APTA Home Health Quarterly Report Vol. 56, No. 3

The Quarterly Report

SUMMER 2021

Vol. 56 | No. 3

In this
Issue:

1 Predicting The Future of Predicting The Future of Home Health
Home Health
By Julie Hardy, PT, MS
2 Did You Hear?
Read All About It! One of the many lessons learned from Michael P. Johnson, PT, Ph.D., is
COVID is that predicting the future is far from the President of the Home Health
6 CMS releases CY 2022 an absolute science. However, forward-thinking Practice at BAYADA Home Health
Home Health leaders look to past developments and trends Care in Moorestown, NJ. The
Proposed Rule to anticipate and prepare for what is coming. Home Health Practice, one of nine
We recently interviewed a few of our industry specialty practices at BAYADA, is comprised
8 1 Rep Max Living: leaders to gather their thoughts on where they of over 90 offices in 16 states that provide
What It Is & How To Avoid It see home health moving in the future. care to over 20,000 clients weekly through a
multidisciplinary team approach delivered by
13 Evidence-informed They are: over 2,500 clinicians and staff.
Home Health
Management of Total April Anthony has a background in Anthony (Tony) D’Alonzo, PT, DPT,
Knee Arthroplasty accounting and is the founder and MBA, is the Vice President of Clinical
former CEO of Encompass Health – Strategy and Innovation at BAYADA
16 Efficacy of Home Health and Hospice. She is also Home Health Care, the nation’s
Telerehabilitation the founder and Executive Chairman largest nonprofit provider of home
Versus In-Person of the Board of Homecare Homebase, one of the health services. In this role, Tony oversees the
Care in the Home leading providers of home health and hospice design and implementation of new care delivery
Health Setting software in the industry. strategies in coordination with partner health
systems and health plans.
22 APTA’s PT Moves Me
Campaign: Continued on Page 3
Spreading the Word About
the Profession

22 2021 APTA House of
Delegates Packet
Posted

23 Celebrating APTA’s
100th Birthday, Home
Health Style!

Published by the Home Health Section - APTA Did You Hear?
a component of the American Physical Therapy Association
Read All About It!
Editor
Dawn Widmer-Greaves, PT, DPT A New Resource and ‘Home’ for Learning!

Managing Editor/Design The Home Health Academy of the American Physical Therapy
Don Knox Association has been busy! Immediately following the Board’s
approval of a name change from the Home Health Section, we
Publications Committee commenced the development of a new logo and are excited to
Zachary Hampshire, PTA; Julie Hardy, PT, MS; Olaide announce that it will be ready for unveiling soon. Once that occurs,
Oluwole- Sangoseni, PT, DPT, MSc, PhD; Aban Singh, the process of re-branding the website, publications, and other
PT; Molly Miller, MSPT; Matt Janes, PT, DPT, MHS items will begin.

Section Officers: In addition to the technical changes at the Academy, the
President......................................Diana Kornetti, PT, MA Board and Committees are doing more than ever to advance the
Vice President............................... Chris Chimenti, MSPT future of PT in the home. For example, the Home Health Toolbox II
Secretary.................................. Monique Caruth, PT, DPT is already available in its digital format and will soon be accessible
Treasurer............................. Philip Goldsmith, PT, DScPT in print; the Practice Committee is working on a 4th edition
Executive Director..............................................Don Knox of Providing PT in the Home; and the Practice and Publications
Committees are collaborating on the Home Health Academy’s first
The Home Health Section Quarterly Report is the peer-reviewed journal.
official publication of the Home Health Section of
the American Physical Therapy Association. It is One of the recent developments that we are most excited
published four times per calendar year (Winter, Spring, about is the creation of the Home Health Academy’s own ‘Learning
Summer, Fall). Statements of fact and opinion are the Center,’ which can be found through the Academy’s website or
responsibility of the authors alone and do not imply an accessed directly at https://aptahhs.mclms.net/en/
opinion on the part of the officers or the members of the
Home Health Section. Much of the Home Health Academy’s educational content has
previously been housed, along with hundreds of other offerings,
Article & Content Contributions on the APTA’s Learning Center. As grateful as we are for the APTA
Guidelines for contributions are available from the providing a home for the content, given our growing educational
Home Health Section website. If you have materials you catalog and plans for the future, the Board determined that it
would like considered for publication, please email them was quickly becoming necessary for the Academy to have its own
via attachment to the Home Health Section Executive Learning Center. That vision is now a reality!
Director: [email protected].
Several key features of the new Learning Center include its
Advertising user-friendly design and intuitive features, making it easy to
Advertising rates and details are available from the navigate and find courses of interest. The system can also keep
Section website, www.homehealthsection.org, or by track of CEUs’ that a user has earned and, once a course is taken
contacting the Section office at 720-459-5559. and the quiz or assessment completed, automatically sends an email
with a personalized CE certificate of completion. No waiting!
Electronic subscriptions to the Home Health Section
Quarterly Report are available at a rate of $100/year. The new Learning Center already contains the courses used in
Order through the Section's online store. the Academy’s Advanced Competency in Home Health Certification
(ACHH), as well as nine different electives. Physical Therapists
Copyright ©2021 by Home Health Section - APTA and Physical Therapist Assistants wishing to complete their
ACHH certification and advance their career have a full 24 months
Postmaster: Send address changes to Home Health
Section APTA , PO Box 3406 , Englewood, CO 80155. Continued on Page 12

www.homehealthsection.org APTA Home Health Section
PO Box 3406 • Englewood, CO 80155 • 720-459-5559

Page 2

Continued from Page 1

Price Ransom, MSPT is the Vice President and Senior delivery and embrace technology that will allow the patient and the
National Therapy Director of Business Development at home health clinician improved “real-time” access to one another.
LHC. He is responsible for assisting in the development Therapists and nurses must practice at the top of their license and
and implementation of therapy-related growth utilize crossover skills that are within their scope of practice to
initiatives and senior living business development across reinforce the interventions that each discipline has established in a
the United States. patient’s plan of care.

Derek Norman, PT, DPT, ATC, is the Chief Clinical The acuity level in home health has increased over the last
Officer for Kindred at Home. Kindred at Home is the several years. How do you see this impacting collaboration
largest provider of home health care, hospice, and across the continuum of care and disciplines?
specialty health services in the United States with over
500 locations. APRIL: It is so true that the acuity of homecare patients is as great
as I have seen during my 30-year career in home health care. For
How do you see Value-Based Payment (VBP) impacting that reason, we are being asked to do exponentially more than we
care delivery? have ever done before, and yet we are not receiving exponentially
more reimbursement for it. As a result, we have to be creative in
APRIL ANTHONY: If done right I hope that VBP doesn’t have finding ways to bring the extra value by providing non-visit-based
any impact upon care delivery. I have always believed that the interventions, coordinating with other providers, and leveraging
best practices in care delivery should be considered independently family resources. I am hopeful that the realization of this acuity
from the reimbursement structure. No matter how we are paid shift will become evident to the payor community and that the
we should be doing all we can to deliver exceptional, high-quality reimbursement increases and structural expansions needed to
care in the most cost-efficient manner. That being said, the one comprehensively address the needs of these patients will follow.
way that VBP could impact care delivery is by altering the scope of
care that is provided. Depending on the nature of the value-based TONY: We can validate that statement with data showing our
arrangements, we could see home health care agencies having average case-mix weight has increased, along with the qualitative
the ability to expand the breadth of services so that high-quality, feedback from our clinicians who report an increasing acuity in
cost-effective care could be even better. For example, consider what our patient base. Numerous factors are driving this, led by the
could happen if home health care providers could coordinate all increasing shift toward the home as the preferred post-acute
needed services including, for example, non-medical home care setting. This moves high complexity patients, historically seen as
services, pharmacy services, and nutritional services. Under that SNF-level, directly home after a hospital stay. This growing acuity
model, we could become true chronic care managers and we could emphasizes the importance of collaboration across disciplines from
potentially bend the cost curve while providing exceptional value - the beginning. We emphasize one core goal – to keep the patient
both to the patient as well as the overall healthcare system. safe at home. This requires communication to create a team-based
plan of care, as opposed to more siloed discipline-specific goals.
TONY D’ALONZO: We expect VBP to expand to the national While each discipline will approach the patient from their angle, we
level, potentially as early as 2022. Just as star rating reporting emphasize working toward a common plan as a team.
was transformative for the industry, VBP could add a wider array
of publicly reported quality measures to the mix, and thus will DEREK: Along with a steep increase in acuity over the past few
impact payment. We have realized that a key driver is the addition years, we also see home health shifting to serve a wider variety
of new functional composite measures, which incorporate OASIS of patients, disease processes, and conditions. COVID-19 has
assessment items that were not previously included in the quality contributed to this shift, bringing its increased acuity, several
star rating calculations. These composite measures emphasize comorbidities, and chronic conditions to the home health space.
the importance of accurate OASIS assessment (correctly capturing This higher acuity level and increased visit frequency have created
the complexity of our patient population), as well as the need for a strain on capacity in home health and worsened existing staffing
therapy when patients demonstrate functional deficits. In this challenges. However, as a result, we have seen disciplines work
aspect, the VBP model once again validates the vitally important more collaboratively, with an increased movement toward “top
role of therapists in the home health setting. of license” practicing. As an industry, as patient acuity increases,
it is ever more important that coordination, collaboration, and
DEREK NORMAN: Value-based care delivery is the present and communication with referral partners and healthcare providers
future of home health. We should continue to see this expand and remain paramount to foster success in caring for patients at home.
consider this a positive for the home health industry. It comes down
to the definition of value: do your best, efficiently take the resources PRICE: As acuity levels continue to increase, it is a must that post-
you have, and provide the best possible outcome every time. acute providers knock down the silos that have historically existed
along the continuum of care. By improving communication and
PRICE RANSOM: To be competitive in alternative payment models collaboration with upstream service providers, the home health
such as VBP, the home health industry must continue to innovate clinician will have the necessary information to hit the ground
the delivery of care to improve efficiencies, streamline costs, running on the first visit and address the specific needs of each
optimize clinical outcomes, and improve each patient’s experience patient. Technologies that allow for remote patient monitoring
of care across the continuum. We must continue to adapt care continue to improve the home health clinician’s ability to make

