- sistive strengthening functional activities are often of General conditioning exercises are extremely effective sufficient intensity to achieve an aerobic training effect. for prefrail older adults and can be done in groups.72,104-107 Enhancing Physical Activity and Mobility.  ​Mobility These classes should focus on strengthening activities, challenged older adults are everywhere but most visibly particularly the lower extremities, dynamic balance (in within assisted care facilities. These men and women are standing position), and functional activities such as get- often one fall or illness away from admission to the ting up and down from the floor, stair climbing, and nursing home. Many of the so-called mobility programs walking distances of 0.25 to 1 mile. An advantage of for sedentary older adults and frail individuals are group classes is the socialization they provide that may chair-based, which is counterintuitive to mobility. Well- promote exercise adherence.108,109 ness activities for this population should heavily empha- Exercise to Enhance Bone Quality/Quantity.  O​ ne of size functional activities, including handling pots and every two women older than age 50 years is on a trajec- pans, carrying items, sweeping and vacuuming, putting tory to develop osteoporosis if she does not have it clothes away, and stooping to pick up items from the already.110 Consequently, wellness programs that em- floor. Gait activities are also important and should in- phasize bone loading are important and highly perti- clude changing direction suddenly, walking slowly and nent. Key components to all of the approaches to very quickly in response to a command, walking the enhance bone health are core strengthening exercises equivalent width of a street in time to cross with the light, and stepping up and down from a curb. Obstacle courses and circuit training kinds of activities can be

456 CHAPTER 24  Wellness for the Aging Adult CONCLUSION fun, meaningful, and effective for individuals struggling Given the burgeoning older adult population, an increas- to stay independent.126-129 ing life span, and the fact that nearly 50% of all those Walking Programs.  W​ alking programs are very easy to older than age 80 years have already lost their indepen- set up, require little supervision, and can provide numer- dence, it has become critical to stave off frailty and extend ous benefits such as socialization, sense of well-being, productive and capable years for older adults. Because self-efficacy, and health benefits such as decreased pain increased physical activity and exercise is most important (in the presence of knee osteoarthritis)130 and improved for health and physical and cognitive well-being, every glycemic control.131 Pedometers are effective in tracking physical therapist should be involved in promoting physi- steps and can promote physical activity more so than cal activity and exercise programs. Physical therapists encouragement alone to be more physically active.132 have the skills required to prevent the spiraling decline in Pedometers with the sponsor’s name on them can also be independence among the aging and aged population. The an effective marketing strategy. Recommendations of efficacy of physical activity and exercise programs has 10,000 steps/day (5 miles) are associated with health been demonstrated. Elements of endurance as in walking, benefits.133,134 strengthening, and balance should be incorporated. All that is required is willingness to begin and an appropriate One of the most successful walking programs in this assessment of resources. country came out of Waukesha, Wisconsin, over a de- cade ago. The basic idea was to start a program with a REFERENCES nucleus of interested people and “grow” that program over the first and second summers by having each mem- To enhance this text and add value for the reader, all ber recruit another walker. There are walking trails references are included on the companion Evolve site throughout Waukesha that are clearly labeled to provide that accompanies this text book. The reader can view the distances, information about where to go from that par- reference source and access it online whenever possible. ticular way-point, and suggestions for an exercise that There are a total of 152 cited references and other gen- can be done at each station. Participants have t-shirts eral references for this chapter. and there is a strong sense of belonging. Hundreds of older adults have joined the walking club over the years with their “train the trainer” concept.

25C H A P T E R Home Health Physical Therapy Christine E. Fordyce, PT, DPT, Claire Gold, MSPT, MBA, COS-C, CPHQ INTRODUCTION has a condition, as a result of an illness or injury, that restricts the individual’s ability to leave the home except Providing care in the home is a unique way to deliver with the assistance of another individual or with the aid geriatric rehabilitation to older adults who are home- of a supportive device (such as crutches, a cane, a wheel- bound. On any given day, the home care clinician may chair, or a walker), or if the individual has a condition such be the only health care professional to see the patient. that leaving home is medically contraindicated.1 Although Although home care offers a great deal of autonomy, the an individual does not have to be bedridden to be consid- home care clinician must be able to coordinate the pa- ered confined to home, the condition of the individual tient’s care with other members of the team, work in should be such that there exists a normal inability to leave collaboration with other health care providers, and home, and leaving home requires a considerable and taxing teach available caregivers. Home care has several advan- effort.1 However, “considerable and taxing effort” is not tages. The clinician spends one-on-one time with the defined and therefore is left to the interpretation of the patient in average durations of 45 to 60 minutes, with a therapist, agency, and intermediary. Thus, as part of the relatively low full-time caseload of about 5 to 6 patients initial home health visit and on all subsequent visits, a day. Most home health agencies and patients allow the the clinician must identify the functional criteria that therapist to set the time of the visit, often accommodat- support the patient’s homebound status. Examples of ing the therapist schedule. The therapist can work with homebound conditions are described in the Medicare the family and/or caregiver within the patient’s actual Home Health Benefit Policy Manual listed in Box 25-1.1 setting to provide care that is relevant to the patient’s Therapy services can also be provided to patients in their environment and needs. Home care also presents unique homes under the Medicare Outpatient Part B benefit. For challenges for the physical therapist. Although the home this benefit, patients do not need to be considered home- care setting has inherent autonomy, it also presents situ- bound but the travel time to the patient’s home is not ational isolation from other health professionals, docu- reimbursable. mentation requirements, variability, and unanticipated circumstances and requires efficient time management. “Fixing to Stay” Clinicians caring for older adults in their homes need to Typically, older adults want to remain in their homes as be prepared to make the best practice decisions. Whether long as possible, even to die at home. This preference is or not the home is one of cramped living conditions, over- fundamental to understanding the needs of the older adult flowing with saved items, or a well-maintained residence home health patient. It cannot be overemphasized: older with lots of space, the therapist is literally a guest in some- adults are “fixing to stay,” a term used by the American one’s home and must be able to project a sincere attitude of Association of Retired Persons (AARP) in a national tele- caring while conveying a respect for the desire of the older phone survey of 45-year-and-older Americans about their adult to remain at home. This chapter will discuss these housing preferences, difficulty getting around the house, unique features as well as federally mandated characteris- and concerns about being able to remain in their homes.2 tics of the home care provision benefit under Medicare The researchers concluded that an overwhelming number Part A and the sequence and scope of an episode of care. of their 2000 respondents intended to remain in their cur- rent residence for as long as possible and 63% of survey DEFINITION OF HOMEBOUND participants believe that their current residence is where they will always live. Furthermore, only 9% expressed a To receive coverage under the Medicare benefit, patients preference for moving to a facility where care is provided, must be “homebound” or “confined to the home.”1 An and only 4% of the respondents expressed a preference individual is considered confined to home if the individual Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc. 457

458 CHAPTER 25  Home Health Physical Therapy BO X 2 5 - 1 Medicare Homebound Requirement In order for a patient to be eligible to receive covered home health services under both Part A and Part B, the law requires that a physician certify in all cases that the patient is confined to his/her home. An individual does not have to be bedridden to be considered confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort. If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of an infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration. It is expected that in most instances, absences from the home that occur will be for the purpose of receiving health care treatment. However, occasional absences from the home for nonmedical purposes, e.g., an occasional trip to the barber, a walk around the block or a drive, attendance at a family reunion, funeral, graduation, or other infrequent or unique event would not necessitate a finding that the patient is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home. Generally speaking, a patient will be considered to be homebound if they have a condition due to an illness or injury that restricts their ability to leave their place of residence except with the aid of: supportive devices, such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person; or if leaving home is medically contraindicated. Some examples of homebound patients that illustrate the factors used to determine whether a homebound condition exists would be: • A patient paralyzed from a stroke who is confined to a wheelchair or requires the aid of crutches in order to walk; • A patient who is blind or senile and requires the assistance of another person in leaving their place of residence; • A patient who has lost the use of their upper extremities and, therefore, is unable to open doors, use handrails on stairways, etc., and re- quires the assistance of another individual to leave their place of residence; • A patient in the late stages of ALS or neurodegenerative disabilities. In determining whether the patient has the general inability to leave the home and leaves the home only infrequently or for periods of short duration, it is necessary (as is the case in determining whether skilled nursing services are intermittent) to look at the patient’s condition over a period of time rather than for short periods within the home health stay. For example, a patient may leave the home (under the conditions described above, e.g., with severe and taxing effort, with the assistance of others) more frequently during a short period when, for example, the presence of visiting relatives provides a unique opportunity for such absences, than is normally the case. So long as the patient’s overall condition and experience is such that he or she meets these qualifications, he or she should be considered confined to the home. • A patient who has just returned from a hospital stay involving surgery who may be suffering from resultant weakness and pain and, there- fore, their actions may be restricted by their physician to certain specified and limited activities such as getting out of bed only for a specified period of time, walking stairs only once a day, etc.; • A patient with arteriosclerotic heart disease of such severity that they must avoid all stress and physical activity; and • A patient with a psychiatric illness that is manifested in part by a refusal to leave home or is of such a nature that it would not be consid- ered safe for the patient to leave home unattended, even if they have no physical limitations. The aged person who does not often travel from home because of feebleness and insecurity brought on by advanced age would not be considered confined to the home for purposes of receiving home health services unless they meet one of the above conditions. (From Medicare benefit policy manual, Chapter 7, Home health services. http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf Updated 2005. Accessed April 29, 2010.) for moving to a relative’s home if unable to care for self.2 assisting a relative with at least one activity of daily living. Therapists treating older adults in their homes need to be As such, home care therapists play a key role in teaching cognizant and accepting of this preference as it provides caregivers a variety of safety techniques, including proper an ultimate therapeutic goal. patient positioning for transfers and fall prevention.3 The patient’s home environment provides a rich context for the ROLE OF THE PHYSICAL THERAPIST therapist to gain insight into the patient’s functional abili- IN HOME HEALTH ties, in particular, the performance of essential ADLs such as bathing, dressing, walking inside the house, and trans- The fundamental roles of the older adult–oriented home ferring from a chair. Frequently, hospitalization or inactiv- care physical therapist are to promote independence in es- ity leads to the development of or restriction of essential sential activities of daily living (ADLs), promote reintegra- ADLs.4 Furthermore, individuals who lose their ability to tion of the patient into the community, and to minimize perform valued functional and social activities are more the risk for either recurrent acute care hospitalizations likely to become dissatisfied with their quality of life and and/or nursing home admission. According to a 2009 are likely to experience depression, increasing the likeli- study of 1480 participants conducted by the National hood of being homebound.5 The effect of decreased physi- Alliance for Caregiving, 60% of family caregivers report cal activity and functioning promotes further decline on

CHAPTER 25  Home Health Physical Therapy 459 the slippery slope of aging6 and increases the risk for started in 2007 is to unite the home health stakeholders physical frailty, recurrent disability, multiple hospitaliza- and providers across multiple health care settings in a tions, and eventual nursing home admission.4 The home shared vision of reducing avoidable hospitalizations and care physical therapist has a critical role to play in this improving medication management. The evidence of na- transitional setting between a higher level of function and tional and individual home health agency’s success is institutionalization. demonstrated with publicly reported comparative mea- sures (Box 25-2). Rehospitalization Rosati et al11 identified several risk factors for medical The process by which patients move from hospitals to adverse events among home health care recipients listed other care settings is increasingly problematic as hospi- in Box 25-3 and found that home health agencies that tals shorten lengths of stay and care becomes more frag- focused on these risk factors were more likely to improve mented. Within 30 days of discharge, there was a 17.6% rate of hospital readmissions in 2008,7 with home health BOX 25-2 Publically Reported Comparative patients the most vulnerable.8 A study on Medicare Fee Measures for Home Health Agencies for Service home health beneficiaries in 2004 revealed that almost one of every five discharges (19.6%) are re- The quality measures available include: admitted within 30 days and 34% of discharges were 1. Three measures related to improvement in getting around: readmitted within 90 days. The study also estimated Medicare’s cost for these unplanned readmissions was a. Percentage of patients who get better at walking or moving $17.4 billion.9 The most frequent reasons for unplanned around readmissions were acute myocardial infarction, heart failure, pneumonia, sepsis, dehydration, postoperative b. Percentage of patients who get better at getting in and out infection, and gastrointestinal bleeding.9 Unplanned re- of bed hospitalizations are almost always urgent or medical emergencies and often signal failure of the transition c. Percentage of patients who have less pain when moving around from the hospital to another source of care. 2. Four measures related to meeting the patient’s activities of daily In 2007 and 2008, more than 5500 home health agen- living: cies joined the first Home Health Quality Improvement a. Percentage of patients whose bladder control improves National Campaign10 funded by the Centers for b. Percentage of patients who get better at bathing Medicare and Medicaid Services (CMS), an agency of the c. Percentage of patients who get better at taking their medi- U.S. Department of Health and Human Services. As a follow-up to this initial project, the CMS funded a second cines correctly (by mouth) campaign that was launched in January 2010. The con- d . Percentage of patients who are short of breath less often tractors for the 2010 campaign, West Virginia Medical 3 . Two measures about how home health care ends: Institute and Quality Insights, the Medicare quality im- a. Percentage of patients who stay at home after an episode of provement organization (QIO) for West Virginia, pro- vided campaign participants with best-practice tools or home health care ends “intervention packages” designed to avoid potentially b. Percentage of patients whose wounds improved or healed preventable hospitalizations. CMS looks to QIOs, non- profit organizations under contract with CMS, to imple- after an operation ment projects that affect process improvements to 4. Three measures related to patient medical emergencies: address issues in medication management, postdischarge follow-up, and plans of care for patients who move a. Percentage of patients who had to be admitted to the hospital across health care settings. As such, QIOs conducted in- b. Percentage of patients who need urgent, unplanned medical care terviews in 2007 with providers in community forums to c. Percentage of patients who need unplanned medical care re- identify gaps across the transition from hospital to home.10 The three main drivers of unplanned rehospital- lated to a wound that is new, is worse, or has become infected izations that emerged were that (1) the patient and family was not engaged in the health care process, (2) there were (From Medicare—the official U.S. Government site for people with Medi- gaps in processes within a provider or provider group care. Home health compare. http://www.medicare.gov/HHCompare/Home. (e.g., not having a focused plan of care for CHF patients, asp?dest=NAV|Home|DataDetails#TabTop. Accessed April 29, 2010.) or not having a uniform discharge transfer tool), and (3) there was not an existing process to communicate BOX 25-3 Risk Factors for Medical Adverse information between providers at discharge including the Events next care provider and the primary care physician (PCP). The overriding goal of this two-phased campaign that • Pattern of one or more hospitalizations or emergency room visits in the past 12 months • History of falls • Chronic conditions such as congestive heart failure, skin ulcers, or congestive obstructive pulmonary disease • Social and cognitive factors such as inadequate support net- work, low literacy level, dementia, needing help with managing medications, and low socioeconomic status (Modified from Rosati RJ, Huang L, Navaie-Waliser M, Feldman PH: Risk factors for repeated hospitalizations among home healthcare recipients. J Healthc Qual 25(2):4-10; 2003.)

