APTA HHS Quarterly Report, Vol 54, No. 3

The Quarterly Report

SUMMER 2019

Vol. 55 | No. 3

In this The Importance of Functional, HIT
Issue: Strength Training – Why, and How

1 1 Hit Strength Training: PDGM and the potential for impact to therapy utilization
Why & How
By Dawn Widmer-Greaves, PT, DPT; Jennifer Stevens-Lapsley, MPT, PhD; Jason Falvey,
2 Did You Hear PT, DPT, PhD; and Donna Diedrich, PT, DPT, GCS
Read All About It!
The new Patient Driven Groupings Model cost report data instead of the prior method
7 New Website (PDGM) for home health payment developed of data from the Bureau of Labor Statistics.
Carries APTA Home Health by the Centers for Medicare and Medicaid So, while the work done by CMS in the
Section into the Future Services (CMS) is to be implemented Jan. development of the model reflects the visit
1, 2020.1 Three primary changes in this utilization for 2017, the net effect is an overall
8 Government Affairs model could affect an agency’s view of value decrease in reimbursement for episodes with
Report on Federal specific to the use of therapy. higher therapy needs compared to the current
Advocacy Forum reimbursement model.2
One, the therapy thresholds are being
10 APTA Launches Two removed from the calculation of Three, the definitions of clinical groupings
New Websites reimbursement. So the link between visits in the new model. The model is driven
provided and reimbursement is eliminated by patient characteristics. One of these
11 Spotlight Interview with under the new model. Two, the cost of care characteristics is the clinical grouping.
Matt Jones is calculated based on the cost per minute There will be 12 clinical groupings, and
plus non routine supplies from Medicare they are determined by the selection of
12 Navigating Dementia,
Delirium, and Depression See Strength on Pg. 3

16 A.I. & Patient Treatment
A Machine Can’t Tell Me How
to Treat a Patient

19 Handy Dandy Guide to
AMA 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 Cindy Krafft appointed to NAHC Government Affairs
Advisory Council
Managing Editor/Design
Don Knox Cindy Krafft PT, MS, HCS-O has been
appointed to the National Association for Home
Publications Committee Care and Hospice (NAHC) Government Affairs
Julie Colaw, PT; Zachary Hampshire, PTA; Julie Hardy, Advisory Council for 2019.
PT, MS; Mary Marchetti, PT, PhD; Olaide Sangoseni, PT,
DPT, MSc , PhD; Aban Singh, PT Per NAHC “The selection process was highly
competitive, but we believe it has yielded a roster composed
Section Officers: of individuals with deep knowledge of, and that are fully
President......................................Diana Kornetti, PT, MA representative of, all aspects of our industry and who will
Vice President............................... Chris Chimenti, MSPT substantially enhance the Association’s advocacy efforts.”
Secretary........................................... Matt Janes, PT, DPT
Treasurer............................. Philip Goldsmith, PT, DScPT Cindy has been involved at the senior leadership level for
Executive Director..............................................Don Knox the Home Health Section of the American Physical Therapy
Association for more than 10 years and is the immediate Past
The Home Health Section Quarterly Report is the President and Federal Affairs Liaison for the section.
official publication of the Home Health Section of
the American Physical Therapy Association. It is Please join in congratulating Cindy on this appointment
published four times per calendar year (Winter, Spring, and in thanking her for her continued efforts to advocate on
Summer, Fall). Statements of fact and opinion are the behalf of our profession, home health and the patients and
responsibility of the authors alone and do not imply an families we serve every day.
opinion on the part of the officers or the members of the
Home Health Section. APTA Reveals Future National Logo as Part of
Association Branding Project
Article & Content Contributions
Guidelines for contributions are available from the APTA CEO Justin Moore, PT, DPT, during his
Home Health Section website. If you have materials you address to the 2019 APTA House of Delegates
would like considered for publication, please email them in Chicago, shared APTA’s new logo. The logo’s
via attachment to the Home Health Section Executive general shape pays tribute to multiple previous
Director: [email protected]. APTA logos -- particularly in the use of a
triangle shape, which can be traced back to the
Advertising association’s first logo from 1921. However, the mark also
Advertising rates and details are available from the features contemporary design that evokes movement and
Section website, www.homehealthsection.org, or by hints at a more open, outward-facing association.
contacting the Section office at 866.230.2980.
The future logo inspired applause from delegates, and over
Electronic subscriptions to the Home Health Section the next few years there will be more reasons to celebrate as
Quarterly Report are available at a rate of $100/year. APTA implements other elements of its association branding
Order through the Section's online store. project. APTA plans to rename several of its products,
services, and events, and it is providing chapters and sections
Copyright ©2019 by Home Health Section - APTA with the opportunity to align within the new brand system.

Postmaster: Send address changes to Home Health See more about the new branding effort here: http://www.
Section APTA , PO Box 3406 , Englewood CO 80155. apta.org/PTinMotion/News/2019/6/10/NationalLogo/

www.homehealthsection.org HHS members - let us know what you think about the new
PO Box 3406 • Englewood, CO 80155 • 866.230.2980 logo and branding, as a Section. We’d like to hear your
thoughts: [email protected]
Page 2
See Hear on Pg. 22

APTA Home Health Section

Strength continued from Pg.1

the primary diagnosis. In the definition of each grouping, performance, in the three months post hospital discharge has
a reference is made to the primary reason for home health also been linked to the increased risk for institutionalization
services. For ten of these the primary reason for home health within 12 months of hospitalization.8
is nursing intervention. For two, the primary reason is
therapy intervention.1 So therapy need may be less obvious Now that we have established the link between functional
to an agency for patients with a primary diagnosis specific activity and performance to risk and outcomes, let’s look at
to one of the nursing driven clinical groupings. Based on the the role of exercise in improving overall function.
modeling from CMS the two “therapy” groupings account for
only 25.5 percent of episodes.2 Exercise and functional activity

These changes combined have led to concern that agencies Intensity of training

may look to reduce use of therapy under the new model. A

recent agency survey conducted by the National Association As we all learned in school, the basic principle of gaining

of Home Care and Hospice (NAHC) to assess the expected strength involves overloading. The overload principle has two

actions that may be taken by home health agencies under basic components. One, a muscle must be exposed to stress it

PDGM showed that 25 percent of agencies responding to is not normally exposed to improve function. Two, intensity

the survey intend to decrease therapy utilization by more must be enough to overload the musculoskeletal system

than 10 percent, and 23 percent intend to decrease therapy without over-straining it. Once the muscle has adapted to

utilization by less than 10 the new stress load, a greater

percent. Only 34 percent stress is required to continue

of respondents replied that to make strength gains.9

therapy utilization will Only 34 percent of respondents replied that High intensity training (HIT)
remain the same.3 It will therapy utilization will remain the same. for strengthening has been
be important under the shown to maintain strength

new model that therapists gains for more prolonged

understand and can use data periods of time then low

to articulate the value they intensity training.10 HIT

bring to the agency. Delivery of effective interventions based has also been linked to a higher level of functional recovery

on evidence promoting optimal outcomes in an efficient than low intensity training.11 HIT for strengthening at

manner will be more important than ever. 70 percent to 80 percent of an individual’s one repetition

maximum (1RM) results in the optimal benefits.12 A white

Why Therapy? paper published in the Journal of Geriatric Physical Therapy

notes the consensus that training intensities of 60 percent of

Outcomes, functional ability, and risk a 1RM or higher are needed to improve strength and function

in older adults.17 The white paper also notes if overload is not

Research has demonstrated links between an individual’s utilized with strength training, the gains are not likely to

mobility, functional status, physical activity and the risk for persist beyond the completion of the training.

rehospitalization. An investigation in 2012 suggested that

older adults with lower levels of ambulatory activity at the Speed and specificity of training

time of hospital discharge are six times more likely to be

re-hospitalized when compared to those with a higher level A study measuring the strength (the force of contraction)

of activity.4 In addition, individuals discharged home from and power (the product of force and velocity of contraction)

a hospital stay with a new unmet activity of daily living concluded that power influenced both chair rise time and

(ADL) need, or 3 to 5 ADL disabilities, are more likely to be step height in healthy individuals 65 to 89 years of age. 14

readmitted.5 A 2015 study by Shih, et al6 demonstrated that Thus, power could influence performance on measures such

for individuals admitted to inpatient rehabilitation, hospital as the Timed Up and Go commonly utilized as a falls risk

readmission models based on functional status were better measure in home health. A systematic review conducted in

predictors of rehospitalization risk than models based on 2004 noted muscle weakness as an independent risk factor for

medical comorbidities. falls.15 Critical thresholds of lower extremity muscle strength

in community dwelling older adults can predict when ADL

Functional performance has also been linked to mortality assistance will be necessary.16

rates as demonstrated in a recent study by Volpato et al.7

The authors concluded that patients with poor scores on A systematic review of functional training completed in 2014

the Short Performance Physical Battery (SPPB) test at the supports the specificity of training principle for older adults.