The Quarterly Report | Summer 2021 Page 3

necessary interventions promptly and address complications as patient and the overall healthcare industry remains strong. We will
they arise. Home health clinicians’ improved ability to remotely learn, we will grow and we will evolve as an industry and continue
monitor areas such as vital signs, medication compliance, to find our place as the low-cost/high-quality solution to the
hydration levels, and activity levels have helped to decrease re- expanding needs of an aging population.
hospitalizations and improve clinical outcomes.
TONY: We believe that more care will be delivered in the home
What have you learned from PDGM that will inform your setting over the next 5 years. To be able to support that growth,
business planning or direction over the next year? we need great people to deliver that care. Much of our current
focus is around staffing and recruiting for all clinical disciplines,
APRIL: That non-visit-based interventions have a valid place in as well as streamlining our onboarding and orientation processes.
the care planning process. PDGM forced home health providers Home health is a unique setting, and we want to create a seamless
to think differently about how to deliver care more efficiently. We transition for therapists and nurses to join us and become proficient
continue to find ways to do that cost-effectively through the use of in the home, regardless of their prior experience. We expect the
non-visit-based interventions such as high-risk phone calls, remote battle for staff to intensify, but we believe our core mission and
monitoring, and texting applications. company values will continue to draw talent to support our patients
in the home. In addition, physical therapists and other clinicians
TONY: We believe that PDGM has been less disruptive and will need to be much more aware of VBP models as their outcomes
potentially more transformative than originally predicted. become a greater determinant for payment. In contrast to recent
Specifically, there was a fear that PDGM would drive agencies to changes that negatively impacted payment for therapy services
heavily reduce therapy usage, and potentially shorten the length of (PDPM, PDGM), VBP has the potential to reward those clinicians
stay for patients, driven by a decreasing reimbursement rate after and teams whose performance drives better outcomes.
the first 30 days of care. However, as we ended 2020, we looked
back at our average therapy visits per episode. We learned that DEREK: One of the most important hurdles to overcome is the
this number remained consistent with averages from 2019, before nursing shortage. Somehow, we need to figure that piece out. We
PDGM. We transitioned into PDGM emphasizing the need for may have an opportunity to leverage things we have not been able
individualized care planning based on the goals of each client – the to do in the past related to HR components. Five to seven years ago
right care, at the right time, by the right team of disciplines. We we had a similar problem in therapy and had to find a solution with
began this transition in 2019, moving to a new care-planning model recruiting and retaining therapists. We need to do the same now for
where our clinicians would participate in daily Zoom “huddles” nurses and this applies to many healthcare settings. The next area
to briefly discuss the goals and plan of care for each new patient. of focus needs to be on how to redefine the way that we provide
As we transitioned into 2020, this model gave us stability and a home health services today. COVID-19 has been a catalyst to move
structured forum to discuss patient needs, despite the disruption us forward in connectivity with patients with predictive analytics
from the pandemic. and machine learning to become smarter on how and when to
provide services to patients.
DEREK: A few things come to mind…as far as the overall construct
of PDGM, I feel it was in the right direction. I think we have learned PRICE: As we move forward, the home health industry must be able
that a very thorough start of care and a better-defined focus of care to attract, recruit, and retain “best-of-class” therapists, nurses, and
has enhanced the patient experience and overall outcome. PDGM home health aides who are equipped to provide the highest level of
has changed the demographic of patient types seen within home care possible to an ever-increasing number of seniors who wish to
health toward greater complexity. However, it remains true that age in place in the comfort of their own homes.
regaining, maximizing, or maintaining function continues to be a
high-level focus for every home health episode. What strategies or policies are you developing in consideration
of social determinants of health (SDOH)?
PRICE: Therapists in the home health industry must continue to
establish plans of care for their patients that result in achieving APRIL: Our data tells us that one of the most reliable predictors of
optimal clinical outcomes, as evidenced by maximizing an patient need are SDOH. Understanding more than just the clinical
individual’s opportunity to remain at their highest possible level of issues is critical to our ability to keep patients out of the hospital
functional independence in their home and prove our value to all of and keep them safely at home. We must have a holistic view of the
the various payor sources. patients we serve and factor all the elements of their environment
into our care planning approach.
What do you see as the most important priorities/influences
over the next 5 years for home health? TONY: We have engaged with several managed care organizations
to begin to collect and report on SDOH information for our
APRIL: I think the changes that will be brought on by shared risk patients. We recognize that a successful home health episode is
relationships with payors will alter the focus we place on care heavily influenced by environmental factors such as access to
planning, care monitoring, and care provision. Each year we are caregiver support, meals, and transportation. These are too often
going to have to learn to achieve more with less, but I think we overlooked. While capturing SDOH information is the first step, the
are prepared for this challenge. Home health has lived under the data will only hold value if we take action based on those findings.
consistent pressure of declining rates, and yet our value to the We are working closely with health plans to create expectations

Page 4 APTA Home Health Section

for care coordination and developing individualized action plans retaining of clinicians, as well as the day-to-day scheduling tasks
for our high shared-risk patients, while also leveraging additional to promote consistency and efficiency in the delivery of care to a
programs that may be offered by the payor or community. Health patient in their home over a large service area. If you are up to the
equity and access to care remain a barrier in many communities aforementioned challenges (to name just a few) that come along
and will continue to be a focus for us moving forward. with opening a home health agency, then you will find that there
is nothing more rewarding than providing therapy and nursing
DEREK: We are looking for areas of opportunities – what is services to a patient, helping them maintain an active lifestyle and
available to serve as an asset to the patient to reduce the overall remain in their home.
burden? Medicare Advantage provides opportunities to put in
stopgaps as part of the benefits package to help provide solutions, What have you learned from COVID and how has it changed
once the issues and barriers are identified. Clinicians on the front your approach to care?
lines must be aware of SDOH that act as limiters and involve social
work to provide community and support-based solutions if needed. APRIL: I haven’t found much to like about COVID, but I do think
it has heightened our awareness of infection control, challenged
PRICE: As a provider of home health services, LTAC hospitals, our mindset around the way care is delivered, shown us the value
community-based services, and hospice care, we have historically of non-visit based care interventions and it has reminded us of the
provided care to individuals in regions and areas identified as having value of simple telephone interaction. Most of all it has reminded us
significant social barriers to healthcare services. These patients and of the beauty of human interaction and human touch. Sometimes
their caregivers have benefited from access to the highest level of you take things for granted until they are taken away from you and
care made possible by the aforementioned service providers. then you realize just how lucky you were

What advice would you give to someone who is thinking of MICHAEL JOHNSON: We learned that the basics of patient
starting a home health business or a career in home health? care, people management, and leadership overall are extremely
important and effective. Daily communication to staff and clients
APRIL: This will be one of the most challenging and most rewarding became routine. Clear accurate information and transparency are
things you will ever pursue. I love what home health care is all about. the most effective antidote to fear and anxiety. Practicing truly
It is cost-effective, high quality, and best of all, it involves providing holistic health care has proven to be beneficial to both patients
care where the patients want to receive it - In their own home. In and staff. Spending as much – and sometimes more – time tending
addition, you will work with some of the most amazing people who to patients’ social, emotional, and spiritual needs was essential
will astound you with their willingness to go the extra mile. What a during the pandemic. The physical and functional recovery of
blessing it is to be involved in home health care. patients remained a key goal, but it had to be balanced with a more
humanistic approach than ever before. Finally, paying attention
TONY: Home health is an extremely rewarding practice setting to and providing care for each other. Our clinicians and staff were
for our clinicians. Being able to work one-on-one with patients in experiencing the same fears and anxieties as the patients and
their own homes can lead to amazing functional improvements families they were trying to serve. This made for a new and unique
and a real impact on our patients’ everyday lives. We have many challenge that required us to provide a higher level of leadership
therapists who shift from a career in the outpatient or inpatient than ever before.
setting and quickly fall in love with home care. However,
starting an actual home health business is more complicated. DEREK: COVID forced the movement of care into the home. It
The administrative burden is growing each year, exemplified by highlighted the fact that patients want to be treated at home. It has
regulations like Review Choice Demonstration and the expansion of shown us the necessity of multidisciplinary care, care collaboration,
VBP. Aside from the regulatory considerations, there is significant and coordination of care. During this time, I took time to learn and
competition in most markets and the barrier to entry is high. If appreciate what great clinicians we have within home health and
you are thinking about starting a home health agency, it will likely experienced the meaning of “our heroes work here”. It also forced
present its fair share of challenges. us to focus on technology and has pushed us forward much more
quickly than anticipated; from this, we shall see great benefits for
DEREK: I have been in home health for over 16 years, and it our patients.
continues to be more difficult and complex. Don’t assume it is an
easy business. My advice would be to take the time to ensure you PRICE: Dealing with COVID-19 over the past 16 months or so has
understand the complexities before jumping in. However, it is the reminded us that we as an industry must always be nimble and
future for healthcare, and we will continue to serve as a solution for flexible to best meet the needs of every patient we are privileged
many patients with varying levels of acuity. to serve. More than ever, home health leaders and clinicians have
had to stay abreast of the constantly changing state and national
PRICE: Home health is a highly competitive and dynamic regulations as they were implemented rapid-fire to combat the
industry that requires a great deal of expertise and resources pandemic. Home health clinicians across the country demonstrated
to be successful. It is an industry that requires awareness of all the utmost professionalism by continuing to provide care for their
the various state and national level rules and regulations and patients amid a global pandemic. In many instances where there
knowledge of the various payors and alternative payment models. were pandemic “hot spots,” home health agencies served a key role
In addition, there are challenges with the recruitment and in decreasing the strain on hospitals that were at or near full capacity

The Quarterly Report | Summer 2021 Page 5

by accepting patients with higher acuity levels and successfully 6. Embrace change.
caring for them. In the majority of instances, home health clinicians 7. Embrace technology.
were successful at keeping patients from going back to a hospital or
back upstream to a congregate healthcare setting. And to end with, here are some final words of wisdom from two
of our executives:
In summary
MICHAEL: We should expect significantly more opportunities for
Clearly, physical therapists can’t afford a “business as usual” care delivery in the home with higher levels of clinical complexity
strategy. If we are to be prepared for the future, we must see that will require new models of care and increasing levels of clinical
ourselves as proactive, collaborative participants in the healthcare competence and multidisciplinary teamwork. Collaboration,
community. We must continue to grow and evolve. Here are some communication, and integration of services will become more and
key points gleaned from our executive interviews. more important as the four walls of the institutional settings are
replaced with the four walls of the home. To that end, a high level
1. Quality over quantity. Adopt a value-based mindset. of clinical knowledge and competence will certainly be required,
Practice at the top of your license and make each visit but to excel in the evolving landscape of health care payment and
propel the patient toward better overall health. delivery, physical therapists will need high levels of emotional
intelligence as well, to support the increasing expectations for
2. Staffing and retention will be one of the most important team-based care (communicate, collaborate, listen, adjust), self-
priorities over the next 5 years. motivation, grit, adaptability, and resilience.

3. Care redesign is crucial. We must KNOW our upstream and PRICE: The most successful home health clinicians will be able to
downstream care partners across the continuum recognize, adapt, and embrace clinical innovations and technology
and COLLABORATE on all aspects of care to the best of that will improve efficiencies in the delivery of care and clinical
our abilities. outcomes for their patients. There is no greater job satisfaction
than establishing a plan of care with skilled interventions that
4. No more siloes – between disciplines within your result in helping an individual live the life they wish to live in the
organization or between your care partners in the wider comfort of their own home.
value-based continuum.

5. Shift focus from reaction to prevention. Engage patients to
focus on their health goals, needs, and abilities to achieve
desired health outcomes.

CMS releases CY 2022 Home Health Proposed Rule

By Dawn Greaves, PT, DPT, and Shannon Liem, MS, CCC-SLP; COS-C

On June 28, the Centers for Medicare and Medicaid Services Expansion of the HHVBP
(CMS) released the Calendar Year (CY) 2022 Home Health CMS proposes to expand the program nationwide. The existing
proposed rule.
model, currently in nine states, would end one year early. CMS
Per CMS, the proposed rule “would accelerate the shift from would utilize the 2019 data as the baseline year instead of 2020
paying for Medicare home health services based on volume to a data, with the first performance year of the expanded program
system that pays for value and quality by proposing a nationwide being 2022 and impacting payment adjustments in 2024. Per
expansion of the Home Health Value-Based Purchasing CMS, the Third Annual Evaluation Report showed an average
(HHVBP) Model.” In addition, the proposed rule contains improvement of 4.6% in home health agencies (HHA) quality scores
the CY 2022 Home Health Prospective Payment System Rate from the calendar year 2016 to 2018 for the current participating
Update, first-year data from the PDGM, case mix and groupings states. They also note an average annual savings of $141 Million
changes, proposed LUPA changes for OT, and its provisions to Medicare. Given the importance of the functional measures
“make permanent changes to the home health Conditions of in quality reporting, as physical therapists, we can add value to
Participation (CoP) that were implemented during the COVID-19 our agencies by advocating for the care patients need to achieve
Public Health Emergency (PHE)”.1 optimal outcomes in this model.