460 CHAPTER 25  Home Health Physical Therapy of the opposite gender, verbal and nonverbal expressions of pain, and patient-specific goal setting allows clinicians the effectiveness and efficiency of their efforts to prevent to adapt care in a manner that is congruent with their rehospitalization of their patients.11 Home health physi- patients’ cultural expectations.14 cal therapists who address a patient’s fall risk and de- cline in physical functioning can play a key role in the Lastly, providing care in the home involves having prevention of unplanned hospital readmissions. A con- to adapt to a variety of structural barriers, sensitivity tinued focus on reducing the factors contributing to re- to the homeowner who may not be the patient, as hospitalization to promote cost containment will con- well as lifestyle preferences of the patient and/or caregiv- tinue in the foreseeable future, with physical therapists ers. Patients typically have daily routines, routines continuing to play a significant role. that when disrupted can be sources of stress and conflict. Home health therapists have to take these concerns into Variability of the Home Environment account when scheduling treatment times. In addition, homes can range widely from being very tidy to In addition to the medical management of the patient, being cluttered, presenting fall risk hazards. All of these providing physical therapy care in the patient’s home variables can make it challenging to prescribe an effec- presents unique personal challenges. The clinician has to tive exercise program, and a substantial degree of be sensitive to and respectful of any boundaries the pa- creativity is needed to make the best of a particular tient sets with respect to their home environment and situation. aspects of care provided. The home health clinician may encounter a wide variety of socioeconomic, ethnic, and REIMBURSEMENT cultural situations. Sensitivity to patient beliefs and AND DOCUMENTATION background is needed to help gain trust and establish rapport with the home health patient. Clinicians in the The Medicare Payment Advisory Commission (MedPAC) home setting are likely to encounter a variety of cultural classifies Home Health as a postacute setting,15 and pay- dynamics. Depending upon the patient’s culture, self- ment is administered under the Medicare Part A pro- care may not be an important personal goal and there- gram. MedPAC advises the Center for Medicare and fore it may be inappropriate to insist that an older adult Medicaid Services (CMS) on setting payment rates for all patient provide self-care, especially when family mem- Medicare providers. Similar to other settings, Medicare bers are available and willing to provide care.12 sets payment rates based on the patient’s medical com- plexity and expected resource use. In 2006, Medicare In some cultures, older adults are considered to be spent $12.9 billion on home health services for 2.8 mil- “entitled” to rest and to be cared for by loved ones. In lion beneficiaries, representing a growth of about 44% fact, the majority of cultures do not consider self-care to since 2002. The number of home health agencies (HHAs) be an important goal of aging, including Asian, His- also increased, from 6553 in 2002 to 8463 in 2006, with panic, and almost all other cultures other than Anglo- more than half of the increase occurring in just two American. These cultures value family interdependence states—Florida and Texas.16 Medicare home health over independence and therefore may feel it is inappro- spending is expected to grow by an average of 6.2% priate for an older adult to insist upon self-care when annually between 2007 and 2016.15 family members are available to provide care. Moreover, younger caregivers may be quite willing to attend to Medicare pays HHAs a predetermined base payment older loved ones as a natural and normal family dy- under what is called the prospective payment system namic. However, although there is great diversity in (PPS).17 The base payment is adjusted for the health con- American culture, American culture typically promotes dition and care needs of the Medicare beneficiary. The continued self-reliance and the maintenance of indepen- payment is also adjusted for the geographic differences dence with age for the most part. Independence in tradi- in wages for HHAs across the country. The adjustment tional American culture is not only the expectation but a for the health condition, or clinical characteristics, and source of self-esteem, whereas dependence can be a service needs of the beneficiary is referred to as the case- source of significant emotional and psychological dis- mix adjustment. The home health PPS will provide tress. See Box 25-4 for a cultural assessment checklist.13 HHAs with payments for each 60-day episode of care for each beneficiary. If a beneficiary is still eligible for Some clients/patients may prefer to have family mem- care after the end of the first episode, a second episode bers present during physical therapy sessions and, de- can begin; there are no limits to the number of episodes pending upon the degree of family involvement, there a beneficiary who remains eligible for the home health may be the need for additional teaching and explana- benefit can receive. Although payment for each episode tions. By contrast, the physical therapist may be able to is adjusted to reflect the beneficiary’s health condition work more effectively with the patient when there are no and needs, a special outlier provision exists to ensure family “observers” as the patient may be reluctant to appropriate payment for those beneficiaries that have demonstrate functional independence in front of family the most expensive care needs. Adjusting payment to caregivers. Sensitivity to cultural differences, such as acceptability of being touched, in particular by someone

CHAPTER 25  Home Health Physical Therapy 461 B O X 2 5 - 4 Cultural Assessment Checklist Health/Illness Issues • Are there health problems that carry a stigma in the culture? • Are there culture-bound illnesses (i.e., illnesses that are only identified within the culture)? • Are there tests/procedures/treatments that violate cultural norms? • In past experiences with the health care system, what has the patient found helpful? Offensive? Confusing? Life Span Rituals/Practices • What beliefs, values, and practices surround life events (birth, childcare, aging, death)? Ask as appropriate to patient’s situation. • When the patient has a terminal disease, should one “tell the truth” or “maintain hope”? Biophysical/Risk Factor Variation • Are there genetic variations or endemic diseases frequently encountered within the patient’s group? • Do members of the culture commonly engage in practices that are harmful? Pain Assessment • Does the patient tend to be stoic or expressive when in pain? • What does pain mean to the patient? • Is pain generally described in quantitative or qualitative terms? • Is the numerical scale confusing? • What is the patient’s attitude about taking pain medications? • Ask the patient: What is the worst pain you have ever had? How did you cope with it? How did you treat it? How well did the treatment work? Nutrition Assessment • What is eaten and when is it eaten? Perform a 2-day diet recall. • Are there dietary patterns that may be in conflict with the plan of care (e.g., fasting)? • Is there potential for food–drug interactions with traditional foods? • What foods are thought to promote health? What foods are considered good for sick people? • Does the patient ascribe to the cold–hot theory of disease and treatment? • Are there religious food prescriptions and restrictions? Medication Assessment • What is the patient’s attitude toward Western medications? Are they valued or distrusted? • Could there be genetic variations in the way the patient responds to medications? • Are there traditional remedies, such as herbs, teas, or ointments that the patient uses? Daily (Health) Practices and Routines • Are there special rituals/practices associated with bathing, toileting, hair/nail care? • Are there gender/age/social class restrictions on who can help a person with ADLs? • How important is modesty? How is modesty shown? • Are there special morning/evening rituals or practices that are important to the patient? Psychosocial Assessment • Who is considered “family”? What impact does the illness have on the family? • Who is the head of the family? Who makes decisions for the patient? • With whom should we discuss your care? Is there someone who helps you make decisions? • How will family members be involved in the patient’s care? • Who helps when you are sick? How do they help you? How would you like them to help you? • What health/support services are available through the patient’s cultural community? Degree of Acculturation • How strictly does the patient/family adhere to the belief/values/practices of their culture of origin? • Is the patient/family traditional (maintains ways of culture of origin)? Acculturated (understands and is able to move in/out of old/new culture)? Assimilated (has internalized the new culture’s norms)? Religion/Spiritual Needs • Are there spiritual practices that providers and caregivers can help the patient to keep (e.g., special prayer times)? • Are there religious articles that the patient likes to use, wear, or keep close? • Are their special rites/blessings for the sick? Spiritual leaders/healers the patient finds helpful? • Are there dietary prescriptions or restrictions that should be kept? Language and Communication • What language is the patient most comfortable speaking? • The patient has a right to a medical interpreter. Would the patient like one? • Is the patient able to read in English or in preferred language? Continued

462 CHAPTER 25  Home Health Physical Therapy BO X 2 5 - 4 Cultural Assessment Checklist—cont’d Patient’s Explanation of Health Problem • What do you call the problem you are having? (Use the patient’s term instead of “the problem” when asking the rest of the questions. • When and how did your problem begin? Why do you think the problem started when it did? • What do you think caused this problem? Why do you think you developed this problem and not someone else? What might others in your family/community think is wrong with you? • Do you know someone who has had this problem? What happened to that person? Do you think this will happen to you? • What are the chief problems this condition has caused you? • What problems has it brought into your life? What do you think will happen? • What do you fear most about the problem? How serious is this problem? Do you think it is curable? • How have you treated the problem so far? What have you done to feel better? Have you tried remedies like herbs or remedies from your homeland? • How do you/your family/your community members think the problem should be treated? Who in your family/community/religious group can help you? Are you consulting other healers? Nonverbal Communication Patterns • Is eye contact considered polite or rude? • Is personal space wider/narrower than American norms? • When, where, and by whom can the patient be touched? • What is the meaning behind certain facial expressions and hand/body gestures? • Is special meaning attached to loud or whispered conversations? Etiquette and Social Customs • How would you like to be greeted and addressed by our staff? • What behaviors are expected of guests? Taking shoes off? • Accepting food/drink? • Is punctuality important? • Is it polite to engage in “small talk” before getting “down to business”? • Should discussions be direct and forthright or subtle and indirect? • What topics are not acceptable? Is it appropriate to share emotions and feelings? Discuss reproduction, sexual, or elimination issues? Discuss the possibility of negative outcomes? At Times Like This, Many People Draw on their Religious/Spiritual Beliefs to Help Them. • Is there anything the nurses can do to help you find the spiritual strength you need at this time? • Are there spiritual practices that we can facilitate for you? • Is there a religious leader/healer whom you might find helpful? Your Nurses and Therapists Want to Be Polite and Respectful to You and your Family. • How would you like to be addressed by our staff? • Are there certain cultural courtesies we should practice when we come to visit you? • Are there things we might do that you would find offensive? • Could you please let us know if anything we do seems rude or offensive so we can fix it? Everyone Has Cultural Beliefs and Customs that They Find Help Them to Heal. • Are there special beliefs or customs you would like to keep related to this health problem? • Are there special herbs/foods/treatments that you have found helpful? • Are there healers from your community who might also be able to help you? • How does your family think this illness should be treated? • What do you think about that treatment? • What are the characteristics of a good doctor? Of a good nurse? (Modified from Narayan MC: Cultural assessment and care planning. Home Healthc Nurse 21:611-618, 2003.) reflect the HHA’s cost in caring for each beneficiary, in- and service utilization (i.e., amount of medically neces- cluding the sickest, should ensure that all beneficiaries sary therapy visits). The computation of the episode have access to home health services for which they are rate is derived from responses to specific data elements eligible. extracted from a unique home health assessment instru- ment called the Outcome and Assessment Information Payment for each home health 60-day certification Set (OASIS).18 The OASIS allows for the computation period, or episode rate, is based on a complex formula and reporting of measures that are calculated from of factors. Factors include the impact of specific diag- standardized data elements. In addition to quality mea- noses within certain groups called case-mix weight surement, a subset of OASIS items is used to calculate diagnoses, the patient’s clinical needs, functional status,

CHAPTER 25  Home Health Physical Therapy 463 payment algorithms under the prospective payment initial OASIS data as part of the patient’s comprehensive system.18 assessment at the start of care. Skilled nursing and speech–language pathology are the other two qualifying The OASIS instrument, in use since July 1999, is used disciplines authorized to collect OASIS data at the start by the HHA nurse or therapist to assess the patient’s of care. However, the Medicare Conditions of Participa- condition. The OASIS instrument has been revised sev- tion for Home Health19 require a registered nurse to eral times with the latest version, implemented January make the initial visit and collect the OASIS data if skilled 1, 2010, called the OASIC-C. Physical therapy is one of nursing is ordered at the time of referral20 (Box 25-5). the three qualifying disciplines authorized to collect the B O X 2 5 - 5 Conditions of Participation: Home Health Agencies, Subpart C—Furnishing of Services PART 484—Conditions of Participation: Home Health Agencies Subpart C—Furnishing of Services Sec. 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment that accurately reflects the patient’s current health status and includes information that may be used to demonstrate the patient’s progress toward achievement of desired outcomes. The comprehensive assessment must identify the patient’s continuing need for home care and meet the patient’s medical, nursing, rehabilitative, social, and discharge planning needs. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. The comprehensive assessment must also incorporate the use of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. (a) Standard: Initial Assessment Visit. (1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician-ordered start of care date. (2) When rehabilitation therapy service (speech–language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. (b) Standard: Completion of the Comprehensive Assessment. (1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. (2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. (3) When physical therapy, speech–language pathology, or occupational therapy is the only service ordered by the physician, a physical therapist, speech–language pathologist or occupational therapist may complete the comprehensive assessment, and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. The occupational therapist may complete the comprehensive assessment if the need for occupational therapy establishes program eligibility. (c) Standard: Drug Regimen Review. The comprehensive assessment must include a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. (d) Standard: Update of the Comprehensive Assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than— (1) Every second calendar month beginning with the start of care date; (2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests; (3) At discharge. (e) Standard: Incorporation of OASIS Data Items. The OASIS data items determined by the Secretary must be incorporated into the HHA’s own assessment and must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. (From U.S. Department of Health and Human Services. Part 484: Conditions of participation: Home health agencies, Subpart C—Furnishing of services. http:// frwebgate.access.gpo.gov/cgi-bin/get-cfr.cgi?TITLE=42&PART=484&SECTION=55&YEAR=1999&TYPE=TEXT. Accessed April 6, 2010.)

464 CHAPTER 25  Home Health Physical Therapy completing medication profiles, the initial home health visit with an OASIS assessment can take as much as This initial visit serves to assess if the patient meets 2 hours. Most importantly, the primary focus for a home health coverage criteria, the patient’s condition physical therapist conducting a home health admission is and likely needs for skilled nursing care, therapy, to ensure that the patient is safe at home and to refer to medical social services, and home health aide ser- other disciplines/services when appropriate. An explana- vices. OASIS items describing the patient’s condition, tion of the services covered by Medicare for Home as well as the expected therapy needs (physical, Health is presented in Box 25-6. speech–language pathology, or occupational) are used to determine a case-mix factor that reflects the rela- OASIS rules and conventions are described in de- tive costliness of patients in a particular case-mix tail in the OASIS Implementation Manual and are category. This payment adjustment is the case-mix periodically updated with information available at adjustment. There are 153 case-mix groups, or Home the CMS website.1 Competence in assessment of all Health Resource Groups (HHRG), available for pa- areas of the OASIS may require additional education tient classification. in differential diagnosis, pharmacology, skin assess- ment, depression screening, and home safety assess- The 60-day-episode payment for a home health pa- ment. Given the uniqueness of the home health ad- tient is calculated from the day the OASIS is com- mission, the therapist new to the home care setting pleted. OASIS regulations require that the expected can benefit greatly from a guided practical orienta- number of therapy visits needed be projected at the tion with a peer mentor. The mentor can role-model beginning of each episode by the clinician conducting how to efficiently conduct the sequence of interview the home health OASIS assessment. This projection is questions that correspond with OASIS data items. adjusted up or down from the initial projection based Some OASIS assessment “quick tips” are described in on the needs of the patient that emerge during the Table 25-1.22 60-day episode. As a disincentive for home health agencies to provide more care than is appropriate, in- Specific observations of the patient’s functional abil- cremental increases in therapy result in a declining ities such as transfers, dressing, and walking are also rather than constant amount of payment per addi- necessary for accurate responses to OASIS items and tional therapy visit.21 serve as the basis for planning the teaching that a therapist would provide the patient. The length of time At the end of each 60-day episode, the actual number a patient or family or caregiver may require education of therapy visits provided to a patient is reconciled interventions should be determined by assessing each against the projected number of therapy visits planned. patient’s individual condition and other pertinent fac- Depending upon the difference (more than projected tors such as the skill required to teach the activity and visits were provided vs. less than projected provided), the unique abilities of the patient. It is important to the home health agency may be subject to an adjustment know that teaching activities must be related to the in their final Medicare episode payment.21 patient’s functional loss, illness, or injury. When a pa- tient or caregiver is incapable of learning, more visits to Home Health Documentation provide patient/caregiver education are subject to Requirements Medicare payment denials. Medicare’s home health benefit is not intended to provide training and educa- The Medicare Conditions of Participation for Home tion to patients, families, or caregivers for an infinite Health mandate an initial comprehensive, individual, period of time. and specific assessment of each patient. Whether the therapist is documenting on paper-based forms or elec- THE INITIAL VISIT tronically, the initial home health visit can average 90 minutes to complete the initial comprehensive assess- This section will describe the features of best practices ment. In addition to the OASIS instrument, therapists for the first visit for a home care patient under Medi- may also have to document the patient’s medication pro- care Part A. The authors suggest contacting the patient file that includes all of the prescription and over-the- prior to the initial visit to arrange a time that is conve- counter medication, including herbs and supplements. nient and to request the patient have a Medicare card When a home health case is “therapy only,” the physical and all medications (including over-the-counter) avail- therapist may find that a great deal of time is spent on able and ready for review. Also, the patient may prefer the initial home health visit resolving medication dis- to have a family member or friend present. Calling crepancies between the hospital discharge medication ahead is useful because Medicare does not require a list and the patient’s actual medications in the home. patient to be home 24/7 to be considered homebound. Follow-up with the primary care physicians and special- Asking the patient or family member to have the Medi- ists to resolve discrepancies or to obtain a referral for a care card and medications ready will help to make the nurse is often necessary. Until the therapist becomes fa- miliar with the OASIS instrument and more practiced in

CHAPTER 25  Home Health Physical Therapy 465 B O X 2 5 - 6 Skilled Services for Home Health Covered by Medicare Part A Skilled Nursing (SN) • Observation and assessment of the patient’s condition • Medication management/assessment and teaching • Tube feedings • Nasopharyngeal and tracheotomy aspiration • Catheters, wound care, heat treatments, medical gases, rehabilitation nursing, venipuncture, psychiatric evaluation, therapy and teaching Speech–Language Pathology (SLP) • A change in functional speech or motivation • Clearing of confusion • The remission of some other medical condition that previously contraindicated speech–language pathology services Occupational Therapy (OT) • Selecting and teaching task oriented therapeutic activities designed to restore physical function • Planning, implementing and supervising therapeutic tasks and activities designed to restore sensory-integrative function (vision and cognition) • Planning, implementing and supervising individualized therapeutic activity programs as part of an overall “active treatment” program with a patient diagnosed with psychiatric illness • Teaching compensatory techniques to improve the level of independence in the activities of daily living • Designing, fabricating and fitting of orthotic and self-help devices • Vocational and prevocational assessment and training • Patient must have a continued need for OT when: the services meet the definition of OT and the patient’s eligibility has been established by virtue of a prior need for skilled nursing care, SLP or PT in the current or prior certification period Medical Social Services (MSW) • Assessment of the social and emotional factors related to the patient’s illness, need for care, response to treatment and adjustment to care • Assessment of the relationship of the patient’s medical and nursing requirements to the patient’s home situation, financial resources and availability of community resources • Appropriate action to obtain available community resources to assist in resolving the patient’s problem • Medicare does not cover the services of MSW to complete application for Medicaid • Counseling services that are required by the patient • Services of MSW are covered if they are necessary to resolve social or emotional problems that are or expected to be an impediment to the effective treatment of the patient’s medical condition AND the plan of care indicates how the services necessitate the skills of a qualified MSW to be performed safely and effectively • Covered on a short term basis and agency must demonstrate that a brief MSW intervention is necessary to remove, clear and direct impediment to the effective treatment of the patient’s medical condition or to the patient’s rate of recovery Home Health Aide (HHA) • Patient care • Simple dressing changes that do not require skills of a licensed nurse • Assistance with medications which are ordinarily self-administered and do not require the skills of a licensed nurse to be provided safely and effectively • Assistance with activities which are directly supportive of skilled therapy services but do not require the skills of a licensed nurse to be provided safely and effectively • Assistance with activities which are directly supportive of skilled therapy services but do not require the skills of a therapist to be safely and effectively performed such as routine maintenance exercises and repetitive practice of functional communication skills to support SLP services • Provision of services incidental to personal care services: however the purpose of HHA visit may not be only to provide incidental services (light cleaning, preparation of a meal, taking out the trash, shopping, etc.) • Must be intermittent and patient is being case managed by SN, PT, OT or SLP (From Centers for Medicare & Medicaid Services: Medicare benefit policy manual. http://www.cms.hhs.gov/manuals/Downloads/bp102c07.pdf. Accessed April 29, 2010.) time spent in the patient’s home more efficient. Items THE PHYSICAL THERAPY ASSESSMENT recommended to have available on the first and subse- quent visits are listed in Box 25-7. It is valuable to The Comprehensive Start of Care OASIS carry everything in a clinical travel bag. In addition to and Consent (Full Disclosure) the bag, home health therapists should always carry a cell phone and keep car keys on their person at all times Opening a Case.  Arguably the primary focus of open- in case of an emergency. ing a case is to complete the OASIS, assure the patient is safe to be in his or her home, and refer to other skilled