time of hospital discharge had a significantly greater risk The authors concluded if the goal was improving functional

of rehospitalization or death compared to those with better activity in the older adult, task specific training may be better

scores. Loss of functional ability, as measured by ADL than strength training alone.17

The Quarterly Report | Summer 2019 Page 3

But is it safe for our patient population? Figure One: HIT indications & Contraindications

Item number two of the American
Physical Therapy Association’s (APTA)
Choose Wisely campaign cautions “Don’t
prescribe under-dosed strength training
programs for older adults. Instead, match
the frequency, intensity and duration of
exercise to the individual’s abilities and
goals”.18 A study published in 2014 by
Cadore et al19 concluded that strength
training is an effective intervention for
healthy and frail elder adults and can
improve muscle strength, power output
and muscle mass in those populations.
The authors recommended that strength
and muscle power training be prescribed
to frail elderly to improve functional
capacity. Further guidance is provided
by American College of Sports Medicines
guidelines. A supervised strength training
program performed at high intensity is
appropriate for most frail older adults,
including those with comorbid conditions
such as chronic obstructive pulmonary
disease.12 The afore mentioned white
paper echoes the Academy of Geriatrics
of the APTA’s support of use of HIT
when caring for older adults.13 Figure 1
provides a summary of the indications
and contraindications for HIT strength
training. 12,13,20

Tying it all together

The research we have presented here principles to patients in the HH setting, a setting where
supports that risk and outcomes are equipment and space are often at a premium.
related to function. It further supports
function is related to strength. In addition, that strength gain Intensity
is dependent on resistive training at the appropriate dosage
of intensity and specificity. Therefore, it stands to reason that As noted earlier, resistance training needs to be at least 60
using task specific functionally based, HIT for strengthening percent of 1RM to be effective.17 Since most of our patients
could help to drive patient outcomes while delivering care in don’t have strength training equipment available in their
an efficient manner in the new payment model. home, we must be creative in our approaches to dosing

What does current practice look like?

Current practice most often consists of general conditioning
activities and low intensity exercise.21,22,23 This could be due
to fear of harm or a lack of understanding of the evidence.
That leaves a gap between the evidence and current practice
as noted in Figure 2.

Closing the gap

Once you have determined that HIT strength training is Figure Two: Pyramid – current practice and recommended practice
safe and appropriate for your patient, adapting exercises
to simulate common functional movement patterns while
applying the principles of overload can be highly beneficial.
Below, we will provide a framework for how to apply these

Page 4 APTA Home Health Section

exercise appropriately. Figure Three: Strategies for progression

Defining the 1RM (which is often called an to under-dose than over-dose. Figure 4 12,13,20 outlines the
8 Repetition Maximum Intensity (8-RM)12 cardiovascular, neurological, respiratory, and integumentary
signs and symptoms to monitor in addition to pain. If the
• During specified exercises, target an patient experiences any of these, you should pause the
eight repetition maximum (8-RM) current training activity and monitor for recovery. Then,
for 2 sets consider reducing the level of resistance or challenge.

• 8-RM = greatest resistance that Figure Four: Exercise Monitoring
can be moved 8 times through
full ROM in a controlled manner
with good form and no movement
substitutions.

• If a ninth repetition can be done
easily, exercise interventionists
should increase the weight during
the next set or the following exercise
session if on the last set.

Process for determining 8-RM:
1. During the first session, warm
up with three repetitions of the
exercise to be tested with low
resistance (1-2 on RPE scale)
2. Determine 8-RM within two sets,
with 30-60 second rests between
sets if participant unable to
complete eight repetitions during a
set. Use the Borg Modified Rate of
Perceived Exertion during the first
few repetitions to guide resistance
used (18)
3. Progressively increase the weight
between sets, until the subject
cannot perform the ninth repetition
with appropriate movement form.
Signs of appropriate form or fatigue
include looking for changes in
fluidity of movement, amplitude of
movement, and speed of movement
as well as using substitutions or
compensatory patterns.
4. The final weight successfully lifted
eight times is 8-RM (80 percent 1RM)
5. Re-calculation of the resistance load should occur each
session to ensure that the intensity is constant at 8-RM
each session.

Functional activity and progression.

The type of functional exercise you prescribe for your
patients will be dependent on your comprehensive
assessment of that individual. Considerations would include
prior level of function, current level of function, potential
to progress, and the patient’s goals. Suggested activities and
strategies for progression are noted in Figure 3.24,17,21

As you begin activity with your patient you will need to
adjust the dose based on their physiologic response to the
activity to prevent under-dosing or over-dosing the activity
level. As noted in current practice, we are far more likely

The Quarterly Report | Summer 2019 Page 5

balance assessment, gait
speed, and a timed 5-time
sit-to-stand.14,27 Each section
is scored on an ordinal scale
from 0-4 scale with scores
ranging from 0 to 12, where
higher scores indicate better
function.14,27 Demonstrating
the progress specific to
functional activity will be
crucial to supporting the care
delivered. Documentation
needs to support the tie
between strength gains and
functional performance
through statements such as
“with improvements in lower
extremity strength patient
is now able to move from
sit to stand with minimal
assistance”.

Figure Five: DOMS graphic In addition, documentation
should include the response to
Another important component of progression is activity and equally important
differentiating between normal delayed onset muscle what you adjusted based on
soreness (DOMS) as a response to activity vs. joint pain or that response. This is where
injury. DOMS25 is pain or discomfort in the muscle itself. your skill is demonstrated.
Patients typically describe this pain as an ache, a bruise or All too often documentation
aptly a sore muscle. A resource such as Figure 5 can help your of exercise is merely a list of
patients to better understand their response to exercise. the activity performed by the
patient. Response to activity such as heart rate at 65 percent
Demonstrating functional progress of max with minimal activity, or use of a perceived rate of
exertion scale, can also help to substantiate home-bound
Use of the principles described in this article can help status for the patient.
in the delivery of efficient and effective care. Gains in
strength alone don’t support medical necessity or skilled In summary, with the introduction of the PDGM payment
need however. The OASIS functional measures will help to model, the direct link between therapy visits delivered and
establish a baseline during the initial assessment. Utilizing reimbursement is eliminated. The cost of the provision
measures that break the functional activity down into the of therapy as compared to nursing services is calculated
smaller components, such as the now mandatory GG codes differently affecting total reimbursement for episodes with
will provide a more detailed baseline to allow demonstration higher therapy utilization. Furthermore, the definitions
of incremental progress. Other validated tools such as the of the clinical groupings are primarily nursing based. The
SPPB can support progress noted. NAHC survey indicated that 48 percent of agencies intended
to decrease the level of therapy provided. The connection to
SPPB scores are strong predictors of disability, value as demonstrated by interventions based on evidence
institutionalization and morbidity in older adults.7,15,26 will be critical to support therapy services in the future.
Additionally, the SPPB demonstrates good sensitivity to Functional resistance training at the appropriate intensity
change.58 The SPPB is a well-accepted measure of lower has been proven to deliver superior outcomes specific
extremity function and consists of three sections: static to function. Functional performance has been linked to
decreased risk for adverse events such as re-hospitalization.
These items as noted on the OASIS are important to an
agency’s 5-star rating. In addition, use of HIT has resulted
in a better durability of response. This article has provided
practical guidance and support to help you incorporate HIT
treatment into your care plans if you aren’t already doing so –
no special equipment required.