Page 6 APTA Home Health Section

Updates to the HH Prospective Payment System (PPS) for groups under the PDGM has an associated case-mix weight and

CY 2022 LUPA threshold. CMS’ policy is to annually recalibrate the case-mix

As required by statute, CMS is proposing updates to the HH weights using the most complete utilization data available at the

payment rates for the calendar year 2022. The estimated net time of rule-making. In this proposed rule, CMS is proposing to

increase would be 1.7% (1.8% HH payment update percentage, recalibrate the case-mix weights, functional levels, and comorbidity

minus the 0.1% decrease with the continued implementation of adjustment subgroups using CY 2020 data to more accurately pay

reductions to the rural add-on percentages). The changes to the for the types of patients HHAs are serving”

rural add-on are mandated by the Bipartisan Budget Act of 2018. CMS suggests changing the point value to the various OASIS

items that comprise the calculation for the functional impairment

First-year data from PDGM level. Changes to the point values are noted in Table 1.

CMS tracked utilization data under PDGM since its

implementation on Jan. 1, 2020, as compared to 2018 data utilized Changes to CoPs

when designing the model. Below are some of the key points noted During the PHE, a waiver allowed for Occupational Therapy to

from that data. perform the Start of Care and initial assessment if any other skilling

• Low Utilization Payment Adjustment (LUPA) percentage of discipline was present in the initial orders, including nursing

8.6% vs. the expected 6.7% as long as the orders weren’t for nursing only. CMS proposes to

• The average number of visits per 30-day period dropped by continue to allow Occupational Therapy the ability to perform the

1.27 visits across all disciplines initial assessment and SOC OASIS. The allowance, however, does

• Physical therapy visits decreased

by 0.6 visits (from 3.3 to 2.71) per Responses Previous Pt Value Proposed Pt Value
30-day period
2020/2021 2022

• Episodes per patient decreased from M1800 Grooming 0 or 1 0 0
3.13 in 2018 to 2.93 in 2020 2 or 3 5 3

• High functional impairment level in

41.7% of 30-day payment periods, vs. M1810 Upper Body Dress 0 or 1 0 0
the expected 31.2%

• High comorbidity adjustments 2 or 3 6 6

in 14% of 30-day periods vs. the 0 or 1 0 0
expected 9.2%

Due to the timing of the public health M1820 Lower Body Dress 2 55

emergency (PHE) brought about by the 3 12 12
novel coronavirus, analysis of the data and

attributing those changes solely to the 0 or 1 0 0

model changes, would be difficult. CMS, M1830 Bathing 2 31
“is not proposing any specific method or 3 or 4 13 9
behavior assumption payment adjustments,”

in this year’s proposed rule. M1840 Toilet Transfer 5 or 6 20 17
As noted by CMS in the rule, they, 0 or 1 0 0
2, 3 or 4 5 5
“anticipate potentially seeing further 0 0
variability in this percentage as we continue 0
to analyze full claims data from CY 2020
and subsequent years and considering that

the COVID–19 PHE is still ongoing. We M1850 Transfer 1 3 3
intend to propose a methodology and, if 2, 3, 4, or 5 7 7
appropriate, a temporary and permanent

payment adjustment based on our analysis M1860 Ambulation 0 or 1 0 0
in future rule-making. However, we note 2 96
that by not proposing any adjustment for 3 11 6
CY 2022, this could potentially result in

larger, compounding payment adjustments 4, 5 or 6 23 19
in future years to fully account for the

difference between assumed versus actual Three or fewer marked 0 0
behavior change on estimated aggregate excluding 8, 9 or 10
expenditures beginning in CY 2020.”
M1032 Risk of Hosp

Changes to Functional Impairment and Four or more marked 11 12
Comorbidity Adjustments and Grouping excluding 8, 9 or 10

Interactions Table 1: Comparison of point values assigned to Functional Measure in 2020/20212 as
Per CMS, “Each of the 432 payment compared to the proposed rule for 2022

The Quarterly Report | Summer 2021 Page 7

not permit OT to initially establish the home health benefit for About the authors
Medicare Part A patients. Meaning, for OT to perform the SOC and Dawn Greaves, PT, DPT, BS is the VP of Home Services
initial assessment, PT and/or SLP need to be ordered at the start of for Aegis Therapies and has practiced in various
the episode and nursing cannot initially be on the plan of care. settings since graduating from Indiana University with
her BS in PT in 1982. She completed her transitional
There are also changes to the supervision and oversight of DPT at Des Moines University in 2010. Over the last 20
home health aides. CMS will allow supervisory visits to occur via years, her practice focus has been Home Health. She
interactive telecommunications. appreciates the opportunity to share her passion for
home care through the support of therapists delivering
Notice of Admission (NOA) services in this functionally focused treatment setting.
Starting in 2022, the Notice of Admission (NOA) process will She is currently serving as the publications chair and
editor of the Quarterly Report for the Home Health
replace the No-Pay RAP which was put in place in 2021. HHAs will Section of the APTA.
submit a one-time NOA that establishes the HH period of care and
covers all contiguous 30-day periods until the patient is discharged Shannon Liem graduated from Florida State University
from the agency’s care. This NOA must be submitted by day 5 of with a Master’s Degree in Communications Disorders.
the episode. Delayed submissions will result in a 1/30th reduction She has been a licensed speech-language pathologist
in payment to the agency for each day it is late. in the state of Florida for more than 28 years with
experience in acute care, skilled nursing facilities,
Please Share Your Comments outpatient, and home health. She has been employed
Comments are due to CMS on or before August 27th. You can by Aegis Therapies for the last 24 years and currently
serves as a National Clinical Director for Home Health
submit your comments to CMS through the APTA Regulatory Services. She is COS-C certified since 2015.
Action Center site. (https://www.apta.org/advocacy/take-action/
regulatory) You will also find a link to the CMS fact sheet about the References
rule through this same link. 1. Centers for Medicare and Medicaid Services. CMS.gov. https://www.cms.

The rule may be reviewed at the following link: https://www. gov/Center/Provider-Type/Home-Health-Agency-HHA-Center. Accessed July
federalregister.gov/public-inspection/current 14th, 2021
2. Centers for Medicare and Medicaid Services. CMS.gov. https://www.cms.
The summary information provided by CMS can be located gov/medicare/home-health-pps/home-health-pps-and-home-infusion-
at: https://www.cms.gov/newsroom/fact-sheets/cms-proposes- therapy-archive. Accessed July 14th, 2021/
calendar-year-2022-home-health-prospective-payment-system-
rate-update

1 Rep Max Living:
What It Is & How To Avoid It

By Dr. Dustin Jones, PT, DPT, GCS, CF-L1

“Hi, Doris! It’s nice to meet you. I’m your physical therapist This seems like an innocent and harmless situation, doesn’t it?
and I’m going to help you with your low back pain.” Eight weeks go Let’s dive deeper.
by and Doris has gone from a 9/10 to a 1/10! She’s ecstatic with her
outcomes so you decide it’s time to discharge. Another successful For Doris to simply pick up her laundry basket, she had to use
course of care! Or was it? 90% of her maximum effort (9# / 1RM of 10# = 90% of her 1RM).
A common household chore was now a maximum lift. Now think
Doris, feeling much better, then attempts to do her laundry about other tasks that Doris may have to do throughout the day;
for the first time in weeks. She goes to pick up her laundry basket going up and down the stairs, laundry, getting dressed, bathing,
(9 pounds) and barely picks it up with an all-out effort. The most multiple transfers per day. If picking up 9 pounds is a near max
Doris can lift off the ground is 10 pounds. This equates to a 1 effort, imagine how these other tasks may make her feel.
Rep Max (1RM) Deadlift of 10 pounds.1 Doris quickly realizes she
doesn’t have the strength or stamina to meet the demands of Doris is experiencing 1 Rep Max Living - when the demands of
laundry so she quits and heads back to the “safety” of her recliner. life are near or exceeding one’s capacity.

Page 8 APTA Home Health Section

Many people may be performing maximal efforts multiple safety must be valued in exercise prescription. However, we must
times per day.2,3 This way of life can potentially result in fatigue, not let the ultimate pursuit of safety result in under dosage and
impaired performance, and reduction in activity levels. The true be a detriment to our patients. This has been demonstrated in the
significance of 1RM Living lies within the concept of physical world of fall prevention in acute settings. Research has shown that
resilience and reserve. To maintain health, function, and measures to maximize safety such as restraints and bed alarms can
independence across the lifespan, one must be able to minimize have negative functional implications on patients and can even
the detrimental effects of injury, illness, or other stressors that increase the rate of falling.5
inevitably occur as we age. This capacity is coined as physical
resilience.4 a physically resilient person is also considered to have In the realm of exercise prescription, physical therapists can
more physical reserve - the difference between one’s physical often equate higher intensity activities to holding a greater risk
capacity and the demand of an activity or process. The concept for patients and thus will be more hesitant to leverage higher
of physical resilience and reserve is portrayed well when viewed intensities which can be beneficial for older adults.6 Many believe
through the lens of functional trajectories (Figure 1). this assumption is a large factor in the prevalence of under dosage
in geriatric physical therapy. Let’s consider the other side of that
The greater the physical capacity, the greater the physical equation. How dangerous is it to prescribe low-intensity activities?
resilience and reserve, making individuals more capable and less What can happen if we don’t provide an adequate stimulus to
susceptible to detrimental effects of injury, illness, or other stressors. elicit positive adaptations? Consider Doris’ situation. We could
The lesser the physical capacity, the lesser the physical resilience easily prescribe “safe” (underdosed) exercises that could fail to
and reserve, making individuals less capable and more susceptible to prevent functional decline. With this in mind, one could argue that
detrimental effects of injury, illness, or other stressors.4 ensuring safety with underdosed exercise is dangerous.

Why does this matter in home health physical therapy? Now, let’s discuss ways we can identify 1RM Living and
This matters because one of the most effective ways to increase address it.
physical capacity is exercise. Yet, day in and day out in many home
health agencies, patients are not receiving exercise or are getting Identifying 1RM Living
underdosed therapeutic exercise that fails to impact their lack
of capacity. Clinicians can even deliver exercise with the hopes There are two main methods to identifying if one is 1RM
of improving certain physical deficits but provide too little of a Living: Observation and Outcome Measures.
stimulus to elicit meaningful change and can thus allow continued
functional decline. Observation

A common concern for many clinicians when prescribing When observing for 1RM Living, we want to pay attention to
exercise for older adults is safety, and for good reason. An injury clues that can tell us that someone is having difficulty meeting
or adverse event experienced by an older adult often has greater the demands of life. Are there signs showing that the patient is
functional implications than for a younger individual. Therefore,

Figure 1 - Functional Trajectories & 1RM Living
Functional Trajectory Chart demonstrating the relationship between physical capacity, physical reserve, and 1RM Living. When
one’s physical capacity is near the demands of life, they are 1RM Living. This individual also likely has limited reserve and
resiliency to different types of stressors.