466 CHAPTER 25  Home Health Physical Therapy TA B L E 2 5 - 1 OASIS Quick Tips Assess (Components of the OASIS) Action Assess: Ambulation/locomotion, dyspnea, cognitive functioning, urinary/bowel incontinence, grooming, Greet your patient at the door. Review and sign agency admission paperwork. confusion, anxiety, hearing and ability to understand Ask about vision problems (e.g., cataracts, glaucoma, diabetic retinopathy) language, speech and oral expression of language or use of corrective devices. Ask the patient to count fingers at arms length. Assess: Ambulation/locomotion, pain, anxiety, confusion, dyspnea, grooming, ability to dress upper and lower Ask if there is anything the patient cannot do or has trouble doing because body, transferring of pain or discomfort. Ask the patient if he or she is more irritable or less tolerant of frustrations? Assess: Ambulation/locomotion, pain, skin lesion or open wound, pressure ulcer, stasis ulcers, respirator treatment Have the patient go to the bedroom. Observe the patient sitting and rising (look for CPAP), anxiety, confusion, dyspnea, behaviors from the bed (or his or her ability to turn if bedfast). Ask the patient to demonstrated at least once a week, grooming, ability get a shirt out of the closet or dresser and put it on, or ask the patient to to dress upper and lower body, transferring obtain a coat or jacket he or she would wear to a doctor appointment. Ask the patient if anyone lays clothes out for him or her. Perform skin Assess: Memory deficit, impaired decision making, behaviors scan. Minimally, ask the patient to remove shirt, remove shoes and socks, demonstrated, cognitive functioning, confusion and lift pant legs. Assess: Management of oral medications, management of Ask the patient what he or she ate at his or her last meal. Ask what he or inhalant medications, management of injectable she would do in the event of a fire. medications, patient management of equipment, O2, IV, cognitive functioning, confusion, anxiety, behaviors Have the patient walk to the bathroom and sit and rise from the commode. demonstrated, reported or observed, hearing and ability Ask the patient to step into the tub or shower. Ask if the patient ever to understand language, speech and oral expression of has help in the tub or needs reminders. Ask the patient what type of language assistance he or she needs to wash his or her entire body in the tub or shower. Ask the patient if he or she ever has “little accidents,” dribbling, Assess: Pain, vision, dyspnea, hearing and ability to stress incontinence, or trouble holding stools. Normalize this occurrence understand language, cognitive functioning, based on age or disease status. confusion, anxiety, ambulation Have the patient walk you to where he or she keeps his or her medications. Assess: Management of oral medications, management Have the patient ambulate 20 feet and negotiate stairs (if indicated). If the of inhalant medications, management of injectable patient is chairfast or bedbound, observe dyspnea while performing ADLs. medications, patient management of equipment, O2, IV, cognitive functioning, confusion, anxiety, behaviors Have the patient open a medication bottle, pour out a pill, tell you the color, demonstrated, reported or observed, hearing and ability read the dosage instructions, and tell you the correct times to take the to understand language, speech and oral expression of medication. language CPAP, continuous positive airway pressure; IV, intravenous OASIS, Outcome and Assessment Information Set. (Adapted from Colorado Foundation for Medical Care. Home health: toolkits and resources. http://www.cfmc.org/hh/hh_toolkits.htm.) services when appropriate. As mentioned previously, The results of the OASIS will help the clinician deter- opening a case for an experienced clinician typically mine if there are issues in an area beyond the scope of takes 1 to 2 hours depending on the complexity of the physical therapy. The clinician is ethically obligated to patient and home situation. The OASIS document serves refer to the appropriate service for additional assessment as a guideline for the clinician to ensure a comprehen- and intervention. For example, if the patient is having sive assessment. difficulty in the OASIS area of Living Arrangements, Sup- portive Assistance, and Emotional/Behavioral status, the TIP: ASSESSMENT OF URINARY AND BOWEL physical therapist may consider a referral to social work INCONTINENCE services. If the patient is having difficulties in the areas of sensation, cognition, vision, ADLs or instrumental activi- The OASIS assessment requires the physical therapist to assess for ties of daily living (IADLs), the clinician may consider a urinary and bowel incontinence. When interviewing the patient, he referral for speech–language pathology or occupational or she may deny this condition especially in the presence of family therapy. An occupational therapist can also assist the members and/or friends. The clinician may need to do some “detec- patient with equipment needs/management. If the patient tive work” (or sense of smell) to answer this question correctly. is having difficulties in the areas of integumentary, respi- During the assessment of ADL/IADLs section of the OASIS when the ratory, cardiovascular, urinary, gastrointestinal, or medi- patient is up and moving around the house, look for adult diapers in cation management, the clinician may consider a referral the bathroom and/or next to the patient’s bed. to a skilled nurse. The need for a home health aide should

CHAPTER 25  Home Health Physical Therapy 467 B O X 2 5 - 7 Items for the Clinical Bag past medical history or current diagnosis. For this skill, the physical therapist needs to have knowledge of medi- The Clinical Bag—Essential Items to Pack for the Trip cations and their appropriate usage. The therapist should Blood pressure cuff also reconcile the patient’s symptoms with possible ad- Cardiopulmonary resuscitation mask verse drug reactions. For example, if a patient complains Disinfectant wipes for equipment of dizziness and is taking multiple medications to lower Gait belt blood pressure, the patient may be experiencing an ad- Girth measurement tape verse drug event. Finally, the therapist should assess Goniometer whether there are medication implications for the ther- Hand soap apy plan of care. In the previous example, if the patient Paper towels is experiencing dizziness from hypotension, a clinical Personal protective equipment (gloves, mask, gowns) hypothesis regarding decreased exercise tolerance should Reflex hammer be explored. Sterile wound care supplies Stethoscope When reviewing medications with the patient, the Stopwatch home care physical therapist should consider if a skilled Tape measure nursing assessment may be warranted. It should be Thermometer noted that there are different regulations by state on medication reviews and providing patient education Additional Useful Items about high-risk medications by physical therapists. For 1000 feet or more measuring wheel example, as a result of the implementation of OASIS-C, Balance pad in January 2010 the New York State Department of Elastic tube/bands Health ruled that a physical therapist may complete the Masking tape comprehensive assessment only if the home health Pedal ergometer agency has implemented a policy and procedure that Pulse oximeter requires collaboration between the physical therapist Weighted vest and other agency staff.25 It is important for home health therapists to be aware of their state regulations regard- also be assessed at the start of care. The patient who is ing medication review. receiving home health services under the Medicare part A benefit is entitled to receive all the services needed. Medi- Older adults aged 65 years or older are at a higher care has defined guidelines for what is considered skilled risk for adverse drug reactions (ADR) than younger in- services in home health.23 See Box 25-6 for a dividuals.26,27 The increased risk occurs for several rea- detailed explanation of skilled services covered by Medi- sons. Older adults are prescribed more medications and care Part A in Home Health. Once the systems review has have more chronic conditions than younger individu- been completed using the OASIS as a guide, a medication als.28 In addition, the older adult may metabolize the reconciliation is required. drug less efficiently, especially in the presence of disease. Medication errors, either patient-initiated or prescribing The Medication Reconciliation errors, can cause an ADR. Physical therapists need to be aware that errors that lead to adverse events most often Pharmacology competencies for the physical therapist occur after the medication regimen is prescribed—while are defined by the American Physical Therapy Associa- the patient is administering the drug and fails to adhere tion (APTA).24 These competencies state that the physi- to medical advice about medication use.28 If the patient cal therapist should, at a minimum, list all medications or family member is unable to tell the clinician what (over-the-counter and prescribed) on the medication medications the patient is taking or the usage and pur- profile for the patient’s clinical record. Importantly, it is pose of the medication, it is likely that the patient is at not within a physical therapist’s scope of practice to risk for an adverse drug event. provide instructions about how to take drugs or assess for possible drug interactions. However, the physical Several red flags pertinent to the physical therapist therapist should be aware of adverse drug reactions for may become apparent during the medication reconcilia- the patient’s safety, and recognize when it is necessary to tion. For example, older adults taking more than four contact the patient’s physician to obtain an order for a medications are at increased risk for falls because of the skilled nursing assessment. Tips for assessing the pa- accumulated and/or enhanced side effects of the medica- tient’s ability to manage medications are described in tions.29 The Beers criteria for potentially inappropriate Table 25-1 (OASIS assessment quick tips). medication can be used to screen the medication profile for inappropriate or problematic drugs. Although the list Physical therapists should then perform a reconcilia- was approved by expert consensus panels of geriatricians tion of the medication list. This reconciliation includes and was widely published, a percentage of older adults assessment of whether the medications correlate with continue to use these medications.26 Adverse drug events occur most often because of prescribed medications30;

468 CHAPTER 25  Home Health Physical Therapy together with warfarin, vasodilator with postural hypo- tension, and bladder antimuscarinic drugs with demen- however, it has been suggested that community-dwelling tia. The authors recommend that the home health thera- older adults who take medications identified on the Beers pist have a copy of the Beer’s list and STOPP when in the list are at a greater risk for an adverse drug event.31 The home to utilize as a quick reference tool during medica- Beer’s list of potentially dangerous drugs for older adults tion reconciliation. is shown in Box 25-8. The Screening Tool of Older Per- sons’ Potentially Inappropriate Prescriptions (STOPP) Apart from a medication review, the therapist could published in 2008 is another valuable reference for determine if the patient or caregiver has difficulty with the home care physical therapist.32 The STOPP criteria managing the medication regimen such as being able to focus on avoiding use of medications potentially inap- visually recognize each drug, describe the purpose, propriate in older adults, similar to the Beers list. The verbalize when to take each medication, and determine criteria are organized by organ system. Examples of the if the patient uses any type of medication-organizing STOPP criteria include theophylline as monotherapy for system. The therapist should be aware of the strain chronic obstructive pulmonary disease, nonsteroidal anti- on caregivers when the burden of managing and inflammatory drugs (NSAIDs) with heart failure, NSAIDs B O X 2 5 - 8 Beers List of Potentially Dangerous Drugs for Older Adults alprazolam (Xanax) guanethidine (Ismelin) amiodarone (Cordarone) halazepam (Paxipam) amitriptyline (Elavil) hydroxyzine (Vistaril, Atarax) amphetamines indomethacin (Indocin, Indocin SR) anorexic agents isoxsuprine (Vasodilan) barbiturates ketorolac (Toradol) belladonna alkaloids (Donnatal) lorazepam (Ativan) bisacodyl (Dulcolax) meperidine (Demerol) carisoprodol (Soma) meprobamate (Miltown, Equanil) cascara sagrada mesoridazine (Serentil) chlordiazepoxide (Librium, Mitran) metaxalone (Skelaxin) chlordiazepoxide-amitriptyline (Limbitrol) methocarbamol (Robaxin) chlorpheniramine (Chlor-Trimeton) methyldopa (Aldomet) chlorpropamide (Diabinese) methyldopa-hydrochlorothiazide (Aldoril) chlorzoxazone (Paraflex) methyltestosterone (Android, Virilon, Testred) cimetidine (Tagamet) mineral oil clidinium-chlordiazepoxide (Librax) naproxen (Naprosyn, Avaprox, Aleve) clonidine (Catapres) Neoloid clorazepate (Tranxene) nifedipine (Procardia, Adalat) cyclandelate (Cyclospasmol) nitrofurantoin (Macrodantin) cyclobenzaprine (Flexeril) orphenadrine (Norflex) cyproheptadine (Periactin) oxaprozin (Daypro) desiccated thyroid oxazepam (Serax) dexchlorpheniramine (Polaramine) oxybutynin (Ditropan) diazepam (Valium) pentazocine (Talwin) dicyclomine (Bentyl) perphenazine-amitriptyline (Triavil) digoxin (Lanoxin) piroxicam (Feldene) diphenhydramine (Benadryl) promethazine (Phenergan) dipyridamole (Persantine) propantheline (Pro-Banthine) disopyramide (Norpace, Norpace CR) propoxyphene (Darvon) and combination products doxazosin (Cardura) quazepam (Doral) doxepin (Sinequan) reserpine (Serpalan, Serpasil) ergot mesyloids (Hydergine) temazepam (Restoril) estrogens thioridazine (Mellaril) ethacrynic acid (Edecrin) ticlopidine (Ticlid) ferrous sulfate (iron) triazolam (Halcion) fluoxetine (Prozac) trimethobenzamide (Tigan) flurazepam (Dalmane) tripelennamine guanadrel (Hylorel) (Data from Fick DM, Cooper JW, Wade WE, Waller JL, MacLean JR, Beers MH: Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 163(22):2716-2724, 2003.)

CHAPTER 25  Home Health Physical Therapy 469 administering the patient’s medication regimen falls to injuries in older adults occur inside the home.35 In addi- the caregiver.33 This strain is more pronounced in care- tion, patients are more vulnerable to sustaining a fall givers of patients with moderate cognitive impairment as within 1 month of hospital discharge.7 The evidence is opposed to those patients with normal or very low cog- strong for multifactor falls risk assessments and indi- nitive functioning.33 When a home health therapist rec- vidually tailored follow-up interventions that include ognizes caregiver strain, it may be appropriate to refer to appropriate exercise intensity and specificity.36 The home skilled nursing or a medical social worker to help the health therapist is in an ideal position to address all patient and caregivers cope with these types of issues. the fall-related factors within a functional and relevant Thus, physical therapists, as frontline professionals, environment. have an important role to play in the home health setting by evaluating the extent to which the patient or caregiver The home health assessment of potential fall risk be- are competent in the management of the patient’s medi- gins with a history of a prior fall or a fear of falling. A cation regimen. Some elements of an interdisciplinary prior fall predicts a decline in function, hospitalization, medication assessment are listed in Box 25-9. and adverse events among older adults and remains in- dependently predictive of a likelihood of future hospital- The home health physical therapist may consider add- ization as well as a future fall.37 In addition, falls occur- ing a small medication resource book to his or her tool ring indoors and an inability to get up after a fall are bag for immediate reference. The Internet is also another positive predictors of falls in older adults.38 Therefore, useful source of information. Potentially serious drug the physical therapist should routinely assess the home- interactions can be quickly identified using “Drug Inter- bound older adult’s ability to rise from the floor, both action Checkers” available on most Internet-based re- as a potential predictor of fall risk and as a safety sources. Box 25-10 provides examples of websites that issue should the person fall. If the person cannot safely these authors have found valuable. rise unassisted, a Lifeline or similar device may be recommended. Fall-Risk Screening Fear of falling is also a predictor of fall risk. Many An important area to assess at the first visit is fall risk. older individuals limit their mobility and become in- Reducing fall risk and fall-related injuries can prevent creasingly sedentary and homebound because of their significant declines in function and independence and awareness of declining balance, near falls, and/or a fear allow older persons to remain in their home.34 Risk fac- of falling. Interviewing a patient about his or her fear tors for falling are diverse and many of them, such as of falling including the completion of a fear of falling balance impairment, muscle weakness, polypharmacy, index such as the Falls Efficacy Scale or the Activities and environmental hazards, are common but potentially Balance Confidence Scale (ABC) may provide useful modifiable in the homebound patient. Approximately information that will inform goals and intervention 20% to 55% of all unintentional falls and fall-related strategies. BOX 25-9 Elements of an Effective Home health therapists need to be aware of the pos- Interdisciplinary Approach to sible underreporting of falls and near falls. Older adults Medication Management in the Home may feel that reporting a fall might result in nursing home placement and/or notification of the fall incident • Assessment of the medication regimen, which includes the to other family members who might arrange for reloca- patient’s understanding of degree of adherence to the pre- tion. Therefore it is likely an older adult may deny or scribed regimen minimize a fall history and/or a fall injury. Because only 20% of older adults who fall seek medical attention, the • Evaluation of the complexity of the regimen for patient/ health care provider may not know about a fall.35 Our caregivers, which includes consistency of correct administration recommendation is to assume fall risk and create a safe environment for the homebound patient to report a fear • Monitoring responses to drug actions, interactions, and side of falling and/or near and actual falls. effects Home Safety Assessment • Provide education Home assessment should be carried out at the first visit. B O X 2 5 - 1 0 Useful Websites for Drug Safety and mobility barriers are the prime focus for the Interactions and Information physical therapist. Because approximately 20% to 55% of all unintentional falls and fall-related injuries in older www.drugs.com adults occur inside the home,35 it is imperative that the www.rxlist.com therapist address any potential hazards. www.drugdigest.com www.epocrates.com Homes are a common setting for nonfatal unintentional www.webmd.com/drugs injuries.2 Although most falls occur on level surfaces, 16% occur on the stairs or from a height, and 4% occur in the