Page 6 APTA Home Health Section

About the Authors: 10. Falvey JR, Bade MJ, Forster JE, et al. Home health care physical therapy
improves early functional recovery of Medicare beneficiaries after total knee
Dr. Greaves is the Vice President for Home Services at arthroplasty. J Bone Joint Surg. 2018;100:1728-34.
Aegis Therapies. She has almost 20 years’ experience
in the home health sector from field clinician to her 11. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing
current role. Dr. Greaves is the current Editor for and Prescription. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.
Home Health Section Quarterly Report.
12. Avers D, Brown M. White Paper. J Geriatr Phys Ther. 2009;32(4):148-152.
Dr. Stevens-Lapsley is a Professor and Director doi:10.1519/00139143-200932040-0000
of the Rehabilitation Science PhD Program in
the Physical Therapy Program at the University 13. Skelton D, Greig C, Davies J, Young A. Strength, power and related functional
of Colorado Anschutz Medical Center. She is ability of healthy people aged 65–89 Years. Age Ageing. 1994;23(5):371-377.
focused on identifying, integrating and advancing doi:10.1093/ageing/23.5.371
innovative evidence-based medicine solutions for
older adult rehabilitation through highly effective 14. Moreland J, Richardson J, Goldsmith C, Clase C. Muscle weakness and falls
research methods and partnerships. in older adults: a systematic review and meta-analysis. J Am Geriatr Soc.
2004;52(7):1121-1129. doi:10.1111/j.1532-5415.2004.52310.x
Dr. Falvey is a board-certified geriatric clinical
specialist and currently works as a post-doctoral 15. Fukagawa N, Brown M, Sinacore D, Host H. The relationship of
fellow at Yale University. He has 7 years of strength to function in the older adult. J. Gerontol. A Biol. Sci. Med. Sci.
experience working in home care as a clinician 1995;50A(Special):55-59. doi:10.1093/gerona/50a.special_issue.55
and researcher.
16. Liu C, Shiroy DM, Jones LY, Clark DO. Systematic review of functional training
Dr. Diedrich is a board certified Geriatric Clinical on muscle strength, physical functioning, and activities of daily living in older
Specialist through the APTA. She is the Vice adults. Eur Rev Aging Phys Act. 2014;11:95-106.
President of Clinical Operations at Aegis Therapies
where she has been employed for over 24 years. in 17. American Physical Therapy Association Choosing Wisely. Choosingwisely.
her role she is engaged in supporting excellence org. http://www.choosingwisely.org/societies/american-physical-therapy-
through service delivery across the post-acute care association. Published 2015. Accessed June 9, 2019.
environments.
18. Cadore E. Strength and Endurance Training Prescription in Healthy and Frail
REFERENCE: Elderly. Aging Dis. 2014;5(3):183. doi:10.14336/ad.2014.0500183.
Home Health Patient Driven Groupings Model. Centers for Medicaid and Medicare
Services Website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service- 19. Tompkins J, Norris T, Levenhagen K. Laboratory Values Interpretation
Payment/HomeHealthPPS/HH-PDGM.html. Published 2019. Accessed June 14, 2019. Resource. Academy of Acute Care Physical Therapy website. https://cdn.
1. PDGM National Summit a Revolution in Medicare Home Health Payment. ymaws.com/www.acutept.org/resource/resmgr/docs/2017-Lab-Values-
Resource.pdf. Accessed July 15th, 2019.
February 5th, 2019; New Orleans, LA.
2. Dombi WA, Krafft C. Therapy in PDGM: What we learned from the national 20. Falvey J, Mangione K, Stevens-Lapsley J. Rethinking hospital-associated
deconditioning: proposed paradigm shift. Phys Ther. 2015;95(9):1307-1315.
survey. National Association for Homecare and Hospice website. https://www. doi:10.2522/ptj.20140511
nahc.org/wp-content/uploads/2019/06/WebEvent_19-06-04-1200_Handout.
pdf. Accessed June 15th, 2019 21. Mangione K, Lopopolo R, Neff N, Craik R, Palombaro K. Interventions used
3. Fisher S, Kuo Y, Sharma G et al. Mobility after hospital discharge as a marker by physical therapists in home care for people after hip fracture. Phys Ther.
for 30-Day readmission. J. Gerontol. A Biol. Sci. Med. Sci. 2012;68(7):805-810. 2007;88(2):199-210. doi:10.2522/ptj.20070023
doi:10.1093/gerona/gls252
4. DePalma G, Xu H, Covinsky K et al. Hospital readmission among older 22. Kortebein P. Rehabilitation for hospital-associated deconditioning. Am J Phys
adults who return home with unmet need for ADL disability. Gerontologist. Med Rehabil. 2009;88(1):66-77. doi:10.1097/phm.0b013e3181838f70
2012;53(3):454-461. doi:10.1093/geront/gns103
5. Shih S, Gerrard P, Goldstein R et al. Functional status outperforms 23. Alexander NB, Galecki AT, Grenier ML. Task-specific resistance training to
comorbidities in predicting acute care readmissions in medically complex improve the ability of activities of daily living-impaired older adults to rise
patients. J Gen Intern Med. 2015;30(11):1688-1695. doi:10.1007/s11606-015-3350-2 from a bed and from a chair. J Am Geriatr Soc. 2001 Nov;49(11):1418-27.
6. Volpato S, Cavalieri M, Sioulis F et al. Predictive value of the short physical
performance battery following hospitalization in older patients. J. Gerontol. A 24. Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness: treatment
Biol. Sci. Med. Sci. 2010;66A(1):89-96. doi:10.1093/gerona/glq167 strategies and performance factors. Sports Med. 2003;33(2):145-6414.
7. Portegijs E, Buurman B, Essink-Bot M, Zwinderman A, de Rooij S. Failure
to regain function at 3 months after acute hospital admission predicts 25. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance
institutionalization within 12 months in older patients. J Am Med Dir Assoc. battery assessing lower extremity function: association with self-reported
2012;13(6):569.e1-569.e7. doi:10.1016/j.jamda.2012.04.003 disability and prediction of mortality and nursing home admission. J Gerontol.
8. Mueller MJ, Maluf KS. Tissue adaptation to physical stress: a proposed 1994;49(2):M85-94.
“Physical Stress Theory” to guide physical therapists practice, education, and
research. Phys Ther. 2002 Apr;82(4):383-403. 26. Pahor M, Blair SN, Espeland M, et al. Effects of a physical activity intervention
9. Fatouros I. Strength training and detraining effects on muscular on measures of physical performance: Results of the lifestyle interventions
strength, anaerobic power, and mobility of inactive older men are and independence for elders pilot (LIFE-P) study. J. Gerontol. A Biol. Sci. Med.
intensity dependent. Br J Sports Med. 2005;39(10):776-780. doi:10.1136/ Sci. 2006;61(11):1157-1165.
bjsm.2005.019117.

The Quarterly Report | Summer 2019 Page 7

Government Affairs Happenings – Report on Federal
Advocacy Forum

By Carol Hamilton Zehnacker PT, DPT, CEEAA

Earlier this year APTA established new public policy priorities opinion to Congress. There is also a Patient Action section for

which were to your patients and non -members to use on the same page.

1. Enact policies that empower people to live healthy and Home Health Payment Innovations Act (S 433/HR 2573)
independent lives
The home health industry scored a victory in its battle to
2. Eliminate barriers of health care services remove widely opposed provisions of the Patient-Driven
3. Support efforts to increase efficiencies in the delivery of Groupings Model (PDGM). On May 8, 2019, a group of
bipartisan House lawmakers introduced a bill targeting the
health services that reduce administrative burdens to payment overhaul’s behavioral assumptions. Introduced by
providers and insure transparency to patients Reps. Terri Sewell (D-Ala.), Vern Buchanan (R-Fla.) and Ralph
4. Prioritize research and clinical innovation to increase Abraham (R-La.), along with eight other co-sponsors, H.R.
access to appropriate value-based health care services 2573 is the House version of S. 433 introduced by Sen. Susan
Collins (R-Me).
These priorities were introduced at the APTA Federal
Advocacy Forum held March 30-April 2, 2019, when more S. 433 and HR 2573 would refine payments in the new home
than 285 APTA member-advocates came to Washington, D.C. health payment system (PDGM) to ensure behavioral-based
With more than 100 new members in Congress, the forum payment adjustments are based on evidence and observed
was a great opportunity to educate policymakers and their data, not on assumptions of provider behavior. It would limit
staff about the physical therapy profession and introduce our the risk of disruption in care by providing a phase-in for any
new policy priorities. Attendees also advocated for: necessary rate increases or decreases. This phase-in is critical
for home health providers, as CMS has proposed cutting
1. The role of physical therapy as part of the solution to the Medicare payment rates in 2020 by more than $1 billion based
nation’s opioid crisis on assumptions of changes in behavior. The phase-in would
operate to ensure full budget neutrality by 2029. In addition,
2. Legislation that would address student loan debt by S. 433 would provide flexibility on waiving the “homebound
adding physical therapists (PTs) to the National Health requirement” when a Medicare Advantage Plan determines
Service Corps Loan Repayment Program that providing care to the patient in the home would improve
outcomes and reduce spending on patient care.
3. The need to add PTs as primary care health providers in
community health centers. Home Health Planning Improvement Act (S296/HR 2150)

Coincidentally, the National Association of Homecare and On April 9, 2019, a bipartisan group of representatives
introduced the Home Health Care Planning Improvement
Hospice (NAHC) was also Act of 2019 (H.R. 2150). If passed, the legislation would allow
physician assistants, nurse practitioners and other advanced
lobbying on the Hill on April practice nurses to certify home health care services, potentially
cutting the need for a physician out of the equation.
2, 2019 for S. 433. Scan the QR
Under current Medicare rules, only physicians can certify
Current Legislation with your
mobile device.