The Quarterly Report | Summer 2021 Page 9

having difficulty maintaining their home? Are they able to perform collect goes way beyond a score. The data you collect with many of
common activities of daily living (ADLs) and instrumental activities these outcome measures can be predictive of functional decline,
of daily living (iADLs)? How is the patient’s mobility throughout a fall, hospitalization, experiencing a chronic condition, and risk
the home? These are common observations by a home health of mortality.7,8,9,10 Leveraging the use of outcome measures can
clinician yet it’s easy to miss the significance of those observations. signal to a clinician that a patient is lacking in a particular physical
Those observations are all clues into the physical capacity of your domain that could result in 1RM Living. This information can help
patient, or lack thereof. clinicians prioritize building physical capacity in their plans of care.
Table 1 highlights common outcome measures that can be of use.
Outcome Measures
Addressing 1RM Living
A large focus in the geriatric medical and physical therapy
literature is prevention. One aspect of prevention is identifying If we identify that our patient is 1RM Living, our chief aim
those that are at risk of an adverse event, whether it be a fall, is to increase their capacity. The most potent method to increase
functional decline, hospital admission, etc. A special emphasis has one’s physical capacity is properly dosed exercise.4 Whether the
been placed on outcome measures as an effective method to assess goal is to improve balance, strength, mobility, or endurance,
the risk of an adverse event which can lead to intervention and there are specific considerations in prescribing exercise for older
ultimately prevention.4 adults to increase the odds for success. We will focus on three key
considerations to build capacity. Exercises should be:
Outcome measures also give the clinician a glimpse into
a patient’s functional capacity which can influence the plan of • Specific
care. Many of us are already using these outcome measures and • Progressive
gathering this data. Yet, it is important to realize that the data you • Sustainable

Outcome Measure Area of Assessment Relevant Cut Off Scores

Activities-Specific Balance Confidence Scale A self-report measure of balance confidence <67% indicates a risk for falling in the non-
(ABC Scale) in performing various activities without losing specific patient population.
balance or experiencing a sense of unsteadiness.

Patient-Specific Functional Scale (PSFS) Assesses functional ability to complete specific
activities. Can give insight into the patient’s
values &/or concerns.

Gait Speed Assesses an individual’s functional mobility. The <1.0 m/s indicates a risk of functional decline in
very simple screen can serve as a predictor of a older adults.
decline in functional mobility.

Grip Strength A measure of isometric muscle strength of the <26kg for men & <16kg for women has
hand and forearm can be a predictor of decline in been associated with a higher hazard for
Timed Up & Go functional mobility among many other outcomes. cardiovascular disease, respiratory disease, and
Short Physical Performance Battery Test (SPPB) functional decline.
Berg Balance Scale (BBS) Assesses mobility, balance, walking ability, and
fall risk in older adults. >14s indicates an increased risk of falling.

Assesses lower extremity function in older ≤10 indicates mobility disability in community-
adults. Common measure in screening for frailty. dwelling older adults.

Assesses static balance and fall risk in adults. <45 indicates a greater risk of falling in older
Some community-dwelling older adults will adults.
ceiling out this test.

Mini Balance Evaluation Systems Test (Mini Balance assessment that identifies 6 different <16-20/32 has been shown to predict falls in
BESTest) balance control systems so that the rehabilitation various patient populations.
approaches can be designed for different
balance deficits.

Table 1 - Geriatric Outcome Measures
Relevant geriatric outcome measures that can be useful in clinical practice. Test details can be found at https://www.sralab.org/
rehabilitation-measures.17 Relevant cut-off scores typically vary by population and will likely evolve along with the research.

Page 10 APTA Home Health Section

Specific challenging in practice. Let’s discuss a few concepts to ensure
success in exercise program implementation.
In physical therapy and sports training, the SAID principle
(Specific Adaptations to Imposed Demands) asserts that the human Setting Expectations
body adapts specifically to imposed demands.11 Exercise programs
should reflect this as well. Physical therapy interventions should For many older adult patients, exercise may be relatively
promote adaptation to specific deficits in performance as well as new or novel. Thus, we should set positive and clear expectations
specific deficits in function. This is only achieved by performing a to increase our patient’s odds of success. Positive expectations
thorough assessment that investigates both. We do acknowledge that relating to physical activity have been shown to demonstrate
many patients will present with very common clinical patterns and physiological benefits (decreased weight, blood pressure, body
thus interventions can look very similar. But we must not let this be fat, waist-to-hip ratio, and body mass index) despite no change
an excuse for non-individualized, cookie-cutter exercise programs. in physical activity levels.14 It can be helpful to build positive
expectations with patients by discussing how exercise will help
Of particular importance for older adults is the specificity them reach their goals and desires. We can also discuss how
of a balance exercise program. Balance interventions should be exercise can ultimately improve pain levels and can help people
specific to the particular balance component that is demonstrating become more resilient.15
decreased capacity.11 Leveraging a valuable assessment tool (such
as the previously mentioned MiniBESTest) can assist in identifying Along with setting positive expectations, clinicians also
particular deficits in balance capacity which will then inform an want to set clear expectations. A regular exercise program can
appropriate intervention. be new territory for many, so clinicians can be of great service by
setting realistic and clear expectations. Discussing topics such as
We must also not ignore function in exercise programs delayed onset muscle soreness, what is an acceptable level of pain
for older adults. Skills such as the ability to get out of a chair, or discomfort during exercise, and ways to modify activities in the
manage steps, traverse different surfaces, and getting to presence of pain or discomfort can help ensure patients continue
and from the ground are very valuable for older adults. An with an exercise program.14
individualized exercise program should address these skills
where deficits may be present. Early Success

Progressive For many older adults, negative experiences early on in the
rehabilitation process can be detrimental to the therapeutic
Exercise programs should be progressive in nature to continue alliance. Positive experiences, or early success, can help build a
to promote adaptation. More importantly, exercise programs should therapeutic alliance that could positively impact the clinician’s
progress to a particular level that correlates to the patient’s desires ability to progress activities, especially in the presence of pain.16
and goals. This requires a regular reassessment of one’s capacity The key to ensuring early success for patients is prescribing
and adjustments of the different variables of the program. With exercises appropriate to the patient’s level of capacity and
the common goal for our patients to continue exercising beyond irritability. Having patients attempt activities that will likely result
physical therapy, educating patients about triggers for progression in failure or large spikes in painful symptoms may not be beneficial
can be helpful and can promote self-efficacy. Even a relatively early on in the rehabilitation process. In the context of Doris, it
simple exercise program that emphasized triggers for progression may not be helpful to prescribe exercises that may increase her
has been shown to reduce the rate of falling by 55% in a long-term irritability without focusing on improving upon her chief complaint
residential aged care facility.12 Stating and following clear triggers of low back pain. Once Doris has had early success regarding
of progression can ensure adequate intensity is achieved while her chief complaint, it will likely be more sustainable to then
patients are in physical therapy and potentially beyond discharge. incorporate exercise focusing on her particular performance and/or
functional deficits.
Sustainable
With this in mind, exercise programs for certain patients may
Last but not least, clinicians must consider the sustainability initially be considered to be underdosed, or at a low intensity,
to build therapeutic alliance rather than promote physiologic
of an exercise program. There is value to continued exercise adaptation. One can glean powerful information from a thorough
beyond the relatively short duration of most courses of physical assessment and measures such as the previously mentioned
therapy. A sustainable exercise program can be maintained over Activities-Specific Balance Confidence Scale to help determine an
time. To create a sustainable exercise program, clinicians need to appropriate intensity when initially prescribing exercise.
consider the patient’s preferences, goals, resources, and health or
exercise literacy. Using a limited number of exercises, giving clear In Conclusion
triggers for progression, and utilizing common or familiar activities
may promote adherence.13 Further referral to community-based Consider the importance of 1RM Living and what that can
programs and leveraging telecommunication can positively impact mean for your patients. Also, consider the opportunity that you
adherence as well.13 have to make an extraordinary impact on the quality of life of your
patients. Helping your patients build their physical capacity, builds
Tips for Implementation their resilience. If you can achieve this with your patients, you have
truly changed someone’s life, now and in the future.
Implementing an exercise program to build capacity can be

The Quarterly Report | Summer 2021 Page 11

About the author 8. Celis-Morales CA, Welsh P, Lyall DM, et al. Associations of grip
Dustin Jones is on faculty in the Older Adult Division strength with cardiovascular, respiratory, and cancer outcomes
of the Institute of Clinical Excellence, co-owner of and all-cause mortality: prospective cohort study of half a
StrongerLifeHQ.com in Lexington, KY, and a former million UK Biobank participants. BMJ. 2018;361:k1651.
home health clinician. He is on a mission to advance
care for older adults across the spectrum of health care 9. Eagles D, Perry JJ, Sirois M-J, et al. Timed Up and Go predicts
and fitness. functional decline in older patients presenting to the
emergency department following minor trauma†. Age Ageing.
Bibliography 2017;46(2):214-218.
1. Reynolds JM, Gordon TJ, Robergs RA. Prediction of one
10. Chun S, Shin DW, Han K, et al. The Timed Up and Go test and
repetition maximum strength from multiple repetition the aging heart: Findings from a national health screening of
maximum testing and anthropometry. J Strength Cond Res. 1,084,875 community-dwelling older adults. Eur J Prev Cardiol.
2006;20(3):584-592. Published online October 20, 2019:2047487319882118.
2. Bryanton M, Bilodeau M. The role of thigh muscular efforts in
limiting sit-to-stand capacity in healthy young and older adults. 11. Brody LT. Effective therapeutic exercise prescription: the right
Aging Clin Exp Res. 2017;29(6):1211-1219. exercise at the right dose. J Hand Ther. 2012;25(2):220-231; quiz
3. Hortobágyi T, Mizelle C, Beam S, Devita P. Old Adults Perform 232.
Activities of Daily Living Near Their Maximal Capabilities.;
2003. 12. Hewitt J, Goodall S, Clemson L, Henwood T, Refshauge
4. Whitson HE, Duan-Porter W, Schmader KE, Morey MC, Cohen K. Progressive Resistance and Balance Training for Falls
HJ, Colón-Emeric CS. Physical resilience in older adults: Prevention in Long-Term Residential Aged Care: A Cluster
Systematic review and development of an emerging construct. Randomized Trial of the Sunbeam Program. J Am Med Dir
Journals of Gerontology - Series A Biological Sciences and Assoc. Published online 2018. doi:10.1016/j.jamda.2017.12.014
Medical Sciences. Published online 2016. doi:10.1093/gerona/
glv202 13. Hughes KJ, Salmon N, Galvin R, Casey B, Clifford AM.
5. King B, Pecanac K, Krupp A, Liebzeit D, Mahoney J. Impact Interventions to improve adherence to exercise therapy for falls
of Fall Prevention on Nurses and Care of Fall Risk Patients. prevention in community-dwelling older adults: systematic
Gerontologist. 2018;58(2):331-340. review and meta-analysis. Age Ageing. 2019;48(2):185-195.
6. White NT, Delitto A, Manal TJ, Miller S. The American
Physical Therapy Association’s top five choosing wisely 14. Crum AJ, Langer EJ. Mind-set matters: Exercise and the placebo
recommendations. Phys Ther. 2015;95(1):9-24. effect. Psychol Sci. 2007;18(2):165-171.
7. Owusu C, Margevicius S, Schluchter M, Koroukian SM, Berger
NA. Short Physical Performance Battery, usual gait speed, grip 15. Smith BE, Hendrick P, Bateman M, et al. Musculoskeletal pain
strength, and Vulnerable Elders Survey each predict functional and exercise—challenging existing paradigms and introducing
decline among older women with breast cancer. J Geriatr Oncol. new. Br J Sports Med. 2019;53(14):907-912.
2017;8(5):356-362.
16. Moore AJ, Holden MA, Foster NE, Jinks C. Therapeutic alliance
facilitates adherence to physiotherapy-led exercise and
physical activity for older adults with knee pain: a longitudinal
qualitative study. J Physiother. 2020;66(1):45-53.