470 CHAPTER 25  Home Health Physical Therapy BOX 25-11 Home Safety Checklist bathroom. Approximately 75% of these falls happen All Living Spaces during the performance of routine daily activities, and _____ Remove throw rugs. 44% occur in the presence of one or more environmental _____ Secure carpet edges. hazards.39 Environmental hazards have been found to be _____ Remove low furniture and objects on the floor. common in the homes of community-dwelling older adults _____ Reduce clutter. and pose a fourfold risk of falling in those without a previ- _____ Remove cords and wires on the floor. ous fall. Interestingly, environmental hazards are not as- _____ Check lighting for adequate illumination at night (especially sociated with a cause of a fall in older adults with a history of falls; perhaps because older adults who have fallen may in the pathway to the bathroom). be more cautious of their surroundings, more aware of fall _____ Secure carpet or treads on stairs. hazards, and more sedentary.40 _____ Install handrails on staircases. _____ E liminate chairs that are too low to sit in and get out of The home health therapist may be familiar with the resistance of many older adults to changing their home easily. environment on the recommendation of the therapist. _____ Avoid floor wax (or use nonskid wax). Resistance to recommendations may be because the pa- _____ Ensure that the telephone can be reached from the floor. tient does not believe the hazard will cause a fall, the patient may be resistant to change and the associated Bathrooms costs of the change, or the patient may resist the per- _____ Install grab bars in the bathtub or shower and by the toilet. ceived lack of control in incorporating a change to his or _____ Use rubber mats in the bathtub or shower. her home. Strategies that may be effective in overcoming _____ Take up floor mats when the bathtub or shower is not in use. resistance include sensitive communication with the pa- _____ Install a raised toilet seat. tient and family member or friend about why the changes are necessary and the implications associated Outdoors with falls and health status in older adults and providing _____ Repair cracked sidewalks. the patient with a list of community resources. These _____ Install handrails on stairs and steps. types of resources may be found from senior centers, _____ Trim shrubbery along the pathway to the home. rehabilitation centers or physician offices, and on the _____ Install adequate lighting by doorways and along walkways Internet. Some states may provide financial assistance for home modifications. In addition, any recommenda- leading to doors. tions should be presented in a way that allows the older adult to remain in control of his or her home environ- (Adapted with permission from Rubenstein LZ: Falls. In: Yoshikawa TT, Cobbs ment. Presenting recommendations in terms of choices, EL, Brummel-Smith K, editors: Ambulatory geriatric care. St Louis, 1993, such as grab handles or a slip-proof stair covering, may Mosby.) allow the older adult to feel more in control. to mobility, such as adapting stairs with a ramp, or The fundamental goals of home safety assessments recommend an assistive device. Examples of adaptive and interventions are to improve and maintain the older or structural changes are listed in Table 25-2. adult’s ability to function safely at home in all seasons. For example, an antislip shoe device reduced the rate of Emergency Situations falls in icy conditions.41 A home safety assessment is es- pecially effective in people with severe visual impairment Being prepared for emergency situations in the home is and in those at higher risk of falling. However, home considered best practice in home health. Because of the safety interventions do not necessarily reduce falls, per- autonomous nature of the home care practice, the thera- haps because of the low rate of compliance.41 Despite pist is often alone with the patient and needs to be this evidence, it seems prudent to advise the patient and adaptable to creating a safe and clear space for treatment family about potential risks in the home. as well as remain cognizant of the patient’s and thera- pist’s personal safety. The authors recommend that the Home safety checklists should address three basic areas: home health therapist always utilize a gait belt when the presence of environmental hazards, problem areas, and working with patients in the home and to keep a cell lack of supportive or safety features (Box 25-11).40 Check- phone on one’s person at all times in case of an emer- lists are commonly available to help organize the home gency when the patient cannot be left. safety assessment. For example, the Centers for Disease Control and Injury Prevention publishes a “Home Fall It is assumed that the home health therapists are aware Prevention Checklist for Older Adults” that is available in of their limitations and know when to call for help. Op- English and several other languages.42 tions include 911, the patient’s physician, or a clinical manager of the home health agency. Basic clinical assess- In addition to the home safety assessment, the home ment skills such as taking baseline vital signs and assess- health therapist also has a role in recommending ing the patient’s perceived rate of exertion during exercise modifications to improve mobility. These recommen- are standard requirements for most home health agen- dations may be to remove or modify potential hazards cies. Moreover, current certification in Basic Life Support for Healthcare Providers is the minimum requirement for

CHAPTER 25  Home Health Physical Therapy 471 TA B L E 2 5 - 2 Home Safety Interventions Personal Safety Environmental Risk Factors Home Modifications The authors strongly believe that employee safety is fundamental to being able to provide patient care, and Throw rugs and mats Replace nonsecure mats policies that promote a culture of safety for employees as an organizational priority are essential. Although Poor lighting with nonslip bathmats incidents of violence in the home health environment Electrical cords are rare, situations do occur. Incidental personal safety Stairways without rails and rugs factors such as unrestrained pets, clutter, and poor Adaptive Equipment Use night lights lighting in homes were found to be commonplace in Tub transfer bench/shower chair Remove electrical cords a 2006 survey of 833 home health nurses.43 Another Cane/walker Addition of stair rails study found that 63% (n 5 465) of home health nurses Bedside commode surveyed reported one or more exposures to violence, Elevated toilet seat with the most prevalent exposure being verbal abuse.44 Grab bars Exposure to violence or other threats to personal Hospital bed safety was associated with the presence of illicit Wheelchair drugs, firearms, or violent family members. For these reasons, cell phones and other mobile communication (Data from Cumming RG, Thomas M, Szonyi G, et al: Home visits by an occupa- devices are considered essential for home health care tional therapist for assessment and modification of environmental hazards: a workers.45 randomized trial of falls prevention. J Am Geriatr Soc 47(12):1397-1402, 1999.) When risk factors for violence are suspected, pre- patient safety. A cardiopulmonary resuscitation mask screening of the patient’s home, using a security escort should be included in the therapist’s tool bag. and/or supervisory visits by a home health agency clinical manager may be necessary. Patients can be The potential for a situation that requires activation of required to sign a contract that they understand that emergency medical services (EMS) always exists. A DNR the home health agency may terminate their care if a (Do Not Resuscitate) Form, called “Emergency Medical home health employee is exposed to violence or any Services Prehospital Do Not Resuscitate (DNR) Form” in threatening activity in the home, including an unre- some states, is an official document. When completed cor- strained animal. rectly, this form allows a patient with a life-threatening illness or injury to forgo specific resuscitative measures Functional Assessment Testing that may keep the individual alive. Home health providers are trained to inquire at the start of care if the patient has Functional assessment testing can provide valuable in- a Prehospital DNR form and to identify where the docu- formation in any setting but is particularly relevant in ment is kept. The Prehospital DNR form is designed to the home health setting because of its specificity to home express the patient’s wishes when the patient cannot speak care activities. Functional assessment is an effective way for himself or herself. The patient should be instructed to to objectively document a patient’s functional status, keep the DNR notice easily visible—mounted by a magnet progress through the episode of care, and justify home- on the refrigerator door is recommended by state medical bound status. Functional assessment testing can also associations. However, EMS personnel are taught to pro- justify discharge from physical therapy services. The ceed with cardiopulmonary resuscitation when needed, functional tests described in Table 25-3 are particularly unless they are absolutely certain that a qualified DNR relevant for the homebound patient transitioning to the advance directive exists for that patient. If, the DNR form community. We have included scores we feel indicate or a medallion such as medical emergency bracelet is not safe mobility at home and in the community that may found, after spending a reasonable (short) amount of time, help with goal setting. Scores on these tests can help EMS personel will proceed with life-saving measures. It is justify skilled services. For example, a patient who scores important to keep in mind that in a situation when every greater than 13.5 seconds on the Timed Up and Go test second has potentially life-or-death consequences, deci- may be at risk for falls,67 thus justifying homebound sions need to be made quickly. EMS personnel are taught status because of the increased risk for falls and supervi- to provide life support if they are in doubt. Home health sion needed. clinicians are usually advised by their clinical managers to do the same until EMS personel arrives on the scene. Gait speed has been shown to be the single best pre- dictor of functional decline and disability and therefore TIP: STORING MEDICAL INFORMATION should always be assessed in the home setting.68 Slower gait speeds of 0.56 m/second or less can also indicate Medical information can be stored in the refrigerator in an empty increased fall risk.69 The scores of usual and fast vial or pill bottle designated with a sticker that would alert emer- gait speed can indicate the patient’s homebound status gency responders such as paramedics or firefighters to its contents. and when an individual has progressed to community

472 CHAPTER 25  Home Health Physical Therapy TA B L E 2 5 - 3 Functional Assessment for the Home Setting Functional Assessment Testing in the Home Scores 4-Square Step Test46,47 ,15 s 5-Repetition Sit to Stand Test48 ,10 s 6-Minute Walk Test49-51 1200 feet in 6 minutes Activities-specific Balance Confidence Scale52,53,56 .85% Berg Balance Scale54-57 .50 Borg RPE58 ,12 for normal activities 30-s Timed Chair Stand Test59 .12 in 30 s Dynamic Gait Index60 .19 Gait Speed61,73 .0.8 m/s (usual); 0.33 m/s difference Performance Oriented Mobility Assessment/Tinetti between usual and fast Assessment Tool62,63 .12 on balance portion64 Physical Performance Test65 26/28 (without stairs); 34/36 with stairs Timed Floor Rise ,20 s66 Timed Up and Go67 ,12 s ambulation (Table 25-4). Gait speed is easy to measure patient. In addition, we recommend having the func- with distances of as little as 8 feet.73 An assistive device tional tests and scores listed in Table 25-3 handy at each can be used. Normative values for gait speed in older visit to aid efficiency. adults exist that can aid in goal setting (Table 25-5). For these reasons, the authors strongly recommend usual GOAL SETTING and fast gait speed be recorded for each home health There is some evidence that when the therapist and pa- TA B L E 2 5 - 4 Functional Gait Speeds tient work together to establish meaningful goals for the for Older Adults patient, the patient has improved enthusiasm, buy-in, and outcomes.74 Many home health patients will have Functional Level Gait Speed the potential and desire to become community-dwelling ambulators, returning to their prior or higher level of Household ambulator at risk for fall 0.5 m/s (1.64 ft/s)70 function. Others may be more limited or not desire to Community ambulator 0.8 m/s71 be integrated into the community. Therefore, it may be Usual adult walking speed 1.2 m/s-1.3 m/s advisable and necessary to involve the patient’s family Well-functioning older people at high risk ,1.0 m/s71 members in the goal-setting process. Family members can help with information on prior level of function that of health-related outcomes is useful in setting realistic goals. For example, the pa- tient may indicate a desire to return to full community TA B L E 2 5 - 5 Normative Values for Gait Speed integration, including driving. However, when discuss- in Older Adults ing this goal with the family, the therapist find may out the patient has had several near-accidents and is often- Gender Age Gait speed Gait speed times confused about the actual location when out in Female Range [ft/sec (m/s)] [ft/sec (m/s)] the community. Some warning signs that it is unsafe for (years) over 8 ft over 20 ft the individual to drive are listed in Box 25-12. This in- Male formation may require a refocusing of the patient on 50-59 3.61 (1.10 m/s) 3.64 (1.11 m/s) shorter-term goals with the expectations that the indi- 60-69 3.28 (0.99 m/s) 3.30 (1.01 m/s) vidual may come to a realization of limitations. The 70-79 3.01 (0.92 m/s) 3.05 (0.93 m/s) Ozer–Payton–Nelson (OPN) model,75 described else- 801 2.50 (0.76 m/s) 2.57 (0.78 m/s) where in this text, may be useful in establishing mean- 50-59 3.66 (1.12 m/s) 3.68 (1.12 m/s) ingful and realistic goals. 60-69 3.38 (1.03 m/s) 3.39 (1.03 m/s) 70-79 3.13 (0.95 m/s) 3.14 (0.96 m/s) In setting goals to reintegrate a patient into the 801 2.77 (0.84 m/s) 2.73 (0.83 m/s) community, it may be useful to refer to Shumway-Cook et al’s required tasks of community-dwelling older (Modified from Bohannon RW: Population representative qait speed and its adults.76 The authors observed older adults for a 1-week determants. J Geriatr Phys Ther 31(2): 49-52, 2008.) period to identify required tasks in community-dwelling

CHAPTER 25  Home Health Physical Therapy 473 BOX 25-12 Warning Signs That Indicate BOX 25-13 Examples of Evidence-Based Goals Someone Should Begin to Limit for Home Health Patients Who Have Driving or to Stop Altogether Potential to Become Community Ambulators upon Discharge 1. Almost crashing, with frequent “close calls” 2. Finding dents and scrapes on the car, on fences, mailboxes, • The patient will score ,13.5 s on the Timed Up and Go without an assistive device. garage doors, curbs, or the like 3. Getting lost • The patient will score  50/56 on the Berg Balance Test. 4. Having trouble seeing or following traffic signals, road signs, • The patient will score ,12 s on the 4 Square Step Test. • The patient will reach .10 in. on the Functional Reach Test. and pavement markings • The patient will score .85% on the Activity-specific Balance 5. Responding more slowly to unexpected situations, or having Confidence Scale. trouble moving foot from the gas to the brake pedal; confusing • The patient will ambulate .1000 ft without an assistive the two pedals 6. Misjudging gaps in traffic at intersections and on highway device with a gait speed of greater than 0.8 m/s with a reported entrance and exit ramps Borg RPE of 10 or less. 7. Experiencing road rage or having other drivers frequently honk • The patient will score 25/28 on the Performance Oriented at driver Mobility Assessment/ Tinetti Assessment Tool. 8. Easily becoming distracted or having difficulty concentrating • The patient will score .19/24 on the Dynamic Gait Index Test. while driving • The patient will score ,14.2 s on the 5 Repetition Sit to Stand. 9. Having a hard time turning around to check over shoulder • The patient will score X reps (insert # of reps based on the while backing up or changing lanes norms for the patient’s age and sex in 50th percentile or 10. Receiving traffic tickets or “warnings” from traffic or law greater) on the Chair Stand Test. enforcement officers in the last year or two • The patient will ambulate X feet (insert # of feet based on the norms for the patient’s age and sex) on the 6-Minute Walk Test (Data from AARP. Driver safety program. http://www.aarp.org/home-gar- with a reported Borg RPE of 10 or less. den/transportation/info-05-2010/Warning_Signs_Stopping.html. Accessed April 5, 2010.) older adults for the purpose of helping home health agreed upon and a treatment consent form is signed therapists set goals. They found that older adults rou- with this information in writing. This consent form tinely: clearly articulates the therapist’s and the patient’s expec- tations for the episode of care and could be considered a • walked a minimum of 1000 feet per errand (often contract. making 2 to 3 separate trips at a time), There may also be cases where a patient may well • carried packages averaging 6.7 pounds while walking, intend to be a community ambulator and home health • frequently encountered stairs, curbs, and slopes, and care is used as part of the continuum of care to transition • engaged in frequent postural transitions (changes in the patient to outpatient care. An example might be a patient who is discharged to home from the hospital a direction, reaching up, looking up, moving back- few days after total hip arthroplasty (THA). That patient ward, etc.).76 may have a goal of getting to outpatient therapy as soon as possible, so goal setting would include increasing am- Ideally, the goals set for patients who desire to return bulation distance, endurance, and car transfers. to the community should reflect these community stan- dards. Box 25-13 lists some examples of evidence-based It is the opinion of the authors that often patients goals useful for a home health physical therapist. are discharged far too early from home health services. Criteria for community mobility have been clearly estab- The therapist and patient need to work closely to de- lished by Shumway-Cook et al and should be used termine what goals are realistic and measurable to as goals for the patient desiring to be reintegrated into achieve the understanding that the episode of care is the community.76 In addition, objective fall risk should limited to achieving specific goals. For example, if the be considered when preparing for discharge. When a patient does not desire to return to the community but person demonstrates substantial fall risk per the Berg expresses a desire to be able to get out of a chair, walk Balance Scale as an example, the person may benefit to the bathroom, transfer on and off the toilet, and from further therapy to decrease fall risk. Unfortunately, return to the chair with the use of a walker without be- the authors have seen arbitrary standards for justifica- coming short of breath, a long-term goal stating tion of discharge that have no basis in Medicare guide- “Patient will transfer independently on/off a chair, lines. For example, one therapist may discharge a patient ambulate 45 feet with a walker from the chair to toilet from home health services simply because the patient and back with a reported Borg RPE of 10 or less” is went out to get a haircut. Another therapist may appropriate. At the time of the goal negotiation, the discharge a patient because the patient can ambulate expected duration of care is determined. In collaboration 200 feet or can drive. However, under Medicare guide- with the patient, the number and frequency of visits are lines, a homebound patient is allowed to leave the home