Please help us to help you
and go to the APTA Take
Action page at www.apta.org/takeaction/ or scan the code
above and support the following bills. There you will find
templates provided by the APTA for you to use to voice your

Page 8 APTA Home Health Section

patients to receive home health services, a common point followed by Q&As on 3/5/2019 and 3/6/2019. Special thanks
of contention within the home health care industry. to Kara Gainer APTA Director of Regulatory Affairs and GAC
Among other challenges, it’s not uncommon for home members Bud Langham and Ellen Strunk.
health providers to experience gaps in communication with
patients’ doctors, as well as costly certification delays that The links to these informative and timely webinars are:
leave individuals vulnerable to negative outcomes without • Overview of PDGM – 2/19/19 - http://apta.adobeconnect.
timely care. com/pqr4iw0o9bax/
• Question and Answer Session 1 via Adobe Connect –
Representatives supporting H.R. 2150 include Jan Schakowsky 3/5/2019 - http://apta.adobeconnect.com/p2hkh1boas8l/
(D-Ill.), Buddy Carter (R-Ga.), Ron Kind (D-Wis.), Mike Kelly • Question and Answer Session 2 via Adobe Connect –
(R-Pa.), Susan Wild (D-Pa.) and David Joyce (R-Ohio). 3/6/2019 - http://apta.adobeconnect.com/pa40ewj3qllg/

This legislation will make their cost-saving, high-quality PDGM Frequently Asked Questions
services more directly accessible to Medicare patients in
need, while greatly reducing the costs of these services. This As promised in the spring edition of the Quarterly Report,
would be a win for patients, a win for providers and a win for the next couple of issues will include select questions posed
Medicare’s bottom line. to the panelists on the Q&A webinars. Here are the Q&A for
this quarter:
The bill comes after counterpart legislation S.296 was
introduced in the Senate earlier this year by Sens. Susan Question: Productivity has been such a major driver of
Collins (R-Maine) and Ben Cardin (D-Md.). S. 296 was read therapy behaviors and measure of financial success. Do
twice after its introduction and referred to the Senate you see the focus of this measure changing in the future
Committee on Finance and is also bipartisan.  As of this and if so, what might therapists expect?
writing there are 40 co-sponsors, or 80 percent, of Senators
supporting this bill. Answer: Productivity as an operational metric for all staff
will not change. Ensuring agencies have a productive,
The Physical Therapist Workforce and Patient Access efficient, and effective workforce is vital to the agency
Act (S. 970/H.R. 2802)  remaining in business and extending services to the patients
who need them. Measuring specific productivity of therapy
The Physical Therapist Workforce and Patient Access Act (S. as a financial measure may change because there is no
970/H.R. 2802) would add physical therapists to the National incremental revenue from it, and that is for the better. There
Health Service Corps (NHSC) Loan Repayment Program. is need for a reimbursement system focused on clinical
Recently, this important legislation was reintroduced, characteristics of the patient’s specific issues, not striving to
and if enacted, will help provide greater patient access to achieving a certain level of reimbursement under the system.
rehabilitation services and non-pharmacological treatment Rehabilitation professionals should take a proactive approach
options in rural and underserved areas of the country. to ensuring agencies have a focus on the right metrics as we
With the enactment of this bipartisan legislation, physical move forward under PDGM.
therapists would be added to the NHSC. This would increase
the availability of rehabilitation services to individuals in Question: Effectiveness of visits made - do you anticipate
rural and underserved areas. There are over 7,026 Health front-loading of visits for increased ability for intensity
Professional Shortages Areas (HPSAs) nationwide at a time and appropriate dosing per evidenced based practice to
when many of these communities are being impacted by the begin to occur?
opioid crisis.
Answer: Yes. It will continue to occur. This is one of the
The House companion was introduced on May 16, 2019. Like things that led CMS to consider changing the 60 day unit of
the Senate version (S 970) sponsored by Sen. Jon Tester ( payment to 30 days, since the majority of visits were done
D-MT), the House version, titled the “Physical Therapist earlier in the timeframe. Also, research and evidence-based
Workforce and Patient Access Act” (HR 2802), would allow practice is lining up rapidly, and is driving the need for front-
PTs to participate in the NHSC loan repayment program. The loaded care. Rehabilitation professionals are being asked to
initiative serves an estimated 11.4 million Americans who live keep patients out of the hospital, which may necessitate more
in designated Health Professional Shortage Areas and repays visits at the front part of the episode. This often necessitates
up to $50,000 in outstanding student loans to certain health additional visits at the initial part of the episode.
care professionals who agree to work in an HPSA for at least 2
years. The House bill is cosponsored by Representatives Diane Question: What does PDGM expect of rehabilitation
DeGette (D-CO) and John Shimkus (R-IL). professionals?

Second PDGM Webinar Answer: It is expecting that rehabilitation professionals will
continue to deliver high quality therapy services that are
As introduced in the Spring addition of the Quarterly Report, reasonable and necessary. It is expecting such professionals
the second webinar on PDGM was recorded on 2/19/2019 will continue to drive value, which requires rehabilitation

The Quarterly Report | Summer 2019 Page 9

professionals to keep asking the question – how are we doing better environment to provide better patient care. If you
this? What do we need to do differently? What do we need to have further concerns or comments, please contact the
do better to drive value for our patient population? Government Affairs Committee through the Home Health
People need to continue to ask questions about technical Section website.
aspects of the rule change, and how it will impact agencies
operationally, from a workflow perspective, a documentation About the Author:
perspective, ensuring the EMR is ready to accommodate
the changes, and how it will impact patient care. If a Dr. Zehnacker is the owner of Physical Therapy
rehabilitation professional has concerns, they should Consults. LLC and contracts with Bayada Home
proactively be an advocate and reach out to CMS to ask Health. She is the Chair of APTA Home Health’s
questions and share their concerns. Government Affairs Committee and may be
reached at [email protected].
Final Thoughts

Thanks to all who have contacted your Congressmen on
our legislative issues and who have helped to make it a

APTA Launches New ‘Find a PT’ and ‘ChoosePT.com’
Website to Support Consumer Awareness

Every day, people choose physical therapy for a multitude of shouldn’t miss, according to Jason Bellamy, APTA’s executive
reasons, from managing pain to building healthy lifestyle vice president of strategic communications.
habits. Now APTA’s consumer-focused website has a new
name—and a new look—to support that reality and help “Millions of people will visit ChoosePT.com this year,
connect patients with physical therapists (PTs) through an and one of their most common destinations will be Find
enhanced “Find a PT” feature. a PT,” Bellamy said. “APTA members should ensure their
information is up-to-date, and add a headshot to make their
Recently, APTA unveiled ChoosePT.com, a consumer website profile more appealing. Our message to members is, ‘do
that replaces MoveForwardPT.com, now retired after 10 years. everything you can to help consumers choose you.’”
The new site is a best-of-both-worlds combination of 2 of the
association’s most high-profile and far-reaching initiatives— ChoosePT.com is also enhanced by geolocation technologies
APTA’s popular online source for consumer-oriented health that, with a user’s permission, create an online experience
information, now operating under a name that leverages the customized to the user’s physical location. APTA state
power of the association’s award-winning opioid awareness chapters that have an active geolocation page—49 to date—can
campaign. The ChoosePT site is expected to receive more add state-specific information to the ChoosePT site, providing
than 4 million visitors in 2019, with anticipated increases in visitors with an additional depth of relevant information.
the coming years.

The transition to ChoosePT does not significantly change Bellamy believes the change to ChoosePT.com is the right
the content on the former MoveForwardPT site, which move at the right time, with more exciting changes coming
still includes information on symptoms and conditions, around the corner.
prevention, and pain management, as well as access to
podcasts and videos that deliver powerful messages about the “When we launched our opioid awareness campaign we knew
difference physical therapy can make in people’s lives. our #ChoosePT message was dynamic enough to extend
beyond the safe management of chronic pain,” Bellamy
But not everything’s the same: The changeover has allowed said. “With APTA’s centennial approaching in 2021, and the
APTA to make improvements to the site’s “Find a PT” public awareness opportunities that will provide, this was the
directory, an APTA member benefit for physical therapists, perfect time to make that our primary call to action.”
that makes it easier for consumers and other providers to
filter results by practice focus or specialization. T-shirts with the new ChoosePT logo are available here:
The upgraded feature is an opportunity that members https://www.jimcolemanstore.com/apta/products.html

Page 10 APTA Home Health Section

INTERVIEW An Interview With The Section Secretary:
Matt Janes, PT, DPT, MHS

Interviewed by Zachary Jarred Hampshire, PTA

Question: What brought you to home health?