17. Shirley Ryan AbilityLab. https://www.sralab.org/rehabilitation-
measures. Accessed July 2, 2021.

Continued from Page 2 APTA Home Health Section

from the time they begin their first online course (see https://aptahhs.
memberclicks.net/achh for more information).

Besides providing a more organized platform for the ACHH, the
Academy’s Learning Center will allow new material to be produced and
added more efficiently. Even more exciting, we can now capture and
organize Academy events, free and paid continuing education,
and even member-generated content for on-demand viewing.

It’s a great time to be a member of the Home Health
Academy of the APTA, and we’re confident that the future
is bright for physical therapy clinicians in the home who are
willing to keep learning and applying the knowledge gained to
the benefit of those we serve.

Henry Ford once said, “Anyone who stops learning is old,
whether at twenty or eighty. Anyone who keeps learning stays
young.” The greatest thing in life is to keep your mind young.

Let’s stay young and keep moving!

Page 12

Evidence-informed Home Health Management
of Total Knee Arthroplasty

By Babatope Olusina, PT, DPT and Olaide Oluwole-Sangoseni, PhD, DPT, MSc.

Introduction Physical therapy (PT) plays a major role in the initial
Osteoarthritis (OA) is a degenerative joint disorder that conservative management of the knee pain before TKA, not only
for pain management but also to improve function and decrease
affects the articulating bones, the articular cartilage, and the limitations afflicted by the condition. Following a TKA, the
surrounding soft tissues. Other causes of joint pain and home health physical therapist is part of the multidisciplinary
degeneration include rheumatoid arthritis (RA), osteonecrosis, team approach that manages the patient upon discharge home.
post-traumatic degenerative joint disease, and other pathologic Our Home Health Agency (HHA) has developed protocols to
conditions. While joint pain is usually the first sign that prompts manage these patient populations effectively. Based on previously
the decision to seek medical attention1, other symptoms soon established protocol with the referring Orthopedic Surgeon, a
develop, including but not limited to joint hypomobility and registered nurse (RN) completed the initial visit, performing
muscle weakness. The progression of the disease results in the a comprehensive assessment of the patient, including the past
development of functional limitations such as difficulties with medical history (PMH), assessment and care of the surgical
transfers, gait abnormality, stair management, and completing incision, medication review/teaching, and the OASIS elements. This
activities of daily living (ADLs), eventually having negative HHA also has established protocol with other Orthopedic Surgeons
impacts on work, pleasure, and quality of life. where the PT is the admitting clinician. The initial PT evaluation
consists of a detailed musculoskeletal assessment of the patient,
The knee joint is the largest weight-bearing joint in the a review of the patient’s PMH, gait and balance evaluation, and a
body, and chronic knee pain has been listed as a “leading cause of home safety evaluation. A PT plan of intervention is formulated to
musculoskeletal disability in the United States (US)”. 2 Total knee address noted impairments and functional limitations, with the
arthroplasty (TKA) is the surgical replacement of the natural knee patient’s self-stated goal as the endpoint.
joint with a prosthesis. It was first performed in the US in 1968,
and with ongoing advances in the technique and materials used, The purpose of this case report is to highlight the physical
significant progress has been made in its effectiveness and success therapy management of TKA in the home health setting.
rate. A 2010 prevalence study of TKA by Kremers et al3 estimated
1.52% in the entire US population, and 4.55% in those over the age of CASE PRESENTATION
50 years, have had TKA. Prevalence is higher in women as compared The patient is a 50-year-old female office worker referred
with men, and it increases with age. Inacio et al4 projects that the
number of TKAs performed in the US will increase by the year 2050 to home PT and Nursing following a right TKA revision due to
to a prevalence of 2.85%, amounting to 2,854 procedures per 100,000 instability and eventual failure of hardware. She resides with her
US citizens. Partial knee replacement is often performed when the husband in a single-level house, with 8 entrance steps, and she was
degenerative changes are confined to a particular compartment of fully independent with all of her functional mobility, including
the knee and mostly in the younger patient. The PT management is ambulating without an assistive device, but she was limited by right
similar to that of a TKA, as described later in this study. knee pain and the knee “locking up”.

The Quarterly Report | Summer 2021 Page 13

PMH: significant for Hypertension, Diabetes Mellitus, muscles, the International Classification of Functioning, Disability
Hyperlipidemia, Asthma, Anemia, Cervical spine stenosis, Elevated and Health (ICF) model ICD diagnosis of M25.661 (stiffness of right
Hemoglobin, Ehlers-Danlos syndrome, Depression, Metabolic knee, not elsewhere classified), was made.
syndrome, and Premature Ventricular Contraction (PVC). Her past
surgical history is significant for Bilateral TKA, Anterior cervical PLAN OF CARE
discectomy with fusion, and Caesarean Section.
PT determined that patient will benefit from skilled
Medications: intervention with a frequency of 3 times per week for 3 weeks,
• Acetaminophen, 500mg, 1 tab Q 4 hours as needed. per previously established protocol with referring surgeon. The
• Apixaban, PO, 2.5mg, 1 tab twice daily intervention included therapeutic exercises (including a range of
• Benadryl, 25mg, 1 cap daily motion [ROM], strengthening exercises, and joint mobilization),
• Celebrex, 100mg, 1 cap twice daily functional mobility training (including bed mobility, transfer, gait,
• Vitamin D3, 125mcg, 1 tab daily and stair training), instruction in-home exercise program, balance
• Crestor, 5mg, 1 tab daily reeducation, safety education, equipment training, patient and
• Doxycycline Monohydrate, 40mg, 1 cap daily caregiver education, and training, to progress her to independence
• Ferrous Sulfate, 325mg, 1 tab twice daily in all areas.
• Lisinopril-HCTZ, 20-12.5mg, 1 tab daily
• Metformin, 500mg, 1 tab twice daily 1. Patient has a diagnosis of Ehlers-Danlos Syndromes (EDS)6,
• Oxycodone, 5mg, 1 tab Q 4 hours, as needed a connective tissue disorder with joint hypermobility as one of
• Senna with Docusate Sodium, 8.6mg-50mg, 1 tab daily its primary symptoms. Her therapeutic exercises, especially her
• Singulair, 10mg, 1 tab QHS ROM, were modified according to her symptoms and feedback.
• Zyrtec, 10mg, 1 cap twice daily Therapeutic exercises prescription and progression was developed
• Vitamin B12, 1,000mcg, 1 tab daily based on the phase of her rehabilitation, described as follows:
• Cephalexin, 500mg, 1 tab 3x daily (started on 12/27/20)
Days 1-10 acute phase (with emphasis on ROM, isometric and
OBJECTIVE EXAMINATION AND ASSESSMENT isotonic exercises)

Physical Status: During her initial evaluation completed on • Right quadriceps isometric contraction in a supine position,
12/26/20, Valerie presented as alert and oriented to person, time, sustained for 5 seconds, 10 repetitions;
and place, and able to follow multi-level commands. She presented
with hypomobility of her right knee (flexion ROM at 81 degrees • Isotonic exercises in supine and sitting position including
and extension at negative 6 degrees) and weakness in her right hip flexion, knee flexion and extension (short and long arc
quadriceps and hamstring muscle strength (2+/5 on the Manual quads), ankle dorsiflexion, and plantarflexion, 10 repetitions;
Muscle Testing grade). She had difficulty with her bed mobility
requiring close stand-by assistance, and she required supervision • Right knee flexion and extension active range of motion
for her transfers. She was dependent on a pair of axillary crutches (AROM) and active-assisted range of motion (AAROM)
for ambulation using a 2-point gait pattern. She also used an in supine and sitting positions, 5 repetitions of in each
antalgic gait pattern and exhibited poor arthrokinematics in the direction, or fewer based on patient’s pain or feedback.
right knee. Her balance was assessed with the Timed Up and Go test
(TUGT)5, with a score of 17 seconds; this identified her as having a • Progression to the next phase (sub-acute) was based on a
high risk of falls. decrease in overall pain and joint effusion and improvement
in Right LE muscle strength.
Integumentary: The patient’s right knee surgical incision was
covered with “Aquacell”, a non-removable dressing on the day Days 11-21 the sub-acute phase (with progression to advancing
of PT evaluation. It was removed by skilled nursing during the ROM, strengthening exercises, and joint mobilization)
subsequent visit on 12/29/20. PT assessed the patient’s surgical
incision during all follow-up visits, for signs and symptoms of • Right knee AROM/AAROM/passive range of motion (PROM)
infection. This is part of agency protocol that all clinicians will to facilitate full extension ROM and maximum flexion ROM,
assess surgical incision and document appropriately; coordination 5 repetitions in each direction.
of care is performed weekly with the RN case manager.
• Grade I knee joint mobilization in sitting and supine
Pain: The patient’s pain level and description were assessed and positions, to improve flexion and extension ROM, with close
documented during the initial PT evaluation and subsequent monitoring of her pain and to prevent hypermobility in
visits. The PT provided education to the patient and her husband either direction, 1-2 repetitions.
regarding pain management strategies with her prescription
analgesics, cryotherapy, and movement. • Strengthening exercises using gravity and body weight for
resistance, including hip flexion, extension, and abduction;
knee flexion and extension (short and long arc quads);
standing ankle dorsiflexion and plantarflexion, 2 x 10
repetitions.

• Use of eccentric muscle action to facilitate improvement of
VMO strength, due to patient’s mild extension lag during
SAQ and LAQ, 10 repetitions.