474 CHAPTER 25  Home Health Physical Therapy Vigor (%)safe for the patient. Skilled physical therapy will be cov- ered throughout the 60-day certification period under to get a haircut, attend physician appointments, and the condition that supporting documentation justifies participate in religious services. They are also permitted the need for skilled services. The documentation needs to to leave their home for special occasions such as holidays include homebound status at the time of start of care or visiting relatives as long as the trip away from home and on every subsequent visit note. is physically taxing (see Box 25-1). It is important to note that no Medicare guideline establishes a prescribed The frail individual’s predicted episode of care is par- ambulation distance to determine homebound status. ticularly challenging with respect to predicting the fre- Box 25-14 lists some examples of statements that may quency and duration of services because frailty is linked justify continued homebound care. with a poor prognosis.77 Frailty is a biological condition characterized by three or more of the following charac- Home health physical therapists have a professional teristics: unexplained weight loss of 10 lbs or more in the obligation to provide the needed patient services while past year, self-reported exhaustion, weakness (as mea- complying with CMS guidelines and regulations. Objec- sured by grip strength), slow walking speed, and low tive documentation and thorough examination of the physical activity.78 A patient who is frail will require patient will help drive an appropriate plan of care. Each more visits on average, spread out throughout the certi- subsequent visit note must stand alone to justify medical fication period to move them to a higher functional level. necessity. The purpose of this section was to assist the However, if the person is so frail that the individual is home health therapist to think critically about patient- almost bedbound (Figure 25-1), fewer therapy visits will centered goals and justify the provision of in-home be needed to educate the patient and family on safe mo- therapy services under Medicare guidelines. bility and a home exercise program. EPISODE OF CARE Application of clinical decision making is imperative when determining frequency and duration of physical Projecting Number of Physical Therapy therapy services. Appropriate exercise for the older Visits and Episode Timing adult—including intensity, overload, and specificity—is needed to effect change. Use of these principles will help A 60-day certification period applies to home health the home health physical therapist determine frequency patients admitted for home health services under the and duration for the home health episode of care and Medicare Part A benefit. A detailed description of what avoid a premature discharge. In all cases, the home Medicare considers skilled physical therapy services is health therapist is responsible for ordering the number available on the CMS website.23 Briefly, the skilled ser- of therapy visits that are medically necessary. The pa- vices should be appropriate, reasonable, necessary, and tient’s needs must remain the therapist’s foremost con- cern when determining the number of therapy visits, BO X 2 5 - 1 4 Examples of Statements That Can Justify Home Care 100 • After returning home from an outing, the patient requires 90 2 hours of rest as a result of exhaustion from the trip. 80 • The patient scored .14 s on the Timed Up and Go and therefore requires the assistance of one person to safely exit the home as 70 Fun a result of fall risk. 60 • The patient reports a Borg score of .12 while ambulating inside the home and is therefore homebound as a result of the taxing 50 effort ambulation requires. Function • Decreased cognition as evidenced by the Mini Mental Status 40 score indicates the patient requires the assistance of one person to exit the home safely. 30 Frailty • The patient lives in an apartment building and is unable to safely negotiate stairs as a result of partial weight-bearing 20 status after total hip arthroplasty to exit home. 10 Failure • The patient reports a Borg RPE of .12 after descending and ascending 14 stairs required to enter his or her home and is 20 100ϩ therefore homebound as a result of the taxing effort required to Age leave the home. FIGURE 25-1  S​ lippery slope and frailty. (Modified from Schwartz • The patient is unable to ambulate .1000 feet with a gait speed of .0.8 m/s and reported Borg RPE of 11 and is therefore RS: Sarcopenia and physical performance in old age: introduction. homebound because the patient is unable to safely ambulate Muscle Nerve Suppl: 5:S10-S12, 1997.) community distances at a gait speed required for community ambulators.

CHAPTER 25  Home Health Physical Therapy 475 regardless of reimbursement models. Considering that few visits. The patient may be discharged to outpatient all therapy visits must be medically necessary, each visit services, self-care, or a home program with assistance note must justify the visit. from a family or friend. The home health physical therapist is expected to coordinate the discharge plan Initial Patient Education Interventions with the physician, the patient, and anyone else who may be involved in the patient’s care. In many cases, Skilled home health therapy includes patient education a patient who is expected to reintegrate into the com- interventions and the patient’s as well as caregivers’ re- munity could benefit from additional outpatient physical sponse to education. Patient education at the start of therapy services to help move the person to as high a care may include information about the patient bill of level of function as possible. This will help prevent rights, the agency’s complaint process, the agency’s di- future functional decline by building up functional re- saster plan, home safety interventions, pain management serve and protecting the person against future hospital- interventions, home exercise program, orthopedic pre- izations.79,80 Discharge planning will be discussed later cautions, fall prevention strategies, and the plan of care. in this chapter. Any patient education provided must be documented at the initial and subsequent visits. Suggestions for docu- Subsequent Visits mentation of patient education are explained further in the subsequent visit section of this chapter. Documentation.  Documentation for each home health visit may differ from other clinical settings. Issues need The volume of information to be shared and taught to be documented each visit as appropriate, such as com- may necessitate several educational sessions. Effective plete vital sign assessment, objective pain assessment, patient education is considered a skilled intervention documentation of subjective/objective assessment, and as teaching must be tailored to meet the older adult’s the reassessment of the physical therapy plan. The thera- physical, cognitive, and psychosocial functioning pist may also document the observance of universal level. Clinicians who take the time to assess their precautions or the use of “clean bag” technique to re- patients’ individual abilities, learning preferences, duce the risk of using contaminated equipment between and motivational differences will find teaching to patients. Documentation of discharge planning and be more rewarding and meaningful for the patient. homebound status should be noted throughout the epi- Chapter 10 on motivation and patient education pro- sode of care. vides many useful tips on how to be an effective patient educator. Documentation of skilled teaching and progress to- ward goal should also be included on every visit. For Start of Care Case Conference example, the home health therapist may document the and Physician Communication provision of patient education regarding THA precau- tions knowing that the patient will require further teach- Communication with Physician Regarding Plan of ing. The teaching intervention may be documented in the Care.  A verbal order from the physician (or an agent of following way: “The patient was provided with educa- the physician) for an initial physical therapy evaluation tion on THA precautions; further teaching is required must be obtained prior to the first visit. If further visits because the patient was only able to verbalize two of are required, the physical therapist must verbally contact three hip precautions.” This example includes what the the physician (or the physician’s agent) to negotiate the patient was taught and the patient’s response to teach- specific plan of care, including frequency and duration of ing. This example requires follow-up documentation on anticipated services. The physician must sign a paper subsequent visit notes because “further teaching is re- copy of the verbal referral; however, the clinician does quired” was documented. When full understanding of not need to wait to get the signed referral from the phy- THA precautions is demonstrated by the patient, the sician before service is rendered as long as verbal com- home health therapist may document the following: munication regarding the proposed plan of care has oc- “The patient verbalized understanding of THA precau- curred.23 The verbal referral prior to the start of care and tions.” If understanding the THA precautions was a goal subsequent signatures on paper copies are typically man- for the patient, the therapist would also document that aged by the home health agency. goal was met on that date in the progress toward goals Discharge Planning at the Start of Care.  ​As in all set- section on the note. tings, discharge planning in home health begins at the start of care. The patient is required to sign a consent The home care setting is rich with opportunities for form at the first visit that includes the agreed upon fre- patient and family education. These opportunities can quency and duration of home physical therapy. Rarely be used as justification for ongoing physical therapy can an older adult afford the luxury of being sedentary; services. The Home Health Section of the American thus some plan for continued physical activity and exer- Physical Therapy Association (APTA) provides guide- cise should be discussed with the patient within the first lines for documentation of plan of care and subsequent visits (Box 25-15).81

476 CHAPTER 25  Home Health Physical Therapy important it is termed care coordination and is required for each patient under CMS Conditions of Participation. BO X 2 5 - 1 5 Documentation Requirements Care coordination is characterized by communication for Home Health Care between all members of the interdisciplinary team. Specific documentation of patient notification of care Guideline: The physical therapist or physical therapist assistant will: provided, the disciplines involved, frequency of pro- 1 . Prepare appropriate documentation for the patient’s/client’s posed visits, notification 48 hours prior to planned dis- charge, and any changes to the plan of care is required. clinical record, including any OASIS-related documents, if The Conditions of Participation also require the agency applicable; to notify the physician of changes in the patient’s condi- 2 . Complete documentation in a timely manner in compliance with tion that may necessitate a change in the treatment plan the agency’s policies and procedures; and that was established on the first visit. For example, if the 3 . Utilize documentation principles consistent with APTA’s physical therapist determines 2 weeks after the start of Guidelines: Physical Therapy Documentation of Patient/Client care that the patient is exhibiting a change in cognition Management [BOD G03-05-16-41]. or having signs of skin breakdown, a referral for a Criteria: skilled nursing assessment is warranted because of the 1. Each visit/client encounter requires that documentation be change in the patient’s medical condition. An interim completed the day of the visit and included in the patient’s/ order from the physician is required for the newly re- client’s clinical record. quired skilled nursing assessment. Also, if a patient is not 2 . The patient’s/client’s health record includes, but is not limited to: progressing as anticipated and/or not participating with a. Documentation of examination, evaluation, diagnosis, therapy, the physician must be notified that services may no longer be skilled and thus need to end prior to what prognosis (including plan of care), intervention, and was originally planned. In such an example the home outcomes; health therapist may work with the physician and pos- b. Progress notes/visit records; sibly the agency’s social worker to coordinate options c. Written exercise and activity programs for a different level of care for those individuals who are d . Summations of care; not safe in the home and yet not progressing sufficiently e. Physician’s order, if required; with rehabilitative efforts. f. A plan of care reflecting the patient’s/client’s current status; and Coordination of care also requires communication g . Outcome measurement tools and scales (e.g., OASIS, Tinetti, between disciplines and typically with the agency’s clini- Pain Visual Analog Scale). cal manager; however, these requirements are agency 3 . Specific documentation should include, but is not limited to: specific. Care coordination needs to take place at the start a. The treatment provided; of care, resumption of care, recertification of care, and at b. The patient’s/client’s/caregiver’s response to treatment; discharge. There are other cases where documentation of c. The progress/lack of progress toward the attainment of the communication between the interdisciplinary team and anticipated outcomes; the clinical case manager are warranted, such as when d . Physical therapy outcomes updated as appropriate; reporting patient complaints/infections and incidents, e. Visit frequency; and lack of progress toward goals, and when providing super- f. Visit date and time: vision of other associates (home health aide, physical i. Time the visit started, therapist assistant, and licensed practical nurse). ii. Time the visit was completed, and iii. Total time spent with the patient/client. In the home health setting the case manager is respon- 4 . Communication about the patient/client among the physical sible for overseeing the care plan and coordination of therapist, physical therapist assistant, and other care providers that care with all disciplines. The physical therapist, reg- are to be documented and include, but are not limited to: istered nurse, speech–language pathologist, or occupa- a. Current problems; tional therapist is allowed under Medicare guidelines to b. Current goal status; be the patient’s case manager. If nursing is involved in a c. Interventions provided; patient’s care, the nurse is considered the patient’s case d. Physical therapy visit frequency and duration; and manager by default. When physical therapy but not e. Supervisory activities. nursing is involved, the physical therapist is the case 5 . Communication/conferences with the patient/client/family manager regardless of what other disciplines are in- members/other care providers involved in or supervising patient/ volved on the case. client care are to be documented, including date and time. The interdisciplinary team is expected to work to- (From American Physical Therapy Association. Home Health Section— gether to set goals with the patient to ensure a cohesive Guidelines for the provision of physical therapy in the home. http:// plan of care. Physical and occupational therapists work www.homehealthsection.org. Accessed April 29, 2010.) particularly closely with each other when both are in- volved in the same episode of care because of the similar- Coordination of Patient Care ity in goals and focus. Both professionals collaborate on Although the home health visit may occur in isolation from other health care team members, communication about the case occurs frequently between clinicians and clinical managers in the office. This communication is so

CHAPTER 25  Home Health Physical Therapy 477 the duration and frequency of the plan of care and spe- the family/caregivers understand the home exercise pro- cific intervention focus. Care coordination is also impor- gram instructions. The Home Health Section of the tant when scheduling visits with patients to ensure that APTA provides additional information on discharge the services are not overlapping. If two individuals are planning and documentation requirements for home needed to provide a service, two visits may be covered by health (see Box 25-15).81 CMS.1 An example given by CMS is an occupational therapist is at a patient’s home supervising the certified CMS uses the Start of Care OASIS and Discharge occupational therapist assistant. In this instance, only OASIS scores as a way to determine the effectiveness of one visit is billable to Medicare. CMS reimburses for the services provided by the home health agency. The joint visits (e.g., physical therapy and occupational results for all agencies are available for public reviewing therapy) only in special circumstances.1 at “Home Health Compare” on Medicare’s website.83 Resumption of Care.  I​f a patient is hospitalized or Box 25-2 lists the quality measures for home health placed in a facility for any reason during an episode of agencies. Written notification and signature of the pa- care, the case manager is responsible for completing an tient is required 48 hours prior to discharge from Home OASIS transfer assessment. If the patient is then subse- Health Services. The purpose of this is to make sure that quently discharged home within the same 60-day epi- the patient is aware that the discharge planned by the sode, the clinician completes an OASIS resumption of home health agency may be disputed by contacting care assessment. The guidelines for completion of the Medicare. A copy of the information is left with the various OASIS assessments are available from CMS.82 patient and kept in the clinician record. The patient has Recertification.  ​At the end of the 60-day certification a right to appeal the agency discharge by contacting period, the patient may still require skilled services. Medicare. There are no limitations as to the number of times a patient can be recertified as long as the criteria for skilled PHYSICAL THERAPY INTERVENTION services is met as defined by CMS.23 The case manager IN THE HOME completes the recertification OASIS assessment.82 If physical therapy is still appropriate to the needs of the Exercise is one of the most often utilized interventions in patient, additional physician orders23 are required for the home health setting as it has been shown to be effective the subsequent 60-day recertification period and the new in improving functional abilities given appropriate inten- plan of care. Physical therapy goals should be reevalu- sity and specificity. The lack of formal exercise equipment ated and updated for each new 60-day certification pe- can make the provision of evidence-based exercise chal- riod to justify the medical necessity for continuing lenging, requiring creativity to achieve the necessary pa- skilled services. rameters of an effective exercise program. Box 25-16 Discharge.  ​The appropriateness of physical therapy provides some suggestions for exercises and activities eas- discharge should be assessed prior to the last day of ser- ily done in the home. Box 25-7 lists a few items that are vices to determine if the patient’s goals were met. Dis- useful and feasible to carry with the therapist when pre- charge should be based on functional assessment testing scribing exercise in the home. The drive spent between that indicates the individual has met stated goals and patients can often be used to develop creative exercises community requirements, as appropriate. Referring to that are functional and of interest to the patient. the Shumway-Cook recommendations for community ambulation may be helpful.76 Home Exercise Programs Care coordination with all disciplines at the time of The literature shows that it is best practice to give a pa- discharge is necessary. Skilled services of various disci- tient only two to three exercises for the home exercise plines of the interdisciplinary team may be discharged at program to ensure correct form and perhaps compli- different times during the episode of care. The last disci- ance.84 Home health patients are typically seen two to pline on the case will be responsible for completion of three times a week initially during the episode of care; the OASIS discharge assessment, with the exception of therefore exercise performance between sessions may be home health aides. Disciplines that discharge prior to the necessary depending on the goals of treatment. If OASIS discharge are responsible for completing less la- strengthening is a goal and the patient is seen three times bor-intensive documentation in accordance with CMS, a week, it would be best to space out the physical ther- state, and agency guidelines. apy visits and prescribe endurance and/or flexibility ex- ercises between sessions. An exercise program of suffi- A home health physical therapist may help facilitate cient intensity does not require additional exercises for the patient’s discharge from home health and any transi- the patient on days they do not have therapy as rest for tion to outpatient physical therapy by communication that specific muscle is necessary. Rather, a home program with the physician and outpatient clinic of the patient’s could consist of a physical activity prescription such as a choice. If the patient does not go to outpatient physical daily walking program with alternating days working on therapy at the time of discharge, it is recommended speed or strength. The home health therapist may also that the physical therapist ensure that the patient and