Answer: I had both acute- and outpatient-based practice experience prior coming to home
health. I was working in outpatient and juggling multiple patients, providing clinic oversight and serving as one of
the VP’s for our 30-plus clinic outpatient network. I was in search of something more, and realized that providing
therapy related services in the home would provide a meaningful and impactful practice. Where else can you
prescribe a home exercise program and validate how they actually perform it in the home? Further, functional
demands vary considerably from patient to patient as well as in each home or patient residence. I thought, what
an opportunity this is to help foster the best possible treatment strategies to optimize function while keeping
patients in their own communities. In addition, practicing in home health provides the opportunity to care for
patients one on one, at your own pace and set a schedule conducive to maximize treatment.

Question: What is your current job/role/work in home health?

Answer: I serve as the division-level Associate VP of Therapy Practice and Quality. I have multiple
responsibilities including a focus on quality and therapy practice concerns covering regulatory- and compliance-
related issues. Home health, as with other health care practice environments, is constantly evolving, and change
is an expectation of practice. Most important for therapists providing care in home health, we should all be
striving to practice at the top of our license and help ensure the best possible outcomes for all of our patients.

Question: How do you balance work, life, and volunteerism/section leadership?

Answer: It is often difficult to balance all elements, however I would say do your best but do not overextend
yourself. Clearly there is opportunity to do so much, however prioritization and time management are key. I would
also say be collaborative in each applicable endeavor. For many aspects of life, they say “many hands make light
work.: My family includes a wife of nearly 20 years, who is also a PT practicing in home health, and three children
ages 16, 13 and 11. Family should come first. Life should be meaningful with a goal of making a positive difference
and contribution to society. We do not need to play a passive role in our lives or work-related practice. While
you can’t change everything that may be considered “bad,” at least if you volunteer or take an active role, you
can at least say you tried. Prior to volunteering I would advise you to discuss your role, responsibilities and time
expectations with your employer and family members. Support and time allotment is essential to foster success
in any volunteer role.

Question: What are your roles and responsibilities within the section, and what is your
favorite part of your role within the section?

Answer: Currently I serve as the secretary of the section and also as liaison to the Membership and Nominating
committees. Most recently I have also been serving as part of the APTA PAC Task Force. My favorite part of the
section is helping other members and interacting with peers from around the country.

Question: Who is your inspiration/who do you look up to and hope to follow?

Answer: This is a tough question. I have always been inspired by my dad. Despite being required to quit school
at a young age to help support his family, he had future opportunities and success that made possible as long as
he tried and did his best. He managed to work his way up the ladder and become a VP for the company. He was
known for being honest, trustworthy and effective in job performance. He was able to make a difference. If I can
do the same and it be perceived as such, that would be great.

The Quarterly Report | Summer 2019 Page 11

Care Navigation Through
Dementia, Delirium,
and Depression

By Shannon Liem

You get a home health PT evaluation referral for Louise H. She whom the family describes as ‘not acting like themselves.’
was recently in the hospital because of an exacerbation of her Or we have seen a patient whose forgetfulness seems to be
Chronic Obstructive Pulmonary Disease (COPD) and a mild getting worse. Or worse yet, we have encountered a family
Urinary Tract Infection (UTI). She was unsteady in the hospital, who does not see any changes in behavior or cognition as
frequently getting up out of the hospital bed despite the nurses troublesome because “grandma is 82 and old, what do you
continually instructing her not to get up without using the call expect?”
bell. Her daughter thought it was a bit unusual for her mother
to not follow directions, but she knows her mother does have Because dementia, delirium and depression have overlap
forgetfulness. She had been meaning to take her mother to her in their symptomatology, it is key for physical therapists to
physician because of her gradual worsening of memory and understand the clinical symptoms.1 Let’s examine what sets
general confusion. Now that she’s home from the hospital, the of symptoms are present in each disorder.
daughter expected her mom to just get back to ‘her normal self.’
As you examine Louise and talk with her daughter you notice
some areas of concern. Louise seems distracted and not fully Dementia is an umbrella term that describes several
participating in the discussion. She is having difficulty following progressive neurocognitive disorders that surround
your requests and conversation. She doesn’t seem to remember progressive memory loss, challenges with problem solving,
the event that took place over the last few days in the hospital, personality changes and changes in communication.2
becoming a bit upset when reminded she was in the hospital. You Common types of dementia are: Alzheimer’s disease, Pick’s
as the physical therapist need to get to the heart of the matter. disease, Lewy body dementia, Creutzfeldt-Jakob, and vascular
How does her state of mind and history of forgetfulness affect dementias.3 For further description of these types of dementia,
your assessment and potential treatment needs? Are these recent visit: https://www.dementia.org/. Dementias typically have
changes in mentation and slow onsets and progressions. It is not to be associated with
behavior expected to resolve to
normal aging.7

her prior levels? Or is this her Knowing the symptom differences of these Delirium can be defined as a
new ‘normal?’ complex series of characteristics is crucial to a neuropsychiatric disorder that
manifests itself in reduced

This scenario is probably therapist providing care to a patient. awareness in the environment
all too familiar to a home as well as confusion.15,16 It

care therapist. A patient typically has a quick onset

presenting with prior issues and may be tied to a recent

with cognition and now has an overall worsening of that escalation of medical events such as medication changes,

condition after a medical decline or hospitalization. Has the infection, surgery or changes in metabolic balances such as

patient’s dementia dramatically worsened in a short period of low sodium. Three types of delirium present themselves:

time, or is something else at work here? hyperactive, hypoactive and mixed.4,16 Patients with

hyperactive delirium can demonstrate characteristics such

As a Physical Therapist, you will need to be able to as irritability, combativeness and uncooperativeness. They

differentiate among three conditions: dementia, delirium can be easily distracted.16 The patient can wander or climb

and depression. Knowing the symptom differences of these out of bed. Hypoactive delirium patients can be sleepy or

characteristics is crucial to a therapist providing care to a withdrawn. 4-5 They can have visual hallucinations and

patient. Many times, we as therapists have seen a patient generally little interest in interacting. Mixed delirium shows

Page 12 APTA Home Health Section

as a shift between the two. It is important as an outside observer to determine the patient’s baseline of cognitive functioning
to help discern if these changes in mentation are sudden and an acute change in the patient’s normal level of cognitive
functioning.1,5

Depression can be described as a discouraged mood that can accompany a calamitous life event such as the death of a loved
one, financial stress, natural disaster or serious illness. Some symptoms that accompany a depressive disorder are poor
concentration, sleep disturbance, appetite disturbance and loss of interest in previously enjoyed activities. The severity of
depression ranges from mild to severe.1

Here is a quick comparison of key features of each condition:1,3,4,5,7

Key Feature Delirium Dementia Depression
Onset Sudden, definite beginning Slow onset, gradual Weeks to months
Duration Days to weeks, could be longer Usually permanent Depends on treatment
Life change events, medical
Cause Another condition Chronic brain disorder illness, change in life respon-
sibilities, loneliness/isolation,
Course Usually reversible Slowly progressive medication side effects
Effect at night Almost always worse Often worse Chronic/depends on treatment
Attention Greatly impaired Unimpaired until be- Difficulty sleeping can occur
comes severe Impaired
Level of consciousness Variably impaired Unimpaired until be-
Orientation to time/place Varies comes severe Unimpaired
Use of language Slow, often incoherent Impaired Typically oriented
Memory Varies Difficulty finding the right Not typically affected
word at times Varies
Impaired

So, let’s head back to Louise and see what questions need to • How is her language when she responds to you? Is it
be asked to determine the characteristics and symptoms she cogent, connected to the topic, flowing properly through
may be presenting. the conversation? Or does she demonstrate difficulty
staying on topic and giving concise answers?
As you read through the medical history available in
your tablet, ask the daughter several questions. • Is she oriented to time, day, date, place and situation?

• What was your mother’s cognition like before she had There are several ways to help differentiate among these
her medical change? conditions. The first is a thorough chart review. If the
patient had a hospitalization prior to the home care
• Was she able to follow a simple conversation like the one episode, looking through available documentation may
we are having now? Or was it difficult for her? provide clues to help discern what is occurring. Were
there any medications added to the patient’s regimen that
• Would you generally say her cognition and behavior may be contributing to this current set of symptoms? Is
now is worse, the same or better than before she was in there a history of infection?6 If the patient did not have
the hospital? a hospitalization or post-acute care stay, what do the
physician’s notes document regarding the need for home
• Is her activity level now that she is at home the same as care services? Do the physician notes talk about a change in
it was before? Or have you noticed a change? mentation, attention, memory or motivation?