Clinical Impression: Based on the hypomobility of her Right Home exercise program(HEP) – the patient was instructed to
knee joint and the weakness of her right hamstring and quadriceps perform her HEP 2-3 times daily. HEP was upgraded from Phase 1

Page 14 APTA Home Health Section

to Phase 2 as the joint effusion and pain decreased, and right LE even though she reports feeling better, she asked for another day
muscle strength and coordination improved. to rest before resuming PT. She had a follow-up appointment with
her primary care physician on 1/11/21 and was started on an iron
2. Functional mobility training – The therapist provided verbal supplement for postoperative anemia.
and visual instructions to the patient to quickly teach bed mobility
and transfer techniques to progress her independence in both OUTCOME
areas. Gait training with a pair of axillary crutches, emphasizing
the proper use of the 2-point gait pattern and ensuring the crutches The patient completed 8 of 9 planned HHPT visits, and she had
support the right LE, was performed. PT emphasized the need to progressed to independent bed mobility and transfers by her third
increase right knee flexion ROM during the non-weight bearing visit on 12/30/21. By the end of the 3rd week her progress was as
phase of gait and facilitate full knee extension at heel strike. She follows:
was started on gait training with a one-handed device by the end of
the second full week and progressed to independence by the end of • ambulating independently without an assistive device
her 3 weeks of home PT. for 180 feet inside her house and with one crutch on
uneven surfaces
3. Balance reeducation - transitional weight-shifting patterns in
the anteroposterior and lateral directions in standing, facilitating • modified independent level managing her 8 entrance steps
increased weight bearing on the surgical leg. Later progressed • right knee AROM at 0-122 degrees.
to using a narrow base of support (BOS) in a modified tandem • right quadriceps and hamstrings muscle strength at
position, where she initially required contact guard assistance and
later progressed to supervision level. 3+/5 MMT scale.
• balance score of 12 seconds TUGT
• most postoperative anemia symptoms were resolved
• independent level with all of her ADLs

4. Patient education: PT provided detailed instruction to DISCUSSION
the patient and her husband regarding pain and joint effusion
management, signs and symptoms of DVT and infection at the The patient’s plan of care was developed based on a
wound site, and edema management. Patient education was specific combination of her impairments following her right TKA,
to the home exercise program. Several studies have identified pain, functional limitations, and goals. She made steady progress
fear of DVT, and edema as the most common reasons patients towards her stated goals of independence with all of her functional
visit the emergency room.(5-7) Therefore, our agency emphasizes mobility and all of her ADLs, without pain and locking up of her
patient education regarding symptoms management and patients’ Right knee joint. The patient regained full AROM of her right
expectations of their recovery roadmap. knee joint and regained muscle strength to engage in her regular
activities. She progressed to and demonstrated independence
Safety education was provided, emphasizing the patient safely with all of her mobility and planned to resume telecommuting the
navigating her house with 2 cats and 2 small dogs underfoot. Her following week once cleared by her surgeon.
husband was instructed to, and he ensured a clear path to the
bathroom from her bed, and he provided assistance that patient During HH services, the patient was diagnosed with
required for her first few shower transfers. postoperative anemia by her PCP, which is common among
surgical patients.7 Following the initial incidence, her vital signs
During her fourth HHPT visit on 1/4/21, the patient reported and symptoms were monitored more frequently. Her surgeon and
feeling sick, dizzy, and nauseous after completing her supine and PCP were contacted to report her symptoms, and because the
sitting exercises. Her vital signs were initially checked at the time patient was discharged from home health skilled nursing services
of the therapist’s arrival, and they were within normal for the on 12/29/21, the PT provided education to the patient regarding
patient. She was assisted back to the couch, and her vital signs were the possible drug interaction of her iron supplement prescribed
re-checked; her blood pressure was now 91/53mmHg, pulse was 94 by her PCP. Ferrous Sulfate can bind to Doxycycline in the
beats per minute, and respiratory rate was 20 per minute, and her Gastrointestinal tract, which may decrease their absorption and
oxygen saturation was 98%. Further, the patient was diaphoretic bio-availability. They should be taken 3-4 hours apart to avoid or
and quite anxious. The PT re-assured the patient and provided minimize this interaction. The therapist also provided education
moving air to cool her down. After about 5 minutes in a supine to the patient and her husband regarding food rich in Iron to
position with her lower extremities elevated, she reported feeling complement her medication.
“somewhat better.” Her vital signs were re-checked - BP at 91/59
mmHg; pulse at 93 beats per minute; respiration at 16 per minute, Several studies have identified the common reasons for visits
and oxygen saturation at 98%. to the emergency room after TKA.(7-9) A study reported 15.6% of
ED visits were for swelling, and 15.8% were uncontrolled pain.8
The patient’s surgeon’s office was contacted and informed Another study reported that among patients who had ED visits
about the incident. Her primary care physician (PCP) was also after THA and TKA, the primary diagnosis in 17.84% was pain.9 To
informed per the patient’s request. Both physicians agreed with the decrease unnecessary visits to the ER, our agency has developed
therapist that the patient did not require emergency care because a comprehensive education program for post-op THA and TKA
her oxygen saturation remained within normal range, and she patients. PTs share the information with the patient on the first
recovered in terms of her subjective feeling. PT ruled out possible visit regarding the red flags of infection and possible DVT; and
Pulmonary Embolism (PE) using Well’s Criteria and ruled out education regarding pain and edema management. The same
possible DVT. information is reviewed on the 2nd and 3rd visits until the patient

She subsequently missed the next scheduled session on 1/6/21;

The Quarterly Report | Summer 2021 Page 15

can verbalize the previously provided information. References:
This case report highlights the effective management of a 1. Zhang Y, Jordan JM. Epidemiology of Osteoarthritis: Clin Geriatric Med.2010

TKA patient in the HH setting while incorporating the patient’s Aug: 26(3): 355-369
unique PMH and postoperative complications. Her exercise 2. Jette DU, Hunter SJ, Burkett L, et al. Physical Therapist Management of Total
program and joint mobilization were modified to accommodate
her Ehlers-Danlos condition and her vital signs more closely Knee Arthroplasty: Physical Therapy. 2020 Aug; 100(9): 1603-1631
monitored with the postoperative anemia. Her exercise program 3. Kremers HM, Larson DR, Crowson CS, et al. Prevalence of Total Hip and
was progressed from the initial set more suited for the immediate
acute phase to more advanced exercises in the sub-acute phase. She Knee Replacement in the United States. J Bone Joint Surg Am. 2015 Sep 2;
was progressed to independent ambulation without an assistive 97(17): 1386-1397
device on a level surface and with a one-handed device on uneven 4. Inacio MCS, Paxton EW, Graves SE et al. Projected increase in total
surfaces. knee arthroplasty in the United States- an alternative projection model.
Osteoarthritis Cartilage. 2017; 25: 1797-1803
About the authors 5. Centers for Disease Control and Prevention: National Center for Injury
Babatope Olusina, PT, DPT, Certificate of Advanced Prevention and Control. STEADI Tools. https://www/cdc.gov/steadi/pdf/TUG
Competency in Home Health (APTA Home Health Test-print.pdf. Published 2017.
Section). He is a member of the APTA and Home 6. Corrado B, Ciardi G. Hypermobile Elhers-Danlos syndrome and rehabilitation:
Health section. Dr. Olusina now works for a home taking stock of evidence-based medicine:a systematic review of the
health agency in Richmond, VA, but previously owned literature. J Physical Therapy Science. 2018 Jun; 30(6): 843-847.
and ran a Contract Therapy Staffing Company. 7. Perelman I, Winter R, Sikora L, et al. The Efficacy of Postoperative Iron
Therapy in Improving Clinical and Patient-Centered Outcomes Following
Olaide Oluwole-Sangoseni, PhD, DPT, MSc, GCS, is an Surgery: A Systematic Review and Meta-Analysis. Transfusion Medicine
associate professor of physical at Maryville University Reviews, 2018 April, 32:2, 89-101.
of St. Louis. She is a Board Certified Geriatric 8. Kelly MP, Prentice HA, Wang W, Fasig BH, Sheth DS, Paxton EW. Reasons
Specialist and a home health PT. Dr. Sangoseni is an for ninety-day emergency visits and readmissions after elective total
advanced physical therapy clinical specialist degree joint arthroplasty: results from a US integrated healthcare system. J
in neuro-orthopedics from the University College Arthroplasty. 2018;33(7):2075-2081. doi:10.1016/j.arth.2018.02.010
London, England. She is an APTA credentialed clinical 9. Finnegan MA, Shaffer R, Remington A, et al. Emergency Department Visits
instructor. She can be reached at osangoseni@ Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps
maryville.edu. in Continuity of Care. Journal of Bone and Joint Surgery: 2017 June 21. 99
(12), 1005-1012.

Efficacy of Telerehabilitation Versus In-Person
Care in the Home Health Setting

By Molly A. Miller, PT, DPT, Certified Geriatric Clinical Specialist

In 2020 the Centers for Disease Control (CDC) declared a Implementing telehealth services allowed practitioners to see
public health emergency (PHE) for the United States due to the patients without having to travel or be exposed to COVID-19 and
2019 Novel Coronavirus (COVID-19).1 The Center for Medicare served to protect the healthcare workers from exposure while they
and Medicaid Services (CMS) responded to the PHE by applying provided these necessary services.1 Home health is a setting that
waivers to regulatory guidelines to facilitate safe and effective had not previously been allowed by CMS to use telehealth services
care to patients. These waivers allowed for telehealth technology for physical therapy. The change in the delivery of care that
to be widely utilized in areas that had been previously restricted. resulted from the PHE was well received, and CMS opted to extend

Page 16 APTA Home Health Section

the telehealth waivers for home health services beyond the timeline heart failure. This was compared to those that received standard
defined as the public health emergency. Telehealth as a permanent care of three days in an acute hospital setting followed by either
option was adopted into the home health final rule for 2021 by a rehabilitation hospital stay or outpatient cardiac rehabilitation.
CMS.2 It is important to note that while the change is a positive The standard care group also received a three-day hospital stay at
one, the rule stopped short of allowing a telehealth visit to count the end of the nine-week rehabilitation period. Piotrowicz et al.5
as an in-person visit. So, telehealth visits do not count towards the measured outcomes by the change in the distance on the 6MWT,
Low Utilization Payment Adjustment (LUPA) threshold. time in cardiopulmonary exercise testing (CPET), peak oxygen
consumption, percentage of peak VO2, respiratory exchange ratio
Education on disease management in patients with heart (RER), and standardized quality of life (QoL) survey. This article
failure (HF) is an essential component of clinical practice for was chosen because of its direct relevance to clinical query with
physical therapists who work with this population.3 CMS identifies outcomes measured via 6MWT.
heart failure as a condition with components that can be efficiently
treated with telemedicine, reducing the burden of cost for the This study was a large multi-centered study. The authors
management of this chronic condition.1 This literature review calculated that 800 participants would be needed to determine
sought to answer the following clinical question: Is telehealth clinical significance for the wider population with an 80%
physical therapy as effective as in-person physical therapy in statistical power. They recruited 850 patients with a primary
improving functional outcomes in patients with heart failure? diagnosis of heart failure who had been hospitalized once in six
months for a cardiovascular incident. To be included in the study
Methods the patient had to be considered stable at discharge. Participation

A literature search using PubMed, Cochrane *Records Screened by Review of title
Library, and Physiotherapy Evidence Database and abstract. Articles excluded if
(PEDro) was performed on March 26, 2021, using the not specific to HF, if study focused
keywords “telerehabilitation” AND “heart failure” on medical management of HF, if
AND “home health.” Filters were set to include outcomes based on a subjective report,
only English articles published since 2010, with full or if the study was designed to test the
text available. Article types included were clinical effectiveness of specific telemonitoring
trials, randomized controlled trials, systematic equipment.
reviews, and journal articles. This search resulted Assessed to be non-eligible: Reason
in the retrieval of 49 articles. Titles and summaries 1: preliminary study or trial proposal;
were reviewed, and articles were rejected if they Reason 2: informational article or
were not specific to HF, if the study focus was on expert opinion; Reason 3: Articles
the medical management of HF, if outcomes were found to miss screening criteria
based on patient or clinician subjective report, or Figure 1 – Prisma4
if the study was designed to test the effectiveness
of a specific piece of telemonitoring equipment
or software application. Seventeen articles were
retained for review. These articles were evaluated
for strength of evidence, relevance to the clinical
query, and availability of the article. Thirteen
articles were rejected for further review based on
the article focus of study protocol and method
for future study, lack of results presented, or
informational expert opinion. Some articles rejected
were published as abstract only. One article was not
published in the cited volume. Four articles were
selected for additional review. All four were based
on randomized controlled trials (RCTs).