478 CHAPTER 25  Home Health Physical Therapy sion or 30 days (whichever comes first). In the states of New York and California, the physical therapist cannot BO X 2 5 - 1 6 Examples of Exercises for Home supervise more than two PTAs at any given time.86 In Health California, the physical therapist is required to make a supervisory visit of the patient at least every 30 days af- Examples of Practical Exercises in and outside the ter the initial evaluation by the physical therapist, and Home the PTA does not need to be present for this visit.87 Car transfers However, within 7 days of the care being provided by Dynamic balance activities the PTA, the supervising physical therapist is required to Floor transfer training either review, cosign, and date all documentation by the Heel raises, progress to unilateral heel raises PTA or conduct a weekly case conference and document Quick toe tapping it in the patient record. These examples demonstrate Repeated sit to stand, progress to one leg sit to stand how each physical therapist should be aware of his or Stair climbing her state’s requirements regarding supervision of PTAs in Step ups the home care setting. Walking on uneven surfaces outside TECHNOLOGY Examples of Task-Specific Activities Repeatedly getting in/out of bed Technology, composed of four categories, has a grow- Repeatedly performing dressing tasks ing presence in the home health environment. These Reaching up into cupboards lifting cans of food, dishes, or weights categories include (1) point of care; (2) office automa- Carrying items (dishes and/or pots) across room from kitchen to tion; (3) telehealth and telephony; and (4) technology such as laptops, tablets, personal digital assistants, or dining area other Web-based portals.88 There is wide disparity in Putting in/removing items from refrigerator and/or stove the current use of technology among home health agen- Repeatedly opening and closing refrigerator and/or exterior door of cies and providers centered around the point of care and office automation types. However, the need for home increased technology in all of its capacity is evident. An Transferring up and down from commode repeatedly increased use of home-based technology will help to Bending over to pick up pet’s food/water dishes from floor ensure that older adults have the health care they need Stand at bedside and put shirts onto hanger and then hang shirts in in the future. Unlike prior generations, baby boomers will be very comfortable and familiar with technology closet as an integral part of their daily lives. Vacuuming and/or sweeping Transferring clothes from washer to dryer Technology adoption in home health becomes imperative as paper-based systems are increasingly choose to have the patient work on task-specific activi- overwhelmed by the burden of multiple regulatory ties on the nontherapy days (see Box 25-16). The home agencies and the complexity and number of aging exercise program should be updated as the treatment adults. Home health agencies are embracing point- progresses. Written exercise prescriptions with pictures of-care technology as electronic systems become more may be useful for patients. The exercises should be re- affordable and intuitive. viewed regularly with the patient to ensure that tech- nique is safe and correct. In some cases, the most effec- Telehealth is the use of electronic information and tive way to prescribe a home exercise program is to telecommunications technologies to support long- involve family members, especially in cases where the distance clinical health care, patient and professional patient has an existing cognitive or visual deficit. health-related education, public health, and health administration. Technologies used in telehealth typically Physical Therapist Assistant Utilization include videoconferencing, the Internet, store-and- forward imaging (the use of transferring medical data), Under CMS guidelines, the physical therapist assistant streaming media, and terrestrial and wireless communi- (PTA) can provide therapy without onsite supervision of cations. Although new applications are increasing, sig- the physical therapist, another unique aspect of the nificant barriers currently exist such as affordability and home care setting. However, physical therapist supervi- having reliable safeguards to secure and protect patient sion and utilization must be in accordance with CMS identifiable information. Many older adults and their and state regulations. The Home Health Section of the families would welcome a low-cost desktop video system APTA provides information on the role of the physical that provides 24/7 monitoring, to facilitate earlier iden- therapist assistant in the home as well as the necessary tification of functional decline, medication administra- qualifications (Box 25-17).85 tion problems, and/or acute exacerbations of chronic diseases. Telephone-based systems are already available, Individual states can also regulate how the PTA is utilized in the home care setting. For example, in New York State, the physical therapist and the PTA must make the initial joint visit together, with the physical therapist performing a follow-up visit every sixth occa-

CHAPTER 25  Home Health Physical Therapy 479 B O X 2 5 - 1 7 Guidelines for the Use of the Physical Therapist Assistant in Home Health Guideline: The physical therapist assistant will provide patient/client care as directed by a physical therapist: 1 . In accordance with APTA’s Standards of Practice for Physical Therapy [HOD S06-03-09-10] and the Criteria [BOD S03-06-16-38]; 2 . In accordance with APTA’s Code of Ethics [HOD S06-00-12-23] and Guide for Professional Conduct, and the Standards of Ethical Conduct for the Physical Therapist Assistant [HOD S06-00-13-24] and Guide for Conduct of the Physical Therapist Assistant; 3 . In accordance with APTA’s policy on Direction and Supervision of the Physical Therapist Assistant [HOD P06-05-18-26]; 4 . In accordance with APTA’s policy on Access to, Admission to, and Patient/Client Rights Within Physical Therapy [HOD P06-03-16-13]; 5 . In accordance with applicable municipal, state, and federal laws and rules and regulations; 6 . In coordination with the supervising physical therapist; and 7 . In coordination with the patient’s/client’s other care providers. Criteria: 1 . The Physical Therapist Assistant (PTA) will perform skilled interventions and related tasks that have been selected and assigned by the supervising physical therapist, consistent with the plan of care. 2 . The PTA will provide instruction to the patient/client/caregiver: a. Verbal; and b. Visual (e.g., demonstration, written, pictures, video, etc). 3 . The PTA will provide documentation to the agency for inclusion in the patient’s/client’s clinical record. a. Documentation to be completed in a timely manner in compliance with applicable state and federal home-health-related rules and regula- tions, agency requirements, and/or third-party payer requirements. 4 . The PTA will monitor and communicate to the supervising physical therapist any changes in the patient’s/client’s condition. Guidelines for the Provision of Physical Therapy in the Home 1 . The PTA will monitor and document the patient’s/client’s response to therapeutic physical therapy intervention: a. Communicating to the supervising physical therapist where appropriate the patient’s/client’s response to physical therapy intervention; and b. Referring to the following algorithm as a problem-solving process utilized by PTAs in provision of selected interventions: Clinical Problem-Solving Algorithm Utilized by PTAs in the Delivery of Physical Therapy Interventions. 2. The PTA will participate in care management processes, such as: a. Individual and multidisciplinary care conferences; b. In-services/continuing education; c. Chart audit activities; d. Quality improvement activities; and e. Other agency initiatives that affect multidisciplinary care. 3. The PTA will maintain confidentiality of information relating to the physical therapist assistant–client relationship in accordance with: a. The agency’s confidentiality policies and procedures; b. APTA’s Standards of Ethical Conduct for the Physical Therapist Assistant [HOD S06-00-13-24]; and c. The Health Insurance Portability and Accountability Act (HIPAA). 4. The PTA will demonstrate knowledge of available community resources/services. (From American Physical Therapy Association: Home Health Section—Guidelines for the provision of physical therapy in the home. http://www.homehealth section.org Accessed April 29, 2010.) such as personal emergency response systems (e.g., of older adults over an extended period of time. How- pendants or bracelets that a patient wears at home to ever, private and government insurers will have to de- activate an alarm that goes to a call center). However, velop new reimbursement policies that include a fee large, regional providers of either a subscription-based structure and standards for “virtual care” or rehabilita- commercial service or a publicly funded “telehome care tion beyond the in-person encounter. The benefits of utility” service that offers equipment rental and a menu telehealth technologies and being able to monitor of patient monitoring options would need to be devel- patients remotely are described in Box 25-18, Point of oped before these types of monitoring systems are read- Care Technologies. ily available. CARE TRANSITIONS AND PATIENT The future trend of postacute rehabilitation is SELF-MANAGEMENT: A VISION “virtual home-based rehabilitation.” In this model, the FOR HOME HEALTH therapist would first conduct an initial in-person assess- ment and then use two-way interactive real-time video- According to the American Geriatrics Society (AGS) posi- conferencing to conduct subsequent visits. By staying tion statement “Improving the Quality of Transitional “connected,” the rehabilitation model could be extended Care for Persons with Complex Care Needs,” practitio- beyond the current face-to-face model. A telehealth ners across health care settings often operate indepen- approach might provide a more affordable means of dently, which interferes with the ability to have seamless tracking the progress and outcomes of large populations

480 CHAPTER 25  Home Health Physical Therapy BO X 2 5 - 1 8 Point-of-Care Technologies Point of Care Technologies: Laptops, tablets, personal digital assistants (PDAs) or other Web-based portals used while a clinician is seeing a patient Benefits • Improves efficiency of clinical processes by making it easier to access and communicate vital information • Provides real-time information and centralizes medical record entries contemporaneously with care • Facilitates use of protocols for assessments and medications management • Improves the accuracy of the information required for electronic validation of OASIS assessments and eliminates data reentry to correct manual errors • Reduces the cycle time for billing • Improves coordination of care and communication between all • Enhances consistency and compliance with orders by providing easy access to plan of care, follow-up notes, and visit schedules Office Automation: Software for home care agencies to track and manage information beginning with the client intake process to workforce management and back office accounting Benefits • Improves efficiency of scheduling of staff and clients by using intelligent scheduling support • Matches staff with clients based on client preferences, staff availability, geographic location, skills required, previous schedule history, and profitability • Improves human resources management by automating time and attendance records, e.g., verifies schedules • Improves general and administrative management through better reporting, financial management, and immediate claim calculation • Automates the documentation of OASIS data and provides validation prior to submission • Manages clinical information quickly and easily • Streamlines physician order tracking process by confirming orders are signed and received by the agency prior to billing and allows physicians to electronically sign their orders • Enables agencies to designate trained case managers to oversee care for certain diagnoses • Tracks patient care so that adverse events are quickly communicated to the entire care team Telehealth: Technologies that include two-way video conferencing, remote vital sign collection and transmission, and education in the home Benefits • Documenting vital signs and symptoms from the home without the intervention of a clinician empowers patients to better control contributing factors that can exacerbate their health conditions, such as diet, exercise, alcohol, insulin and medication use, and stress levels, translating into higher patient satisfaction • Using two-way interactive video improves communications between patients and caregivers, giving the caregivers and patients data in real time, thus enhancing the overall diagnosis • Monitoring patients remotely improves patient care by collecting vital patient information on a daily basis from the patient’s home without the need for a clinician or caregiver to be present, thus eliminating gaps in patient monitoring Telephony: Telephony is communications via a voice messaging system through specialized dissemination to a category of caregivers or broadcast to the entire workforce Benefits • Collects activity codes, supplies, and mileage helping to ensure that information is accurately and immediately captured • Improves scheduling and manages missed visits, no-shows, and reassignments in real time transitions of the patient among care settings.89 During infrastructure to deliver transitional, postacute, and transitions, patients are at risk for medical errors, service primary care/chronic care management for older adults. failures, and ultimately poor clinical outcomes. Interven- tion strategies to improve care transitions involve a SUMMARY timely transfer of health care information from the acute care setting to post–acute care health care providers Although Medicare may limit the definition of home and vice versa. Organizational tools such as care transi- health to short-term, intermittent, treatment-focused tion coaches who support patients and teach self- medical care for homebound patients, these restrictions management skills will enhance health information ex- historically came from when home care was initially change across care settings. When patients and their designed to be incident to acute care. Moreover, reha- caregivers are able to easily track key medical informa- bilitation programs for older adults were considered tion, health care concerns, medications from all prescrib- possible only if delivered in facilities with therapy gyms ers, and their history of provider contacts, patients’ and an array of therapeutic equipment. Home health competence in self-management and likelihood to remain is now recognized as a transition in the continuum independent at home increase. Thus, the authors feel that of care that provides a window of opportunity to affect should tools become widely used to promote seamless the functional abilities of older adults. There are many transitions, home health becomes the only truly scalable functional assessment tests and interventions that are

CHAPTER 25  Home Health Physical Therapy 481 extraordinarily adaptable to being performed in the pa- REFERENCES tient’s home. The provision of evidence-based exercise in the home allows for comparisons of outcomes across To enhance this text and add value for the reader, all settings and overall sound clinical decisions about the references are included on the companion Evolve site patient’s readiness to progress to self-management. All that accompanies this text book. The reader can view the physical therapists should advocate for their patients to reference source and access it online whenever possible. reintegrate into the community and progress to outpa- There are a total of 89 cited references and other general tient care or community-based exercise programs. The references for this chapter. challenges in the home health setting present opportuni- ties for physical therapists to demonstrate their expert clinical decision making while practicing in the most functional environment for their patients.

26C H A P T E R Patient Management in Postacute Inpatient Settings Greg W. Hartley, PT, DPT, GCS, Sabrina Camilo, PT, MSPT, GCS INTRODUCTION provide multidisciplinary, team-oriented services to pa- tients with intense rehabilitation needs. For the purposes Postacute care of the geriatric patient has undergone mas- of Medicare (and most other payors) in order for a pa- sive change since the Balanced Budget Act of 1997 tient to be admitted to an IRF, patients must meet specific (BBA).1 According to the United States Department of criteria, including reasonable and necessary care and a Health and Human Services, Agency for Healthcare significant rehabilitation potential. Patients must also re- Research and Quality, there was a 30% increase (from quire the coordinated care of at least two therapy disci- 4 million to 5 million) in the rate of patients discharged to plines, which includes physical therapy, occupational nursing homes or rehabilitation facilities between 1997 therapy, and speech–language pathology. One of the two and 2006.2 New payment methodologies like prospective disciplines must be either physical therapy or occupa- payment systems (PPSs) have significantly altered patterns tional therapy. Patients are also required to participate in of patient placement upon discharge from acute care set- a minimum of 3 hours of therapy per day, at least 5 days tings.3 These changes have forced physical therapists a week at the time of admission. Therefore, IRFs must be working in these postacute environments to broaden the reasonably assured that patients require these services rehabilitation services offered and to expand upon tradi- and can fully participate at the time of admission. Trial tional roles, most especially skilled nursing facilities admissions are not permitted. Care must be coordinated (SNFs). This chapter will focus on several, but not all, and team oriented, with an emphasis on discharging pa- inpatient postacute care settings. Rehabilitation hospitals tients to the community.5 These criteria were revised in will be discussed briefly since regulatory changes in this 2009 and made effective January 1, 2010.5 environment have subsequently impacted the patient pop- ulation of other postacute care environments.4 The bulk For geriatric patients in a rehabilitation hospital, of the chapter will focus on the nursing home environ- Medicare is most often the payor. Since 2002, CMS has ment, both short-term skilled (subacute) care and long- reimbursed IRFs prospectively, a system referred to as term care (LTC). Specifically, this chapter will address the Prospective Payment System (PPS).6 Because of the how physical therapy practice has evolved to keep pace level of care that is required in IRFs, CMS’s payments with the changing population in these settings. In the are typically higher than other settings.7 Because pay- United States, Medicare is the predominant payor in all of ment is at a higher tier, CMS requires IRFs to meet spe- these settings, and since Medicare is the predominant cific criteria in order to be paid under the PPS. Chief payor for geriatric patients, a discussion of Centers for among these criteria is a requirement that at least 60% Medicare and Medicaid Services (CMS) regulations that of all patients have a diagnosis that qualifies for the impact the provision of physical therapy services in these setting.5 There are currently 13 diagnoses, or diagnostic settings will be provided where applicable. categories, that qualify. These diagnostic categories are collectively called the CMS-13. The qualifying diagnoses INPATIENT REHABILITATION FACILITIES in the CMS-13 are listed in Box 26-1. The remaining 40% of patients admitted to IRFs may have any diagno- Profile of an Inpatient Rehabilitation sis; however, the patients must still meet all of the re- Facility and Its Patients quirements, including admission requirements, a need for multidisciplinary rehabilitation, and intensity of Rehabilitation hospitals, or inpatient rehabilitation service (3 hours/day).5,6 facilities (IRFs), are either free-standing hospitals or units within an acute care hospital whose purpose it is to CMS regulations for IRFs have undergone significant change since PPS became the means of reimbursement 482 Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc.

CHAPTER 26  Patient Management in Postacute Inpatient Settings 483 B O X 2 6 - 1 List of Medical Conditions Requiring Intensive Rehabilitative Services The following list includes the medical conditions that require intensive rehabilitative services (i.e., qualify for inpatient rehabilitation hospital) under revised Title 42 CFR 412.23(b)(2)(iii). (1) Stroke. (2) Spinal cord injury. (3) Congenital deformity. (4) Amputation. (5) Major multiple trauma. (6) Fracture of femur (hip fracture). (7) Brain injury. (8) Neurological disorders, including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy, and Parkinson’s disease. (9) Burns. ( 10) Active, polyarticular rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies resulting in significant functional impairment of ambulation and other activities of daily living that have not improved after an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission or that result from a systemic disease activation immedi- ately before admission, but have the potential to improve with more intensive rehabilitation. ( 11) Systemic vascularities with joint inflammation, resulting in significant functional impairment of ambulation and other activities of daily living that have not improved after an appropriate, aggressive, and sustained course of outpatient therapy services or services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission or that result from a systemic disease activation immediately before admission, but have the potential to improve with more intensive rehabilitation. (12) Severe or advanced osteoarthritis (osteoarthrosis or degenerative joint disease) involving two or more major weight bearing joints (elbow, shoulders, hips, or knees, but not counting a joint with a prosthesis) with joint deformity and substantial loss of range of motion, atrophy of muscles surrounding the joint, significant functional impairment of ambulation and other activities of daily living that have not improved after the patient has participated in an appropriate, aggres- sive, and sustained course of outpatient therapy services or services in other less intensive reha- bilitation settings immediately preceding the inpatient rehabilitation admission, but have the potential to improve with more intensive rehabilitation. (A joint replaced by a prosthesis no longer is considered to have osteoarthritis, or other arthritis, even though this condition was the reason for the joint replacement.) ( 13) Knee or hip joint replacement, or both, during an acute hospitalization immediately preceding the inpatient rehabilitation stay and also meet one or more of the following specific criteria: • The patient underwent bilateral knee or bilateral hip joint replacement surgery during the acute hospital admission immediately preceding the IRF admission. • The patient is extremely obese with a Body Mass Index of at least 50 at the time of admission to the IRF. • The patient is age 85 or older at the time of admission to the IRF. (Data from Centers for Medicare & Medicaid Services: IRF classification criteria website: www.cms.hhs.gov/ InpatientRehabFacPPS/03_Criteria.asp#TopOfPage. Accessed July 15, 2010.) for IRFs in 2002. One of the most significant changes that cannot be provided in a less “intense” environment. occurred in 2004 with the elimination of unilateral total But in general, patients with uncomplicated unilateral joint replacements from the CMS-13 list of qualifying total joint replacements no longer qualify for an inpa- diagnoses.8 After analysis by CMS, it was determined tient rehabilitation hospital level of care. When possible, that these patients could achieve similar outcomes in a these patients when able go directly home from acute less expensive setting (SNF, home health, outpatient).8 care, where they typically receive home health care or Some patients may continue to qualify for the rehabilita- outpatient therapy. However, in many cases, patients are tion hospital setting (in the other 40%) if they meet re- not able to go directly home after acute care.9 Patients in quirements for IRF admission, including requiring more this category are frequently discharged from acute care than one discipline (e.g., physical therapy and occupa- to SNFs, whereas they might have been sent to a reha- tional therapy as well as a coordinated team approach bilitation hospital several years ago. The effects of the