• Is she having trouble sleeping or is she having more
difficulty at night?

When assessing, Louise look for the following: What further considerations come into play with Louise
• What is her ability to follow simple directions and more and her daughter now that you’ve looked at the record
complex direction? even further?

The Quarterly Report | Summer 2019 Page 13

• What are Louise and her daughter’s goals now that she consistent with depression.10 The use of the PHQ-2 was
has returned home? introduced on the OASIS C in 2014.11 This standardized
depression screening is available as an option for screening
• What impact does the current cognitive impairment a patient for depressive symptoms. It is a short, two-
have on those treatment interventions. question screening aimed at determining whether further
assessment is necessary for symptoms of depression. If
• If the Patient Health Questionnaire-2 (PQH-2) was the response for M1730 showed the patient presents with
positive for depressive characteristics on the OASIS, characteristics that are consistent with depression, was
what impact might that have on Louise’s motivation to there a referral from the referring provider to investigate
participate and follow through with recommendations? further? Going further in the OASIS to question M1740
Will you have to engage the daughter more fully in the for cognitive, behavioral and psychiatric symptoms
treatment plan to assist with that carry over? demonstrated at least once a week, look for responses 1-6.
Any of those will indicate these symptoms were observed
• If the introduction of a new assistive device is in Louise’s or reported by the Start of Care clinician. For an example of
future, will that device be easily integrated into her the PHQ-2, refer to the SOC OASIS.
routine, or will more direction and repetition be needed
to ensure safety? Can the daughter assist with that GDS (Geriatric Depression Scale) is widely used with the
regular repetition when you are not present in the home? older adult population to assist with determining if the
presence of depression is noted. There is a short, 15-question
• How will her current cognition affect the frequency form asking the person how they have felt over the past
and duration of treatment? Will shorter more frequent week.12 Link to the scale: https://consultgeri.org/try-this/
interaction be required as her daughter takes on general-assessment/issue-4.pdf
repetitious tasks. Or will longer, more extended
treatment duration to allow for carryover and safety? Depending on the results of these screenings and
assessments, you may refer patients to another discipline to
The following assessment tools are listed below to help a assist with structuring the care plan and help with return to
clinician discern among the three conditions: independence. If cognitive deficits appear to be worsening as
it relates to dementia or delirium, a referral to Occupational
Confusion Assessment Method (CAM) short version is Therapist or Speech-Language Pathologist may be useful
a standardized evidenced-based assessment tool to detect to provide more in-depth testing and goal creation. If
delirium. There are four quick questions to answer that can depression appears to be the culprit, working with the agency
assist the clinician in the identification process. The features to refer to a Master of Social Work (MSW) or back to the
are: Feature 1: Acute Onset or Fluctuating Course; Feature physician for treatment should be beneficial.
2: Inattention; Feature 3: Disorganized Thinking; Feature
4: Altered Level of Consciousness. The diagnosis of delirium Let’s now look at some strategies that can be employed after
requires the presence of Features 1 and 2 and either 3 or 4.8,14 the assessment of the patient.
Here is a link to test: https://deliriumnetwork.org/wp-
content/uploads/2018/05/CAM.pdf If delirium is suspected, here are things to consider:6,13,15
• Thoroughly examine the medication list for any meds
MoCA (Montreal Cognitive Assessment) is a quick test that may contribute to or worsen the delirium.
designed to be sensitive enough to distinguish between • Establish a connection with the caregiver for effective
normal aging, mild cognitive impairment and Alzheimer’s carry over of strategies and risks.
Disease. It is a 30-question screening to assess several • Determine the level of communication in which the
cognitive domains: Memory recall, visuospatial abilities, patient is most effective. Direct eye contact, simple
executive functioning, attention, language performance direct one-step commands, allow for time to respond to
and orientation.9 Here is a link to the test: requests or conversation.
https://www.mocatest.org/

PHQ-2 helps a clinician determine whether to refer a patient
for further assessment because of characteristics that are

Page 14 APTA Home Health Section

• Maximize orientation strategies. About the Author:
• If communication is affected, consider a referral to a
Shannon Liem graduated from Florida
Speech-Language Pathologist. State University with a Master’s Degree in
• If activities of daily living are affected, specifically Communications Disorders.  She is a licensed
speech-language pathologist in the state of Florida
self-feeding for nutritional support, consider an and has been in practice for more than 26 years
Occupational Therapy referral. with experience in acute care, skilled nursing
facilities, outpatient and home health.  She serves as a National
If dementia is suspected, consider the following:7 Clinical Director for Home Services with Aegis Therapies.
• Learn the best way to communicate with the patient. Shannon also has her COS-C certification.
The family can offer tips from their experience.
If communication barriers become an issue with REFERENCES:
intervention, consider a Speech-Language
Pathology referral. 1. Differentiating among Depression, Delirium, and Dementia in
• Rely heavily on procedural memory and tasks that Elderly Patients. Virtual Mentor. 2008;10(6):383-388. doi:10.1001/
have a connection to the patient. Involve activities virtualmentor.2008.10.6.cprl1-0806
that the patient experienced during previous
occupations or hobbies. 2. Overview of Delirium and Dementia - Neurologic Disorders - MSD Manual
• Begin a behavioral analysis should the patient become Professional Edition. MSD Manual Professional Edition. https://www.
anxious or combative. What was the catalyst for the merckmanuals.com/professional/neurologic-disorders/delirium-and-dementia/
behavior? What helped reduce its incidence or duration? overview-of-delirium-and-dementia#v1036243. Published 2019. Accessed May
• As with delirium if ADLs are affected, consider an 28, 2019.
Occupational Therapy referral, specifically to help with
dining situations. 3. Dementia - Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/
• Be alert for pain or fatigue. The patient may not be able diseases-conditions/dementia/symptoms-causes/syc-20352013. Published
to express it as expected. 2019. Accessed June 19, 2019

If depression is suspected here are some strategies:5 4. Delirium - Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/
• Ensure a referral to an MSW or other external care diseases-conditions/delirium/symptoms-causes/syc-20371386. Published
provider aimed at further diagnosing or treating the 2019. Accessed June 19, 2019.
symptoms of depression is in place.
• Look for signs of suicidal ideation. 5. O’Sullivan R, Inouye S, Meagher D. Delirium and depression: inter-relationship
• Be sure to be alert for nutritional decline, medical and clinical overlap in elderly people. The Lancet Psychiatry. 2014;1(4):303-
changes, difficulty with following routines or 311. doi:10.1016/s2215-0366(14)70281-0 
medication regimen.
• Allow the patient to make as many decisions as possible. 6. Fong T, Davis D, Growdon M, Albuquerque A, Inouye S. The interface between
Fully involve them in the process of their rehabilitation, delirium and dementia in elderly adults. The Lancet Neurology. 2015;14(8):823-
give them control over many aspects of their care. 832. doi:10.1016/s1474-4422(15)00101-5
• Educate the patient and family of the risk factors due
to the lack of motivation, participation and emotional 7. Alz.org. https://www.alz.org/media/Documents/alzheimers-facts-and-
changes they are experiencing. figures-2019-r.pdf. Published 2019. Accessed May 27, 2019.

As you treat Louise through her frequency and duration, how 8. McCabe D. The Confusion Assessment Method (CAM). Best Practices in
does her cognition change? Are some areas of concern resolving, Nursing Care to Older Adults. 2019;(13).
or are the deficits seen at evaluation still present several visits
into her treatment regimen? Are goals being achieved or is the 9. Nasreddine Z, Phillips N, Bédirian V, et al. The Montreal Cognitive
cognitive change prohibiting advancement of the progress? How Assessment, MoCA: A brief screening tool For mild cognitive impairment. J
has the team approached these challenges? Are the depressive Am Geriatr Soc. 2005;53(4):695-699. doi:10.1111/j.1532-5415.2005.53221.x
characteristics such as lack of motivation providing a unique
challenge to the patient’s condition management? What does the 10. Maurer D. Screening for Depression. Aafp.org. https://www.aafp.org/
daughter have to say about her progress with therapy goals; is it afp/2012/0115/p139.html. Published 2019. Accessed June 19, 2019.
meeting her expectation?
11. Sheeran T, Reilly CF, Raue PJ, Weinberger MI, Pomerantz J, Bruce ML. The
The key to providing distinctive and individual treatment PHQ-2 on OASIS-C: a new resource for identifying geriatric depression among
to a patient in the home care setting, is in the ability to home health patients. Home Healthc Nurse. 2010;28(2):92–104. doi:10.1097/
identify and mitigate characteristics in the patient that may NHH.0b013e3181cb560f
affect the patient’s overall treatment plan and functional
recovery. Learning the features of delirium, dementia and 12. Greenberg S. The Geriatric Depression Scale. Best Practices in Nurse Care to
depression allow you to navigate a growing circumstance Older Adults. 2019;(4).
among the elderly.
13. Martins S, Fernandes L. Delirium in elderly people: a review. Front Neurol.
2012;3. doi:10.3389/fneur.2012.00101

14. Hospitalelderlifeprogram.org. http://www.hospitalelderlifeprogram.org/
uploads/disclaimers/Short_CAM_Training_Manual_8-29-14.pdf. Published
2019. Accessed May 28, 2019.