In-depth Review of Randomly Controlled Trials

Piotrowicz, E., et al.5 Effects of 9-week hybrid
comprehensive telerehabilitation program
on long-term outcomes in patients with heart
failure. JAMA Cardiology 5(3), 300-308.

Piotrowicz, et al.5 sought to determine whether
one week of in-hospital education and monitoring
and eight weeks of telerehabilitation in the home
would improve long-term outcomes in patients with

The Quarterly Report | Summer 2021 Page 17

in telerehab or usual care was randomly assigned. Evaluators The control and telerehab groups in this study were provided
at baseline and at the end of the study were blinded to group with 2 days per week of supervised exercises in a group setting
assignment. Independent investigators blinded to group status with a physical therapist. This was continued for 12 weeks. The
compiled hospitalization and mortality data. Tertiary outcome data telerehab group received sessions via two-way videoconferencing
were collected before implementation of the program and after in small groups, with two to four participants in each group. This
the nine-week intervention period. The authors discovered that method was chosen by the authors because it was felt that group
outcome heterogeneity may have been based on the experience and interaction and peer accountability would keep patients adherent to
expertise at some of the centers providing care. The authors used the exercise protocol. The group format also more closely mimicked
the Wilcoxon-Mann-Whitney rank-sum test to account for the skew the treatments received by the center-based groups. The control
of the data. group received a weekly half-hour educational group program
regarding self-care and self-monitoring of heart failure, including
At the end of the intervention period, all outcome data proved condition-specific education on medications, nutrition, risks, and
favorable to improved care for the telerehab group. P-values for symptom mitigation, and advice on seeking medical attention. The
analysis were set for clinical significance at <0.05. Patients enrolled telerehab group received an electronic slide show with an audio
in telerehab improved 6MWT distance by a mean of 30.0m, vs. overlay on these same topics and were required to view them before
20.7m for the standard care group. The confidence interval was exercise sessions. Fifteen minutes was allotted at the beginning
95% with a range of 24.7 to 35.3m for the telerehab group, and 95% of teleconference exercise sessions for follow-up discussion. All
with a range of 15.4 to 26.0m for patients receiving standard care. participants received appropriate instruction in individual home
Changes in cardiopulmonary function also showed statistically exercise programs to perform between sessions.
favorable outcomes in the telerehab group. Primary outcomes
included hospitalization rates and all-cause mortality between 14 Peng, X., et al.8 Home-based telehealth exercise training
and 26-months post-intervention. The authors found no significant program in Chinese patients with heart failure: A randomized
difference in these outcomes for the two groups. controlled trial. Medicine, 97(35), e12069.

Hwang, R., Bruning, J., Morris, N. R., Mandrusiak, A., & Oxford Centre for Evidence-Based Medicine (OCEBM) classifies
Russel, T.6 Home-based telerehabilitation is not inferior to a randomly controlled trials as level 2 for the strength of evidence. The
center-based program in patients with chronic heart failure: a OCEBM does allow for down-grading if the study does not answer
randomized trial. J Physiotherapy, 63(2), 101-107. the proposed question or if the study design reduces validity.9 The
authors sought to compare home-based telerehabilitation to usual
Hwang, et al.6 sought to show the non-inferiority of care care; however, the usual care in this study did not include any kind
provided via two-way videoconferencing in small group format of exercise intervention. The authors stated that outpatient cardiac
compared to center-based group rehabilitation for patients rehab is not available in China. The operational definition of usual
with chronic heart failure. This was a quasi-experimental study care in this instance reduced the internal validity of the study,9 as it
with blinded assessors for each outcome measure. The authors was unclear if the change in the dependent variable was caused by
acknowledge that patients and physical therapists could not be the delivery method of care via the mobile app or if the change was
blinded to the participation groups but requested that the patients due to the introduction of an exercise program. This study was rated
not mention group assignments during assessments. The authors a level 3 on the OCEBM scale.
did a priori analysis to determine the sample numbers needed to
provide 80% power to the study for anticipated change in 6MWT. Participants were randomly assigned to a control group that
Hwang et al.6 determined that they needed at least 48 participants. received simple discharge instructions and routine follow-up care
Fifty-three patients met eligibility criteria, and all were enrolled in at the clinic and a telerehab group. The control group received no
the study to account for potential dropouts. These 53 participants exercise instruction at discharge. The telerehab group received
were randomly placed into groups with 24 in the telerehab group, a brochure with medical information regarding heart failure
and 29 in the control. Three patients, all in the control group, were patient self-care instructions and physical exercise instructions
lost to follow-up before the end of the 12-week intervention period. and safety. This group also received a one-hour instructional
session before leaving the hospital. The telerehab group was given
The primary outcome measure for this study was the 6MWT. an exercise program that included three sessions per week of
Other measures examined included the 10-meter walk test aerobic activity for the first one to four weeks, with the addition of
(10MWT).6 the balance outcome measure for elder rehabilitation strength training and weight-bearing exercises added five times
(BOOMER) scale,7 a quality of life measure, grip strength, and per week for the remainder of the 8-week intervention period.
quadriceps strength. A comparison graph was used to show Communication and supervision were provided to the patients
confidence intervals of 6MWT at 12 weeks, post-intervention, through a common mobile application by the multidisciplinary
and at 24 weeks, without further intervention, this showed a medical team from the hospital.
favorable change toward the telerehabilitation group, confirming
non-inferiority of intervention. All outcomes measured were All outcomes were compared between groups and within
assessed for in-group change over time, and between-group mean groups over time using analysis of variance (ANOVA) models. P
difference. Analysis of covariance was performed for each outcome values <.05 were considered statistically significant. Outcomes
measure. All outcome measures for both groups showed statistically measured included quality of life, depression, and anxiety
significant improvement. No statistical difference existed between measures. The telerehab group showed significant improvement
groups for any of the outcome measures. This study had an OECBM in self-reported quality of life at the end of the intervention
strength of evidence rating of Level 2. period, and at 6 months post-hospital discharge. There was not
a significant change in anxiety or depression scales. Functional

Page 18 APTA Home Health Section

outcome measures of improved resting heart rate (RHR) and 6MWT centers and within clinician teams were uniform. The study does
both showed significant improvement. No significant change was not address the blinding of evaluators for outcome measures. The
observed in New York Heart Association (NYHA) classification or control group received no formal instruction in physical activity
left ventricular ejection fraction. or exercise parameters and did not have a structured delivery of
medical advice or monitoring following hospital discharge. These
Bernocchi, P., et al.11 Home-based telerehabilitation in older differing variables between the two groups were unaccounted for
patients with chronic obstructive pulmonary disease and in the statistical analysis. The level of evidence for this study on
heart failure: a randomized controlled trial. Age and Ageing the OECBM scale is a 3.
47(1), 82-88.
The control group for this study received standard medical
Bernocchi. et al.11 sought to determine if a telehealth care with oxygen prescription, access to a general practitioner,
approach that combined structured educational calls with check-ups in the hospital as needed, and instruction in maintaining
physiotherapist-guided physical activity calls would improve a healthy lifestyle, including active participation in daily physical
physical function and reduce hospitalizations in patients with activity. The telerehab group received the same in-hospital
chronic obstructive pulmonary disease (COPD) and HF. Patients education and information. Each participant in the telerehab group
that participated in this study had diagnoses of HF, NYHA level was given a pulse oximeter and single lead heart monitor for home
I, II, or III12 and Global initiative for chronic Obstructive Lung use. A physical therapist designed a personalized exercise program,
Disease (GOLD) level B, C, or D.13 Patients were excluded if they and the participants were provided with an ergomometer device, a
had an orthopedic condition that prevented full participation in pedometer, and an exercise diary. These patients received weekly
the prescribed exercises, had a life expectancy of < 6 months, or if telephone calls from a nurse tutor (NT) to discuss health-related
they had severe cognitive impairments. This was an open, multi- issues and receive advice and instruction regarding their care.
centered, randomized controlled trial. 112 patients from three They also received a weekly call from a physiotherapy tutor (PTT)
hospitals were randomly assigned to groups upon discharge from to educate the patient regarding exercises, to modify the exercise
the hospital. The sample size was determined by estimating the plan as needed, and to verify the weekly rehabilitation targets. The
improvement on 6MWT in the telerehab group based on a previous weekly calls continued for four months.
RCT with data collection on subjects presenting with COPD and
CHF, at a power of 80% and statistical significance set at p<0.05. Outcome measurements were taken at four months, after the
It was determined that 44 participants would be needed in each completion of the telerehab program, and at six months, after
group. The authors accounted for dropouts and disenrollment by a 2-month no-treatment period. Changes in outcome measures
including 56 participants in each group. The authors acknowledge were assessed with an analysis of variance (ANOVA) statistical
that they could not blind participants and clinicians to the group measure, comparing between control and telerehab groups, and
assignments but sought to ensure that interventions across between timepoints to assess for intergroup change. Significant
improvement was noted in all study parameters. Improvements
were maintained after the no-treat period.

Summary of Results

Study Level of Evidence Subject Characteristics Specifics for Outcome Measures Other information
Intervention with Results relevant to PICO
Piotrowicz, E., et al. OCEBM Level 2 N=850, 753males, 97
(2020) females diagnosed 1 week of inpatient At 9 weeks: 6MWT*, The subject
with stable HFpEF, education and CPET time***, populations and
NYHA level I, II, or III monitoring followed Peak O2 outcome measures are
by 8 weeks of in- consumption*** relevant to the patient
home telemonitored %peak VO2*** and clinical query. The
exercise and electronic RER*, short-term functional
assessment QoL**. outcomes and quality
At 26 months: All- of life measures
cause mortality 12.4% support the efficacy
p=.86, All-cause of telerehabilitation.
hospitalizations 60.5% Telerehab shows
p=.32 no significant
difference from usual
care in reducing
hospitalizations or all-
cause mortality.

The Quarterly Report | Summer 2021 Page 19

Summary of Results (Cont. from page 19)

Study Level of Evidence Subject Characteristics Specifics for Outcome Measures Other information
Intervention with Results relevant to PICO

Hwang, R., et al. OCEBM Level 2 N=53, 40 males, 13 12 weeks of 2x/wk 6MWT This study compared
(2017) females. Diagnosed small group exercises 10MWT two similar exercise/
with stable HF NYHA lead by PT via 2-way Grip strength self-management
level I, II, or III all videoconference. Quad strength programs with
met safety screening Educational slides Balance score the telehealth
guidelines for patients with audio delivered QoL delivery of care as
with HF electronically to No statistically the independent
be watched before significant difference variable. Care was
exercise sessions. was shown between provided via two-way
15 minutes allotted groups teleconferencing,
for group discussion in small groups to
and q&a before each engage patients in
exercise session peer interaction during
active care.