484 CHAPTER 26  Patient Management in Postacute Inpatient Settings changes in CMS policy have contributed to a change in to an IRF.11,12 Accordingly, the remainder of this chapter SNF patient populations over the past several years, will focus on patients/residents in short-term (skilled/ particularly in urban areas, where IRFs are more abun- subacute) and LTC facilities. dant.10 As a result, the total population of patients with major joint replacement in IRFs has decreased more than SKILLED NURSING AND LTC FACILITIES 10% between 2004 (when the elimination of this diag- nostic group became effective) and 2008 as the numbers Profile of a Skilled Nursing Facility of these patients in SNFs has been increasing.11,12 The and Its Patients (Residents) payment system in SNF was reconfigured in 2006, add- ing new payment groups to accommodate the patients A SNF is a nursing home that has been certified by CMS who require some medical monitoring but do not require to provide Medicare-reimbursable short-term skilled the intense level of services provided in IRFs.13 Subse- nursing/therapy services. Among SNF residents, the most quently, CMS findings indicate that many SNFs have common diagnoses are hip fracture, stroke, pneumonia, reconfigured themselves to better care for this type of and heart failure.24 Because the participation and pay- patient (i.e., subacute rehabilitation).12 ment rules for SNFs were created as a “subset” of nurs- ing home rules and regulations, clients in an SNF are re- Inpatient rehabilitation facilities are paid under the ferred to (by CMS) as “residents” (a product of LTC PPS when Medicare is the primary payor. The prospec- language).25 Historically, patients treated in SNFs were tive payment system in IRFs is based on data gathered those with lower functional levels and required longer via a tool called the Inpatient Rehabilitation Facility– courses of treatment (nursing or rehabilitation) in order Patient Assessment Instrument (IRF-PAI).14 Diagnoses, to return to the community. If a return to the community comorbidities, and demographic data are combined with was not possible, patients could potentially stay as an information gathered from the Functional Independence LTC resident. Historically, SNFs also had a greater vari- Measure (FIM) tool.15 Initial FIM scores, along with the ety of diagnoses than rehabilitation facilities (there is no other demographic and diagnostic data combine to de- “60% Rule” in SNFs), with more individuals having termine which case-mix group (CMG) the patient will be lower functional levels.20 Although SNFs have continued assigned to. Each CMG is associated with a payment to care for the complex, lower functional-level patients amount. This payment, set upon admission, is the pay- who may (at least initially) require less intense rehabilita- ment the facility will receive for the care of the patient tion services and longer lengths of stay, SNFs also care for that entire admission. Payment is based on an ex- for a myriad of patients with advanced rehabilitation pected or average length of stay for that particular needs who require relatively short stays, have the poten- CMG. If the patient is discharged to the community tial to return home or to the community quickly, and (e.g., home, assisted living facility), the IRF receives the who tolerate intense levels of rehabilitation services. In entire payment regardless of the patient’s length of stay. fact, in the calendar year 2006, the average length of However, if the patient is discharged to another health stay for patients with Medicare in SNFs nationwide was care delivery site (e.g., SNF, acute care), the IRF receives 26.4 days.26 The regulatory changes in other settings a prorated payment based on the anticipated length of have meant more patients in SNFs have elective joint stay. For example, if the anticipated length of stay replacements, “acute” rehabilitation needs, and the was 16 days, and the patient is discharged to an SNF on potential to make rapid, substantial progress with an day 7, the IRF receives 7/16 of the total projected pay- expected discharge to the community.12 The growth in ment.16,17 Knowledge of the payment system is impor- this group of patients has led to greater use of the term tant for physical therapists. Clearly, it is in the best finan- subacute to describe this cohort more effectively. In addi- cial interest of the rehabilitation hospital to discharge tion, the growth of Medicare Advantage (MA) programs patients to the community and not to another health has also affected rehabilitation utilization in SNFs. care facility. Therapists must be cognizant of this incen- More and more, patients enrolled in MA programs are tive when developing goals and making discharge rec- referred to SNFs instead of other, higher-cost settings ommendations. In addition, physical therapists must such as IRFs.27 understand the importance of accurately capturing FIM scores. These data are used to determine payment and to The availability of SNFs and IRFs makes a difference in generate outcome reports that are shared with external where patients ultimately receive postacute care.18-23 One agencies like CMS and the Joint Commission.16 study confirmed that utilization of services (and therefore total health care costs) is frequently determined by what Although rehabilitation hospitals play a large role in services are available in the community.28 For example, the postacute rehabilitation, the vast majority of Americans study found that where more intensive care beds are avail- needing postacute rehabilitation receive this care in an able, more intensive care is provided. Likewise, where SNF. Although this is partly related to the IRF criteria there are more specialists, more referrals to specialists are described earlier, it is more likely related to accessibility provided. Similar studies have confirmed that the same issues.18-23 Many communities simply do not have access

CHAPTER 26  Patient Management in Postacute Inpatient Settings 485 practice holds true for postacute care placement.22,23 How- BOX 26-2 Major RUG-IV Classification ever, in the authors’ experiences, it is observed that many Category Requirements MA programs will not authorize treatment in IRFs even when the patient has a qualifying complex diagnosis and Ultra High Rehabilitation IRF beds are available. This is an internal administrative Residents receiving physical or occupational therapy, or speech– decision made by each participating MA program. language pathology services Overview of SNF Prospective Rehabilitation Rx 720 minutes/week minimum Pay System (PPS) AND At least one rehabilitation discipline 5 days/week The Medicare payment structure for SNFs is a PPS but is AND entirely different from the IRF system discussed earlier.13 A second rehabilitation discipline at least 3 days/week The SNF benefit under the Medicare system can poten- tially last up to 100 days per qualifying episode. Resi- Very High Rehabilitation dents must have had a 3-day stay in an acute care facility Residents receiving physical or occupational therapy, or speech– at least 30 days prior to admission to a SNF in order to meet criteria for skilled services. There are no specific language pathology services diagnostic criteria for admission; however, residents Rehabilitation Rx 500 minutes/week minimum must require skilled services of a nurse, therapist, or AND both. If Medicare is the primary payor, payment to the At least one rehabilitation discipline 5 days/week SNF is based on a calculated per diem which is, in large part, determined by the amount of rehabilitation services High Rehabilitation provided.29 To determine the exact amount of this per Residents receiving physical or occupational therapy, or speech– diem payment, residents are assessed using the minimum data set (MDS).30 The MDS is an instrument that ana- language pathology services lyzes clinical information as well as utilization of re- Rehabilitation Rx 325 minutes/week minimum sources and categorizes the resident into a “resource AND utilization group” or RUG for payment purposes. The At least one rehabilitation discipline 5 days/week MDS and RUG levels are periodically refined, and the MDS 3.0 was implemented in 2010.31 Medium Rehabilitation Residents receiving physical or occupational therapy, or speech– With the MDS 3.0 and the fourth generation of RUGs (RUGs IV), there are 66 different RUG levels. Of those, language pathology services 23 are directly associated with the amount of rehabilitation Rehabilitation Rx 150 minutes/week minimum provided.13 The RUG level is associated with a per diem AND payment that lasts for a specified period of time. MDS as- 5 days any combination of three rehabilitation disciplines sessments are required on admission (day 1), day 14, day 30, day 60, and day 90 (and also when there is a significant Low Rehabilitation change in status or a readmission).30 There are “grace Residents receiving physical or occupational therapy, or speech– days” that can be used for each assessment due date, allow- ing some flexibility for when the reports are actually gener- language pathology services ated and which dates are actually used; however, when a Rehabilitation Rx 45 minutes/week minimum RUG level is assigned, the SNF is paid the associated rate AND for that RUG for the specified assessment window (day 1 3 days any combination of three rehabilitation disciplines through day 14, day 14 through day 30, and so on). A AND RUG level is assigned for each time interval, so payment Restorative nursing, two or more services, 6 or more days/week can and does vary for each interval. Rx, treatment. As mentioned, the amount of rehabilitation physical therapy, occupational therapy, and/or speech-language Logically, per diem payments are higher for RUGs pathology plays a significant role in determining the with higher rehabilitation utilization because of the in- RUG, that is, payment level. Therapists determine the creased cost of providing rehabilitation. It is important frequency and duration of services (utilization) on admis- to note that physical therapists determine the RUG level sion. The amount of therapy, inclusive of physical when they set frequency and duration of treatment. therapy, occupational therapy, and Speech, provided in a Clearly, this puts decision making, reimbursement, re- week (measured in minutes/week) determines which one source utilization, and staffing levels in the hands of the of several rehabilitation RUGs best classifies the resident. therapist; such authority is a clear example of autono- Please refer to Box 26-2 for a detailed explanation of the mous practice in the SNF setting. Rehab RUGs.29 A third factor is added to the amount of therapy ser- vices provided to determine the final RUG level. This factor includes how much assistance the resident re- quires with several activities of daily living (ADLs) and how much medical care and oversight the resident re- quires. Specifically, if in addition to rehabilitation ser- vices, the resident requires tracheostomy care, a ventila- tor or respirator, or isolation for active infectious disease while a resident, the resident will qualify for a higher payment. Varying degrees of ADL assistance without the

486 CHAPTER 26  Patient Management in Postacute Inpatient Settings medical complexity are associated with slightly lower An exception to the PPS reimbursement system in an per diem rates.30 SNF occurs when a resident has a Medicare Advantage (MA) Plan (formerly known as “Medicare Plus Choice”). As mentioned, if residents require a skilled service, In those cases, Medicare beneficiaries sign up with pri- they may stay in an SNF for up to 100 days.29 After that vate managed care organizations that contract with and point, the “skilled” benefit is exhausted under Medicare are paid by CMS to manage the beneficiary’s care.33 guidelines, and the resident must be discharged or con- As of December 2008, 10.1 million (23%) of the nearly vert to LTC. As one can infer, the SNF benefit was origi- 45 million Medicare beneficiaries have enrolled in MA nally intended for individuals with conditions that re- plans.34 Enrollment has steadily grown each year. quired daily skilled care over a longer period of time MA plans offer a different approach to health care deliv- when rapid recovery or discharge was not necessarily ery than beneficiaries experience under fee-for-service anticipated. This provision would include those who are Medicare. Instead of focusing almost exclusively on not able to tolerate the intensity of services provided in treating beneficiaries when they are sick, these plans also a rehabilitation hospital, who do not meet the other re- place an emphasis on preventive health care services that quirements for rehabilitation hospitals, when the ex- help to keep beneficiaries healthy, detect diseases at an pected length of recovery is relatively long, or in cases early stage, and avoid preventable illnesses. In addition, where the individual may not be discharged to the com- many MA plans help reduce beneficiaries’ out-of-pocket munity. However, this “typical” resident has changed in costs by providing additional benefits not covered in recent years. Although SNFs have always been providers the Medicare program and reducing cost sharing of postacute rehabilitation, the emphasis on rehabilita- for Medicare-covered benefits.35 Facilities that accept tion has grown. This is in large part due to the transition patients/residents with MA must contract directly with of patients who in the recent past would have gone to an each MA plan. Payment is typically a flat fee per day. It IRF or other postacute settings.12,27 Now, because of is not uncommon for MA case managers to determine regulatory changes, payor mix changes, accessibility, and the level of care, including the amount of therapy that some outcome data, these individuals are increasingly will be covered, based primarily on the individual’s going to SNFs.18-23 Recent CMS data indicate that the admitting diagnosis. so-called “rehabilitation RUGs” are the most frequently used RUGs, representing 86% of RUG scores for the All of these factors combined (i.e., payment and regu- fourth quarter of 2009, nationwide.32 As recently as latory changes, growth of the Medicare Advantage 2005, the use of rehabilitation RUGs was 11% lower.32 program, and a lack of accessibility) have led to more acutely ill patients with high rehabilitation needs filling Clearly, rehabilitation services are a large part of the beds in America’s SNFs. These individuals are the services provided by SNFs. Of the rehabilitation treated with aggressive rehabilitation, and most are dis- RUGs used during the same quarter, more than half charged home in a short time.36 So, although the SNF (54.4%) were in the ultra high, very high, and high cat- benefit allows for slower recovery for individuals who egories (Figure 26-1).32 require longer lengths of stay, there is a large and grow- ing cohort of residents who have a relatively short stay 100 in an SNF.37 Although SNFs are legally classified as 90 14.1 nursing homes, the skilled patient (as opposed to the nonskilled, long-term resident) is clearly different today 80 than 20 years ago. 70 38.8 Profile of the LTC Resident (Percent) 60 Non-rehab RUG In some cases, residents do stay in a nursing home as an Rehab medium LTC resident once the SNF benefit is exhausted or when they no longer require skilled services. The leading rea- 50 Rehab high sons for LTC admission are decrease cognition, inconti- nence, decreased falls leading to a decrease in functional 40 11.3 Rehab very high status.38 About 1.46 million residents of all ages lived in Rehab ultra 16,435 nursing facilities in 2006. Of those, 90% were age 65 years or older.38 In 2006, only 3.5% of people 30 16.8 older than age 65 years lived in nursing facilities, a de- cline from 7.5% in 1982.39 It is unknown exactly why 20 the percentage decreased so much during this time. It could be due to economic reasons as the cost of care has 10 19 risen drastically. Alternatively, it might be related to im- proved social support systems, accessibility, or a greater 0 FIGURE 26-1  ​National RUG III Medicare frequencies: fourth quar- ter 2009 (5-day assessment). (From CMS MDS 2.0 Public Quality Indicator and Resident Reports 32.)

CHAPTER 26  Patient Management in Postacute Inpatient Settings 487 focus on health promotion and wellness over the past TABLE 26-1 Percent Distribution of Long-Term several years. However, the percentage is likely to in- Care Residents by Primary crease again in future years as the numbers of individuals Diagnosis at Admission, surviving into their 8th, 9th, and 10th decades of life will United States, 2004 represent the fastest-growing segment of the popula- tion.40 Disability rates are strongly related to age; about Diagnosis Percentage 50% of the population ages 85 years and older has a dis- Distribution ability, compared with only 10% of the population ages 65 to 74 years. Among the population aged 65 years and Diseases of the circulatory system 23.7 older, 69% will develop disabilities before they die, and Mental disorders 16.4 35% will eventually enter a nursing home.41 Other mental disorders 14.2 Diseases of the nervous system and sense 14.0 By definition, long-term institutional care is custodial. Of course, LTC can be interpreted to include much more organs 9.6 than institutional care. The broader definition of LTC Supplementary classification 8.8 would include assisted living (where less supervision is Posthospital aftercare (including fractures) 8.5 provided, but typically some supervised services are of- Alzheimer’s disease 8.3 fered), adult day care (per day/daytime supervised care), Heart disease 6.7 home care or sitter services (nonskilled home care under Diseases of the respiratory system 5.8 the Medicare Part A benefit), and many other local or Acute, but ill-defined, cerebrovascular disease community-based services, whether paid or unpaid. As the population of aging adults who require these services (Data from Centers for Disease Control, National Center for Health Statis- increases, the availability and variety of these alternative tics, National Nursing Home Survey, 2004. www.cdc.gov/nchs/data/nnhsd/ LTC settings and services will also expand. However, for Estimates/nnhs/Estimates_Diagnoses_Tables.pdf#Table33.) the purposes of this chapter, the focus will remain on institutional LTC. performs periodic screens for the need for rehabilitation services. When the need for skilled therapy is identified, In the LTC setting, no regular, skilled intervention is residents are treated under the Medicare Part B (outpa- provided. The staff administer medications and provide tient) benefit, assuming Medicare is their payor, or a simi- ongoing restorative, recreational, and social activities for lar benefit if the individual has a Medicare Advantage residents. Because LTC is, in fact, nonskilled, Medicare product or private insurance. The same rules that apply to does not cover this cost. LTC is paid out of pocket, by regular outpatient (Part B) also apply in the LTC setting. private insurance, or by Medicaid for residents who For example, documentation requirements, billing, and qualify based on their income.42 Medicaid is the primary coding rules are the same. A study commissioned by CMS payor for most nursing facility residents. Almost two indicates that in 2006, 29.2% of all Part B therapy claims thirds (65%) of LTC residents had Medicaid as the pri- were billed from a SNF, more than private practice settings mary payor in 2009. The remaining nursing facility resi- (26.6%) or hospitals (20.0%).46 From these data, one can dents had other sources of payment such as private LTC hypothesize that many of the residents who reside in LTC insurance or paid out of pocket.43 Institutionalization is have the potential to benefit from physical therapy. a term that unfortunately conjures up images of an older person being abandoned forever at the door of some PHYSICAL THERAPY PATIENT dark building. However, admission to LTC institutions MANAGEMENT IN THE LTC SETTING is not permanent in many cases. In fact, in a report to Congress, the Centers for Disease Control and Preven- The clinical management of the LTC resident who is not tion, National Center for Health Statistics, indicated receiving the “skilled” benefit (i.e., not in SNF) will be that 29.2% of all LTC residents are discharged to the the focus of the remainder of the chapter. Long-term community because they have either stabilized or recov- residents are different from those patients who are in a ered.44 The average length of stay for all nursing home nursing home for short stays receiving skilled services. As residents (which includes the skilled residents as well as discussed previously, in today’s health care environment, the long-term residents) is 341 days, which includes SNF residents present clinically as “subacute” patients, those who are discharged to the community, those who and the clinical management of those types of patients are discharged to acute facilities, and those who die in and diagnoses is dealt with in various other chapters of the facility. Of those who die while a resident, the aver- this text. Long-term residents are those patients who, for age length of stay is 729 days.44 Table 26-1 describes the whatever reason, reside in the nursing home for extended most common diagnoses for residents in LTC settings at periods of time, often for the reminder of their lives. the time of admission.45 There are a wide variety of functional abilities among these patients. Although many individuals are frail, not If permanent residence is required, a wide variety of all fit that description. Of the settings discussed in this services are available to residents to ensure quality of life chapter, long-term residents show the most variability in for the remainder of life. In long-term settings, staff