15. Delirium - Neurologic Disorders - MSD Manual Professional Edition. MSD
Manual Professional Edition. https://www.merckmanuals.com/professional/
neurologic-disorders/delirium-and-dementia/delirium. Published 2019.
Accessed May 14, 2019.

16. Kalish V, Gillham J, Unwin B. Delirium in older persons: evaluation and
management. Am Fam Physician. 2014;90(3):150-158

The Quarterly Report | Summer 2019 Page 15

“A Machine Can’t

Tell Me How to

Treat a Patient”

Or Can It?

By Bud Langham, PT, MBA

I have been reflecting on a particular episode of The Office process and learn, somewhat like humans.¹ Some of the
from season 4. It originally aired Oct. 4, 2007, titled “Dunder activities computers with artificial intelligence are designed
Mifflin Infinity.” In this episode, a former (and younger) for include: speech recognition, learning, planning, and
colleague returns to the Dunder Mifflin unit lead by Michael problem solving.1 Can AI help us make better decisions
(played by Steve Carell) with a new technology that will about patient care? Should we use AI to tell us how to treat
save the company, “Dunder Mifflin Infinity.” The staff are patients? What considerations are there for using this
worried that the new technology is meant to replace older technology?
workers and is inherently evil. Michael shares their concern,
so he goes on a road trip to prove that personal and human First, let’s ensure we all understand a few terms related to AI
interactions are superior technology, and to win back former in healthcare. The field of AI is broad and seemingly infinitely
clients with a pro-human, anti-tech approach. He fails of deep. The deeper I go in researching AI the more I am
course. This leads to a hilarious scene where he and Dwight delightfully overwhelmed. This article will be quite narrow in
(played by Rainn Wilson) are driving in a rental car guided by scope but hopefully sufficient to whet the appetites of many
a GPS device and automated assistant that tells them step by of you to continue your own research. Now…key terms related
step how to arrive at their destination. By this point Michael to AI:
has succumbed to the fact that technology has, or will soon,
defeat him. The device instructs him to “turn right,” he obeys Big Data - Data sets, typically consisting of billions or trillions
without questioning, having fully acquiesced to the superior of records, that are so vast and complex that they require new
intelligence of technology and … drives directly into a lake. and powerful computational resources to process.2
The episode concludes with a brief monologue from Michael:
The term, “Big Data,” refers to the vast collection of
“Everyone always wants new things. Everybody likes new information from traditional and digital sources inside and
inventions, new technology. People will never be replaced outside your company that is available for use.³ It may be
by machines. In the end, life and business are about human structured (neatly organized and understood information)
connections. And computers are about trying to murder you in a or unstructured (information that is not organized or easily
lake…” – Michael interpreted by traditional databases or data models and is
typically text-heavy).3
As members of the physical therapy profession, I think we
need to take a slightly less fatalistic approach to technology. Machine Learning - Machine learning is an artificial
For the purposes of this article, I am referring to the field intelligence (AI) discipline geared toward the technological
of Artificial Intelligence (AI), and its potential impact on development of human knowledge. Machine learning allows
healthcare. AI is an area of computer science that emphasizes computers to handle new situations via analysis, self-
the creation of intelligent machines and algorithms that training, observation and experience.4

Page 16 APTA Home Health Section

Machine learning allows us to quickly process millions of • How many visits would be a “just right” care plan
data points for many purposes, including making evidence- to create a high probability of achieving a specific
based and data-driven predictions. outcome?

What Does This Mean for Home Health Therapists Today? • What time of day is best for treating patients with heart
failure, COPD, Alzheimer’s?
I am confident that AI is already affecting your practice as a
home health clinician. Disagree? How do you determine your • What interventions are most effective at lowering risk of
best route to your first patient from your home? The next hospitalization?
patient? Ah…Waze, Google or Apple maps, you say? Surprise!
AI has already affected your home health clinical practice. • What routes create the most efficient schedules?
These platforms all leverage the power of big data and AI (in • What medications should be most closely monitored for
this case, information about your common routes, driving
practices, and community reported incidents such as accidents impact on ER utilization?
or construction) to optimize your route. You can optimize the
route to the least amount of travel time, to avoid tolls, or even Using vast stores of already collected data elements, the
to avoid highways. The AI programs and algorithms are always possibilities are endless for the potential applications of AI
working at a furious pace to consume and analyze so much to home health agency practice using vast stores of already
information that it is beyond comprehension, and far beyond collected data elements. When used appropriately and
the ability of the human brain. ethically, AI has the potential to change our practices for
the better. It already has. Remember those crazy Mapsco
maps that we used before we had our smartphone AI
backed apps? Perhaps some of us still use them today, but I
certainly hope not!

Here is another example of how AI is already impacting AI is also already affecting you in ways you perhaps can’t see.
your practice. Healthcare insurers are rapidly developing Healthcare providers are not the only groups leveraging the
AI practices including machine learning in order to analyze power of AI to identify trends and opportunities. Healthcare
their vast warehouses of data for many purposes, including: payers are aggressively employing predictive analytics and
customer outreach, anticipating needs of customers, AI as well. AI is being used by CMS (Centers for Medicare
authorizing claims, and reviewing claims for approval and Medicaid Services) and commercial payers to improve
or denial.5 The days of humans combing through your the health of populations, to manage risk and reduce
documentation and creating spreadsheets of claims data to expenditures, and to identify payment errors.
make decisions about authorizing more visits, or even paying
the claim, may be numbered. There are many more examples CMS has enormous amounts of data that have incredible
of how AI is already touching your day-to-day home health value. The value of the data is reflected by how it is protected.
practice, but we have limited time here, so we have to move If you have ever visited your U.S. senator, you know that you
on. have to go through a metal detector and empty your pockets.
But when you visit CMS, you are stopped at a gate about
What Might This Mean for Home Health Therapists an 1/8th of a mile away from the CMS building. Everyone
Tomorrow? has to get out of the car and show identification. The car is
searched and bags are searched. Only then can you enter
A better question for the physical therapy profession might the facility for the usual metal detector screening. Then you
be “how might this impact my practice going forward?” To are sequestered to a waiting area where someone must sign
answer that question, we have to consider the types of data you in and escort you to your meeting. You are subsequently
available regarding home health physical therapy services. escorted back to the security desk for check out. The data
Below are several that came to mind for me: CMS has is that valuable. CMS is also using data to identify
providers who merit additional auditing. Our data is a unique
Number Of Visits Outcomes Achieved fingerprint of our agencies and our practices. AI is helping
Patient Geolocation Worker Geolocation CMS identify agencies for a variety of audit programs such as
Intervention Types Time Of Visit Targeted Probe and Educate (TPE), Unified Program Integrity
Day Of Visit Patient Diagnoses Contractor (UPIC) audits, Recovery Audit Contractor (RAC)
Referral Source Hospitalizations audits, etc.
ER Utilization Patient Satisfaction
OASIS Measures Duration Of Visit CMS is also actively trying to engage AI to improve the
PT vs PTA Medications provision of healthcare for Medicare beneficiaries. On
Nov. 16, 2018, CMS announced the Artificial Intelligence
Your agency likely has thousands, hundreds of thousands, or (AI) Health Outcomes Challenge.6 This challenge website
perhaps millions of visits that have been completed over the doesn’t provide a great deal of information, but the following
years. Those visits are treasure troves of sweet, ripe data, just quote shows us what CMS is thinking: “With innovation
ready to be harvested and utilized to help you, your agency, central to its mission, CMS wants to be at the forefront
and your patient population. Using AI-based predictive of these efforts. We’re interested in exploring how to
analytics, and maybe machine learning, you could potentially harness AI to predict health outcomes that are important
leverage the data elements above to predict: to patients and clinicians, and to enhance care delivery.