Peng, X., et al. (2018) OCEBM Level 3 N=98, 58 males, Participants in the Changes identified: The subject population
40 females with a study group were QoL** and outcome
diagnosis of heart given a 1 hour basic 6MWT*** measures for this
failure for at least 4 HF education class RHR*** study were relevant
months, NYHA level before DC from the NYHA p=.562 to the clinical query.
I, II, or III, no cardiac hospital and given a LVEF p=.471 This study specifically
incidence in past 30 brochure with medical addressed the needs
days, no previous instructions and a of a rural population
cardiac rehab. All were description of physical with limited access to
recruited from one exercises. Eight weeks healthcare. This study
teaching hospital. of exercise supervised showed a significant
via a mobile difference in QoL and
application functional outcome
measure at the end of
the intervention period,
but no significant
difference at the
4-month follow up

Bernocchi, P., et al. OCBEM Level 3 N=112, 92 males, 20 Weekly structured 6MWT** The subject population
(2018) females diagnosed phone calls for 4 QoL*** for this study was
with stable HF NYHA months from NT and MRC* more involved than the
class I, II, or III, and PTT to assess disease All-cause subject of a clinical
COPD GOLD class B, process progress hospitalizations* query with the addition
C, or D. and performance of Physical activity** of COPD diagnosis.
exercise and self-care The interventions
protocol. consisting of
structured weekly
telephone calls from
the nurse and physical
therapist to educate
and guide the patient
is a practical, and
feasible approach
for home health
practitioners

Key: 6MWT = 6-minute walk test, QoL = quality of life, CPET = cardiopulmonary exercise test, 10MWT= 10meter walk test RER = respiratory
exchange ratio, HF = heart failure, RHR = resting heart rate, MRC = medical research council dyspnea, NT = nurse tutor, PTT = physiotherapy tutor,
NYHA = New Your Hear Association heart failure classification, LVEF = left ventricular ejection fraction
*p< .05, **P<.01, ***P<.001

Page 20 APTA Home Health Section

Discussion group was provided with recorded electronic versions of these
sessions and given time before exercise sessions to discuss the
Four randomly controlled trials were reviewed that addressed education with the therapist, and with the exercise group. There
the efficacy of telehealth physical therapy compared to usual care was no electronic remote monitoring device used in the Hwang, et
in the treatment of patients with heart failure. All four studies al.6 study, all patients were given a pulse oximeter and educated
used the 6MWT as a measure of functional outcomes. Three of the on the use of the BORG perceived exertion scale,14 which they
studies, Piotrowicz, et al.,5 Bernocchi, et al.,11 and Hwang, et al.6 reported to their health professionals during televisits. The goal
used a priori analysis to determine the sample size needed for a of the Hwang, et al.6 was to demonstrate telerehabilitation was
study with 80% power. Hwang, et al.6 and Bernocchi, et al.11 used not inferior to center-based cardiac rehab for patients with heart
previous RCT results for the 6MWT to determine the necessary failure. Their findings confirmed that telerehab did not show a
sample size. Piotrowicz4 needed a larger sample population, as the significant level of inferiority on any of the outcome measures
primary focus of the study was no adverse events and all-cause tested when compared to center-based care.
mortality with telehealth in place of usual care. These three
studies were multicenter, selecting patients that were scheduled Conclusion
for discharge, or had been recently discharged with a diagnosis of
stable heart failure NYHA Class I, II, or III. Peng, et al.8 used similar All four studies reviewed found that home-based
inclusion criteria, but all subjects were selected from one teaching telerehabilitation is a viable option for patients with heart
hospital. All four studies attempted to reduce bias by blinding failure. Two studies, Peng, et al.8 and Bernocchi, et al.11 found
evaluators to the groups that subjects participated in. All addressed telerehabilitation to be superior to usual care. The control
in discussion the futility of attempting to blind patients or treating sample in each of these studies was not given a formal course
clinicians to the intervention groups. of physical therapy or structured exercise, so the effectiveness
of the independent variables cannot be attributed entirely
All four studies detailed the physical activity interventions to telerehabilitation. Piotrowicz, et al.5 concluded that
for the telerehab groups. All telerehab participants had individual telerehabilitation was superior to usual care in the short term.
exercise programs that were designed for them by a physical The functional outcome measures improved during the
therapist. All telerehab participants had weekly or twice weekly intervention period compared to the control. They attributed this
calls with the therapist, either to engage in physical activity while increase to better compliance and accountability in the telerehab
being monitored via electronic communication or to review the group. The long-term improvements did not carry over, as the
prescribed exercise and determine if modifications to the exercise functional outcome measures were not significantly better between
program were required. The participants in the Hwang, et al.6 and the two groups at 14 and 26 months post-intervention. Hwang, et
Piotrowicz5 studies also received telehealth visits from a cardiac al.6 did not show any superiority in the telerehab group compared to
nurse or other health care professional. the control. Of the four studies reviewed, this one did the best job
of ensuring homogeneity between groups, with exercise frequency
The largest difference in study design was what the author and dosage the same for controls and telerehabilitation groups.
considered usual care for the control group. Neither Peng, et al.8 This study found no significant difference between the groups.
or Bernocchi, et al.11 introduced exercise or any formal physical
activity to the control group. Peng, et al.8 did not address any The results of these studies all show that telerehabilitation
physical activity for the control, and the control group in the is a feasible alternative to in-person physical therapy for patients
Bernocchi, et al.11 study were told to engage in physical activity with heart failure, and answers the question: is telehealth
if they desired. This lack of uniformity in care between control physical therapy, as effective as in-person only physical therapy
and study group is viewed as a threat to internal validity.10 In in improving functional outcomes? Limiting factors would be the
these studies, the telerehab group showed statistically significant availability of internet service and equipment. The authors of all
improvement in functional outcomes and quality of life indicators. four studies cited the need for training in the use of technology for
The authors did not discuss the possibility that the implementation the patient. Hwang, et al.6 included only patients with available
of an exercise protocol may have been the effective variable; the caregivers in the home for participation. At the time of the public
discussions centered around the superiority of outcomes in the health emergency, CMS still required in-person visits to initiate
telerehab group. physical therapy services in the home and required in-person visits
when warranted by patient needs.1
Piotrowicz, et al.5 and Hwang, et al.6 both used control groups
that were provided similar levels of structured physical activity. About the Author
The controls in the Piotrowicz group received usual care including Molly A. Miller, MSPT is a Board Certified Geriatric
exercise in outpatient cardiac rehab where appropriate, there Clinical Specialist, a Certified OASIS Specialist
was not an adequate description of criteria used to determine – Clinical, and is Certified in Advanced Clinical
participation in an outpatient rehab program.5 Hwang, et al.6 used Competency in Home Health. She is currently a Quality
a very structured program for the control group. The controls and Outcomes Specialist with Encompass Home
were seen at a cardiac rehabilitation center two times a week for Health. Molly can be reached at [email protected]
12 weeks. The telerehab group received two sessions via two-way
videoconferencing each week for 12 weeks. The telerehab sessions
were designed with two to four participants in each group, so
there could be peer interaction during the exercise sessions. The
control group was provided with educational courses on disease
management before exercise sessions at the center. The telerehab

The Quarterly Report | Summer 2021 Page 21

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ifc.pdf\. Accessed March 20, 2021. program in Chinese patients with heart failure: A randomized
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3. Shoemaker MJ, Dias KJ, Lefebvre KM, Heick JD, Collins AM. Physical Practice. 4th ed. Philadelphia, PA; F. A. Davis Company: 2020.
therapist clinical practice guideline for the management of individuals with
heart failure. Physl Ther. 2020;100(1):14-41. https://doi.org/10.1093/ptj/ 11. Bernocchi P, Vitacca M, La Rovere MT, et al. Home-based telerehabilitation in
pzaa130. Accessed July 6, 2021. older patients with chronic obstructive pulmonary disease and heart failure:
4. PRISMA Transparent Reporting of Systematic Reviews. http://www.prisma- a randomized controlled trial. Age Ageing. 2018; 47(1): 82-88. https://10.1093/
statement.org/. Accessed July 6th 2021. ageing/afx146. Accessed April 08, 2021
5. Piotrowicz E, Pencina MJ, Opoloski G, et al. Effects of a 9-week hybrid
comprehensive telerehabilitation program on long-term outcomes in patients 12. Committee NYHAC. Nomenclature and criteria for diagnosis of diseases of the
with heart failure: The telerehabilitation in heart failure (TELREH-HF) heart and great vessels. 1994. https//manual.jointcommission.org/releases/
randomized clinical trial.” JAMA Cardiol. 2020;5(3): 300-308. https://doi. TJC2018A/DataElem0439.html Accessed March 09, 2021
org/10/1001/jamacardio. 2019.5006. Accessed July 6, 2021.
6. Hwang R, Bruning J, Morris NR, Mandrusia A, Russel T. Home-based 13. GOLD. 2021 GOLD Reports – Global Initiative for Chronic Obstructive
telerehabilitation is not inferior to a center-based program in patients with Pulmonary Disease. 2021. https://goldcopd.org. Accessed March 20, 2020
chronic heart failure: a randomized trial. J Physiother. 2017; 63(2): 101-107.
https://doi.org/10.1016/j.jphys.2017.02.017. Accessed April 18, 2021 14. Shirley Ryan Abilities Lab. Rehabilitation Measures Data Base. 2013. https://
www.sralab.org/rehabilitation-measures/ Accessed April 18, 2021

APTA’s PT Moves Me Campaign:

Spreading the Word About the Profession

More students than ever, from more diverse backgrounds than ever, are learning why becoming a PT or PTA might be right for them.
As the physical therapy profession enters its second century, APTA is doing its part to nurture the generations of PTs and PTAs that
will shape its future — particularly the ones who’ve never considered a career in physical therapy before.
Called “PT Moves Me,” the national campaign began just this year but already has notched up some significant achievements in its
efforts to get the word out about the physical therapy profession to young people considering their career options, from elementary to
college students.
The goal of PT Moves Me is fairly straightforward, according to Ryan Bannister, director of centralized application services and
student recruitment.

Scan here
to read more.

2021 APTA House of Delegates Packet Posted

The House will consider 13 motions, including 11 proposed changes to the APTA bylaws.

APTA members can now access the first official packet of motions that will be considered by the 2021 APTA House of Delegates when
it convenes August 28 virtually and Sept. 11-12 in Washington, D.C.

Members, scan here to log in for more
information and to access the packet.

Page 22 APTA Home Health Section

Celebrating APTA’s 100th Submitter: Carolyn Buckley, PT, MSHP
Birthday, Home Health Style! This photo was taken with some of Carolyn’s
neighbors black angus cattle in Cypress Mill,
APTA Home Health started its year of the 100th centennial Texas. Her neighbor received home health physical
celebration of the American Physical Therapy Association with a tribute therapy this past year.
to our founding mother, Mary McMillan.

Members are touring the world with their “Flat Marys” in tow, a nod
to the children’s book, “Flat Stanley.” We have monthly prizes for the
most adventuresome Flat Mary photo and the Flat Mary photo that most
depicts the “Day in the Life of a Home Health PT/PTA. “

There’s still time to play! To get started, scan
here to download and print out your “Flat Mary” and
submit your photos.

Some sneak peeks of other celebrations are “PPE
Fashion Show” and “Vaccination Fascinations.” More
details for each will be coming soon.

For a complete list of APTA’s
Centennial Celebration Events,

scan here.

Submitter: Dee Kornetti, PT, MA, HCS-D, COS-C Submitter: Matt Hansen, MPT, DPT, MBA
Photos were taken at Amelia Island State Park in Matt and his wife, Veronica, in La Paz, Mexico
Fernandina Beach, Florida. after a day of fishing. The Hansens and “Maria
Plana” (Flat Mary) made new friends that evening
The Quarterly Report | Summer 2021 with their tasty fish tacos.

Page 23

P.O. Box 3406
Englewood, CO 80155
www.homehealthsection.com