488 CHAPTER 26  Patient Management in Postacute Inpatient Settings functional abilities, ranging from being an independent 4 . Slow walking speed ambulator to being totally bed-bound. 5. Low levels of physical activity47 In the LTC setting, the goal is often to return the In a study of 5317 older individuals who were living resident to a prior level of function or higher. The prior in the community, Fried et al found that 6.9% of these level of function, though, may be lower than that of a individuals were frail.47 They also found that frailty was patient in a rehabilitation hospital or even SNF. For ex- a reliable predictor of a general decline in health. Frailty ample, the prior level of function may be ambulation of was highly associated with cardiovascular disease, low short distances with a rolling walker, or perhaps it is education and poverty, hospitalization, and death. The simply the ability to sit independently. However, thera- frail older adult faced increased risk for falls, deteriorat- pists should not underestimate the residents’ ability to ing mobility, and disability. As frailty is not a disease per make significant improvements, sometimes beyond the se, other diseases and medical problems are related. prior level of function. Residents whose status com- Rothman et al suggest that the frailty phenotype might monly declined by virtue of disuse and with physical be strengthened by the inclusion of cognitive impair- activity along with physical therapy, can reasonably ex- ment. In their study to determine the independent prog- pect the achievement of a higher functional level. This nostic effect of seven potential frailty criteria, including variability of patient function coupled with altered men- five from the Fried phenotype, it was found that cogni- tal status (in some cases) and complex regulations can tive impairment was associated with chronic disability, make for challenges as well as opportunities in the LTC long-term nursing home stay, and death and the magni- setting. These opportunities create a perfect environment tude of these associations was comparable to that of the for autonomy in decision making and teamwork with weight loss criteria.48 other health professionals, especially nurses and physi- cians. In the LTC setting, the therapist must function as The problems or conditions that cause frailty are a team member who will delegate tasks and follow multifactorial and interrelated in a cycle of cause and through with other team members. Collaboration be- effect represented in Figure 26-2.49 Sarcopenia, or loss tween team members is vital to the success of any LTC of muscle mass, can lead to weakness, difficulty walk- therapeutic program and can be one of the greatest chal- ing, falls, and eventually immobility. Less oxygen (Vo2) lenges of this setting. Next we will highlight important reaches the tissues and organs of someone with athero- differences and nuances in the physical therapy assess- sclerosis, which can lead to cognitive impairment. ment and management of residents in the LTC setting. Vascular disease caused by atherosclerosis can result in nutrient deprivation of the muscles, slow walking Frailty in LTC speeds, and ultimately sarcopenia. Decreased balance can initiate the vicious cycle in which a fall can lead to Frailty is highly prevalent with increasing age and thus it is fear of falling and decreased mobility. Depression can imperative for the good management and treatment of older cause failure to thrive, weight loss, and decreased mo- adults, especially those in LTC settings, for physical thera- bility. Cognitive impairment can lead to a decline in pists to understand it.47 When one thinks of frailty, the pic- mental processing time and reaction speed, resulting in ture that commonly comes to mind is one of a bed-bound falls. The relationship of multiple physical factors that contracted resident in a nursing home or an extremely ky- are associated with frailty was examined by Brown photic, osteoporotic older woman sitting in a wheelchair. et al.50 They combined chair rise and Romberg test But the frail older adult extends beyond those stereotypes, to the original seven functional items of the Physical and it is important to realize that frailty is not a disease but Performance Test (PPT)51 to examine the relationship rather a combination of a variety of medical problems. of factors believed to be associated with frailty, includ- The term frail should be considered a cluster of medical ing isometric and dynamic strength, range of motion conditions and not a characterization—differentiated from (ROM), sensation, coordination, balance, and reaction disability or advanced old age. time. Their findings strongly indicate that frailty is mul- tidimensional, and evaluation of only one domain does Geriatricians define frailty as a biological syndrome not provide complete insight into this phenomenon. It of decreased reserve and resistance to stressors resulting is important to highlight that they also found that bal- from cumulative declines across multiple physiological ance items were the most strongly associated with systems and causing vulnerability to adverse outcomes.47 frailty.50 Fried et al provide a standardized definition for frailty that is widely accepted.47 These authors suggest that The Modified Physical Performance Test used by Brown someone should be considered frail if that person has et al and presented in Box 26-3 can be used to determine three or more of the following five characteristics: the severity of an older adult’s frailty. Each of the nine items on the PPT is worth a maximum of 4 points, for a perfect 1. Unintentional weight loss (10 lbs or more in a year) score of 36. For purposes of their study, the group with PPT 2. General feeling of exhaustion (self-report) scores ranging from 32 to 36 was considered “not frail,” 3 . Weakness the group with scores ranging from 25 to 32 points was

CHAPTER 26  Patient Management in Postacute Inpatient Settings 489 Dysphoria Pain Cognitive impairment Dementia Atherosclerosis Anorexia Decreased Decreased physical balance activity Falls Testosterone cytokines ↑ Homocysteine Undernutrition Sarcopenia Vo2max Fear of Hip falling fracture Healthy Functional impairment Frail Falls/fractures Disease Institutionalization Fried’s definition Weight loss Exhaustion Weakness (grip) Slow walking speed Low physical activity FIGURE 26-2  C​ auses of frailty. (Redrawn from Morley JE: Frailty: management and treatment. Website: www.thedoctorwillseeyounow.com/ content/art2070.html?getPage=2.) considered to have “mild frailty,” and the group with PPT muscle weakness leads directly to the simple preventive scores between 17 and 24 points was considered to have and remedial strategy of physical exercise.52 The type of “moderate frailty.” It has been their experience that those exercise program that will be most beneficial remains to scoring below 17 points no longer function independently be determined but is likely to include balance activities, within the community.50 resistance training, and endurance types of exercise.50 Understanding the relationship of multiple impair- Screening in LTC ments to frailty will better enable the clinician to develop appropriate treatment strategies for the remediation of The continuous-care nature of LTC requires ongoing frailty. Residents who are frail and in LTC may take and regular screening of the functional status of each longer to achieve goals than patients in other settings. resident. Although there is no regulation that designates However, the frail older adult should not be excluded a specific discipline to conduct screens, physical thera- from any therapeutic interventions as this patient popu- pists are aptly qualified to perform them. Screenings are lation can benefit from strength training just as the not meant to replace an evaluation and should be used healthy older adult. Physical activity and exercise are of to determine a change in status, for better or worse. Im- extreme importance to break the frailty cycle. Boltz sug- portant information on residents’ status can be obtained gests that the starting point of the cycle is muscular from the MDS, but the therapist should obtain informa- weakness. He defines frailty as “a state of muscular tion beyond the MDS. A more comprehensive picture of weakness and other secondary widely distributed losses any change is usually obtained from nursing staff, nutri- in function and structure that are usually initiated by tionists, and residents themselves. The therapist per- decreased levels of physical activity.”52 Older persons forming the screening should then visually inspect and/ may be less active as a result of habit or limitations or observe the resident. Changes in ability to transfer, to caused by certain conditions. The decline in physical ambulate, any new onset of pain, worsening or develop- activity initiates sets of negative outcomes, as seen in ment of contractures, new difficulty in eating, swallow- Figure 26-2, that accelerate the deterioration process. ing or speaking, and difficulty propelling the wheelchair Acknowledging that the state of frailty is keyed by

490 CHAPTER 26  Patient Management in Postacute Inpatient Settings BO X 2 6 - 3 Modified Physical Performance Test BOX 26-4 Medicare Coverage for Skilled Items Therapy in LTC (Part B) 1. Book lift. • Service must be of a level of complexity and sophistication, or A 7-lb book is lifted from waist height to a shelf 12 in. above the condition of the patient must be of a nature that requires shoulder level. Scores are based on the time required to the judgment, knowledge and skill of a qualified therapist. This complete the task. means that the services can only be performed by a qualified therapist. If a CNA, family member or other caregiver can 2. Put on and take off a coat. perform the treatment, then it probably does not meet this Subjects put on and take off a standard lab coat of appropriate criterion. Document tests and measures, functional assessments, size as quickly as able. Scores are based on the time re- special techniques and specialized teaching that only you can quired to complete this item. provide as part of your scope of practice. 3. Pick up penny. • Positive Expectation for Improvement: The condition of the Subjects pick up as quickly as possible a penny that is located patient is expected to improve materially in a reasonable and 12 in. in front of the foot. Scores are based on the time generally predictable period of time or services must be neces- required to complete the task. sary for the establishment of a safe and effective maintenance program. Ask yourself what do you see in the patient’s environ- 4. Chair rise. ment and behavior that suggests intervention would be benefi- Subjects sit in a chair that has a seat height of 16 in. They then cial (i.e., social support, prior level of function, motivation and stand fully and sit back down, without using the hands, five attention, ability to follow directions). times, as quickly as possible. • The services must be considered under accepted standards of 5 . Turn 360 medical practice to be a specific and effective treatment for the Participants turn both clockwise and counterclockwise quickly patient’s condition. This requires knowledge of the research. but safely. They are subjectively graded on steadiness and Know the tests and techniques that have been found to be ability to produce continuous turning movement. effective within our scope of practice. 6. 50-ft. walk. • The service must be reasonable and necessary for the treatment Subjects walk 25 ft in a straight line, turn, and return to the of the patient’s condition including amount, frequency and initial starting place as quickly as possible, safely. duration of services. Documentation of a change of condition, ongoing problems and risk factors can add support to the neces- 7. One flight of stairs. sity of your treatment. Documentation of the patient’s complica- The time required to ascend 10 steps. tions and safety issues related to his or her impairments and functional deficits is important to meet this criterion. 8 . Four flights of stairs. Participants climb four flights of stairs. One point is given for (From Medicare benefit policy manual, Chapter 15: Covered medical each flight of stairs completed. and other health services. http://www.cms.hhs.gov/manuals/Downloads/ bp102c15.pdf. Accessed July 15, 2010.) 9. Progressive Romberg test. Subjects are scored according to their ability to maintain a reduced base of support: feet together, semitandem, and full tandem, for a maximum of 10 seconds.50 should be noted. Inspection of the prosthesis, braces, or requirements of each specific payor; however, many pay- splints can identify problems that may impair mobility ors will follow CMS’s lead. and/or comfort and safety. Periodic assessment of the fit of the prosthesis or orthosis is necessary as the resident Gait training and ambulation are clear differentiators may experience muscle atrophy and weight loss over of a skilled service and a nonskilled service. Gait training time. When function is measured over time, a snapshot provided by a physical therapist or physical therapist of the resident’s ability to maintain basic self-care activi- assistant is considered skilled care under CMS criteria ties is obtained and indicates if there has been a decline, under three conditions: (1) when a therapist needs to improvement, or stabilization of a condition.53 After give specific instructions, verbally or manually, to a resi- recognizing resident’s change in functional status, physi- dent in order to improve the gait pattern; (2) a gait as- cal therapists working in an LTC setting may determine sessment needs to be made to determine the impairments that skilled intervention is required or they may refer the causing any abnormalities; or (3) recommendations need resident to a restorative nursing program. Therapists to be made for assistive devices. When a therapist deter- should attempt to make this decision process as objective mines that no improvement can be made in the gait pat- as possible. Therefore, it is of paramount importance for tern, but a resident should continue walking to maintain the physical therapist to understand payor definitions of the functional status or simply improve distance ambula- skilled therapy. tion for endurance, it can be performed in a restorative nursing program and does not require the skill of a Medicare sets forth its definition of skilled physical therapist. It is also important to differentiate between therapy services in § 220 and § 230 of Chapter 15 of the manual cues and physical assistance. A resident can be in Medicare Benefit Policy Manual.54 The CMS definition a restorative nursing program even when physical assis- of skilled therapy is presented in Box 26-4. It is incum- tance is required to ambulate as long as the referring bent upon the physical therapist to understand the therapist believes it is safe, and the person assisting is

CHAPTER 26  Patient Management in Postacute Inpatient Settings 491 providing support to the resident where no significant BOX 26-5 Comparison of Causes of Falls in functional improvement is expected. Nursing Home and Community-Living Populations Ranked by Prevalence Active ROM or passive ROM provided in order to maintain the range does not require the skills of a physi- Nursing Home Community-Living cal therapist and can be performed in a restorative nurs- Gait or balance disorder or Environmental related ing program. However, exercise to improve ROM or to Other causes maintain range in a complex circumstance, such as in a weakness Gait or balance disorder or joint near an unstable fracture, should be performed by Dizziness or vertigo a physical therapist or physical therapist assistant. It is Environmental related weakness important to understand that goal setting and plans of Other causes Drop attack care in an LTC setting will be different when compared Confusion Dizziness or vertigo to goals and plans of care provided in a rehabilitation Visual disorder Unknown hospital where patients tend to quickly improve in func- Drop attack Confusion tion. LTC residents may not require treatment for mobil- Unknown Postural hypotension ity deficits at all. The potential for skin breakdown alone Syncope Visual disorder may warrant admission to skilled services for position- ing, education, devices, contracture management, and (Data from Rubenstein LZ, Josephson KR, Robbins AS: Diagnosis and treat- prevention. As with all patients, a thorough history and ment: falls in the nursing home. Ann Intern Med 121(6): 442-451, 1994. chart review are the first two steps to determine the need http://www.annals.org/content/121/6/442.full#T2) for skilled therapy. history can be fundamental in establishing an appropri- EXAMINATION AND EVALUATION ate intervention and prevention. Box 26-5 compares the causes of falls in nursing-home and community-dwelling History individuals.57 Although information provided in the chart, such as his- Physical therapists are often the ones identifying resi- tory of condition, MDS scores on ADLs, nutritional dents at risk for falls resulting from medications, includ- status, and laboratory values, is important when deter- ing their adverse effects and polypharmacy concerns, mining the plan of care and setting goals, history taking and this information should be shared with the nursing should not be limited to the medical chart. Interviewing and medical staff. Sometimes falls may be reduced by the resident and staff most involved with the resident is just decreasing or reducing a medication. In a trial con- key. Certified nursing assistants, restorative nursing staff, ducted by Tinetti et al in a community-based population, nutritionists, and any other staff that have regular inter- medication review was specifically identified as part of a action with the resident can provide information, such as multifaceted intervention.58 In this study, sedatives were how much assistance the resident needs and whether the withdrawn and the number of medications was de- resident’s ability to perform ADLs has changed recently. creased. The intervention group demonstrated a relative The individuals in regular contact with the resident may fall-risk reduction of 31%. Other studies targeting the be the first ones to realize a resident’s change in func- reduced use of psychotropic, cardiovascular, and analge- tional status and behavior. sic drugs have also reported success in decreasing the risk of falls in older people.59-63 The role of the physical Any history of falls and mitigating circumstances for therapist in identifying these risk factors by taking a the falls should be noted. Some facilities may have fall thorough history cannot be underestimated. For exam- assessment teams, often directed by a physical therapist, ple, adverse drug reactions such as orthostatic hypoten- where the team analyzes the reasons for a particular fall sion and dizziness are common, and medications should or looks for patterns that may be contributing to falls be reviewed carefully for their contribution to the cause and then discusses and plans ways to intervene. of falls. Ooi et al reported that more than half of 900 nursing home residents studied had at least one The incidence of falls in LTC institutions is about episode of orthostatic hypotension during the trial three times the rate for community-dwelling older adult period.59 Their operational definition for orthostasis was persons.55 This increase is caused both by the nature of a 20 mmHg or greater decline in systolic blood pressure persons living in institutions and by more accurate re- (BP) 1 or 3 minutes after changing from a supine to a porting of falls in institutions. Falls are a major determi- standing position. Orthostatic hypotension was most nant of functional decline, nursing home placement, and frequent before breakfast. Those patients with persistent restricted activity.55 LTC residents are generally more orthostasis tended to complain of dizziness or light- frail than older adults living in the community. They also headedness, be independent in ambulation, have hyper- may have difficulty with concentration or memory and tension (systolic greater than 160 mmHg or diastolic may need help getting around or taking care of them- greater than 95 mmHg) or mood disorders, be taking selves.55,56 All of these factors are linked to falling, and determining the cause of the fall through an extensive