The Quarterly Report | Summer 2019 Page 17

We are brainstorming how we can incorporate AI in the will help us. If we can harness the power of data in an ethical,
implementation of both our current and new payment and effective, appropriate manner it will empower better care for
service delivery models.” patients, achieving better outcomes. It will help us be more
efficient so we can care for more patients, thus expanding
Are There Any Ethical Concerns? access to care. Good technology in the hands of good
clinicians can be a great advantage. But we do have to remain
There are concerns regarding incorporating AI into practice diligent. AI is not without error and not without risks. Like
that we all will have to keep in focus. Consider the use of AI all technology, AI requires careful supervision and oversight.
for care planning. As time passes, to improve outcomes based There will never be a day where healthcare professionals
on data-driven evidence-based visit plans, more and more can check out, and simply do what the algorithm tells us.
companies will be leveraging AI to help clinicians develop Diligence is required. I hope physical therapy professionals
their care plans. More and more companies will be leveraging are gently nudged to consider researching AI and its
AI to help clinicians develop care plans to improve outcomes implications in their practice. Start by researching the terms,
based on data-driven evidence-based visit plans. Soon it will then seeking to understand the concepts, finally being open
be common for agencies, and perhaps even payers, to deploy to integrating AI into practice. It is a brave new world, let’s
these technologies that review patient-specific information embrace it with responsible open arms.
and propose a suggested number of visits. For example,
imagine doing a start of care, and as soon as you complete About the author:
it, you get a pop up on your point-of-care device that says:
“Based on the OASIS and clinical information, this patient Bud Langham, PT, MBA, is a Physical Therapist
needs 13 visits -- eight nursing and five PT.” What do you do and serves as the CCO for the Home Health and
if your clinical determination is different? Before you answer Hospice division of Encompass Health. He has
let’s reflect on our code of ethics.7 Principle 3a and 3b (figure been in leadership roles in acute and post-acute
below) reminds us that we are responsible for demonstrating care settings as well as outpatient rehab and
independent and objective professional judgement based on cardiac rehab. Bud is responsible for clinical
professional standards and evidence. care, quality and innovation at Encompass Health. He has a
passion for innovation and clinical excellence in patient care.
Bud believes that all clinicians must maintain a commitment to
always Learn, Unlearn, and Relearn when it comes to patient
care. He graduated from the University of Oklahoma Health
Sciences Center with a degree in PT and later from the OU Price
College of Business with an MBA.

There may be occasions where the recommendation from BIBLIOGRAPHY:
the AI engine is out of bounds. If so, we have an ethical
obligation to speak up and ensure the patient gets what 1. Technopedia.com: Artificial Intelligence definition. https://www.techopedia.
he/she really needs. If we know the patient needs six PT com/dictionary. Accessed 6/18/19.
visits and the recommendation is two or 32, we have to say
something and do the right thing for the patient. In other 2. Dictionary.com: Big Data definition. https://www.dictionary.com/browse/big-
words… don’t blindly follow the guidance and drive off into data. Accessed 6/20/19.
a lake.
3. Arthur L. What is Big Data? Available at https://www.forbes.com/sites/
AI Is Coming, It’s Ok, But Be Diligent lisaarthur/2013/08/15/what-is-big-data/#686c697d5c85. Accessed 6/18/19.

“Everyone always wants new things. Everybody likes new 4. Technopedia.com: Machine Learning definition. https://www.techopedia.com/
inventions, new technology. People will never be replaced dictionary. Accessed 6/20/19.
by machines. In the end, life and business are about human
connections. And computers are about trying to murder you in a 5. Healthcarefinancenews.com: How Artificial Intelligence Can Save Health
lake…” – Michael Insurers $7 Billion. August 10, 2018. Susan Morse, Senior Editor. https://
www.healthcarefinancenews.com/news/how-artificial-
intelligence-can-save-health-insurers-7-billion.
Accessed 6/20/19.

6. Artificial Intelligence (AI) Outcomes
Challenge. CMS.gov.https://innovation.
cms.gov/initiatives/artificial-
intelligence-health-outcomes-
challenge/ . Accessed 6/25/19.

7. APTA Code of Ethics for Physical
Therapists. https://www.apta.org/
uploadedFiles/APTAorg/About_Us/
Policies/Ethics/CodeofEthics.pdf.
Accessed 6/25/19.

As we conclude, I want to return to Michael’s quote and
address the tension with technology. AI is not trying to take
us out, it is OK … in fact, it is a wonderful advancement that

Page 18 APTA Home Health Section

A (Relatively) Brief Handy-Dandy Guide to AMA Style

By Mary T. Marchetti, PT, PhD, Board Certified Geriatric Clinical Specialist

Editor’s Note: Sharing your knowledge and expertise with colleagues by writing an article for the Quarterly Report
can be rewarding and a great way to give back to your profession! While the process my seem intimidating at first, the
publications committee members are here to assist you every step of the way. To that end, this issue includes an article on reference
formatting. We hope you find this to be a useful tool that will help inspire authorship. In addition, the pro writer author guidance is
available on the section website for easy reference. If you have an idea for an article, are interested in writing an article, or would like
to recommend an author please email your thoughts to the section at [email protected].

All of the APTA publications are to be referenced using the AMA Style, i.e., the style of the American Medical Association. In
our writing classes in school, we were often required to use MLA style (the style of the Modern Language Association, in case
anyone has ever wondered what MLA stood for). In the psychology courses we had to take, we were to cite references according
the American Psychological Association (APA) style. Of course, there were the odd instructors who required some other
specific style or made up their own for a given class. With all of these variations, it is hard to keep track of the details and
requirements of any given style. To that end, we have decided to provide a handy-dandy, quick-and-dirty guide to AMA style.
This will not cover all types of reference materials that you may want to cite, but it will hit the biggies. The most accurate
and comprehensive source is the AMA Style Manual, but unless you are on a college campus or have access to a rather large
library, you most likely don’t have access to the Style Manual. You may also simply search on “AMA style” using your preferred
search engine, and you will find many examples. The difficulty with those can be that you must be very observant to identify
the correct details. So, here you go: For a reference to be complete it needs to provide all of the necessary information for the
reader to locate the reference including author, title, source, date and detail of editions and/or pages if any. Each section below
builds a piece of the complete reference.

CITATIONS WITHIN TEXT
• Citations within the text are numerical (sequentially ordered), in super-script, generally following punctuations (if any)
• If more than one reference is cited for a given statement, the references should be cited in order, separated by commas
but no space
-- Home health physical therapy has been shown to have favorable outcomes for a variety of patient populations.1,3,8
• If three or more sequential references support a given statement, then the sequential citations should be noted as the
first and last, separated by a hyphen; any others supporting that statement should be separated by commas
-- Home health physical therapy has been shown to have favorable outcomes for a variety of patient
populations.1,3-5,7-10,16
• Generally, when a particular study or authors’ names are part of a statement within your text, the citation should
directly follow the mention of the study or author(s)
-- One study5 found…
-- Yoakam et al5 found that…

CITATIONS WITHIN REFERENCE LIST
• Sources must be listed in the reference list according the order in which they are cited within the text. So, the first
reference you cite in the text will be #1 in your reference list, the 2nd would be #2 on your list, etc. (other styles have
you listing them alphabetically)
• Each reference is listed only once within the reference list, according to when it is first cited within the text, and then
the number of the order of that reference is used for all subsequent citations of it within the text
• The references within the reference list should be single-spaced

Authors’ names: Authors’ names are listed as Last Name[space]Initial(s)[comma], next author
-- A period follows the last author’s name, then double space before typing the title of reference
-- Authors’ initials must be listed as their names appear on that particular article, regardless of how an author’s name
appears on any other articles or your knowledge of the author’s name
-- There are no punctuations between the author’s last name and initials; commas are used in-between each of the
authors’ names, with a period at the end of the list of the authors’ names
§§ DON’T:
Wilson, BD; Wilson, CD; Wilson, DC; Jardine, AC; Love, ME. (or something similar…)
§§ DO:
Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME.

The Quarterly Report | Summer 2019 Page 19

-- For six or fewer authors, all authors’ names should be listed; for more than six authors, only the first three names
should be listed, followed by “et al.”
§§ DON’T:
Lennon JW, McCartney JP, Harrison G, Starkey R, Best P, Sutcliffe S, Epstein B.
§§ DO:
Lennon JW, McCartney JP, Harrison G, et al.
Jagger MB, Richards K, Watts CR, Wood RD, Jones LBH, Wyman WG.

-- If the source is an entire book that has editors rather than authors, then you indicate that after listing the editors’
names
§§ Hall DH, Oates J, eds.

The title of the reference follows authors’ names
-- If the reference is a journal article or a book chapter, only the first word and any proper nouns should be
capitalized; all other words should be in lower case letters (i.e., sentence case)
-- The title should be followed by a period and two spaces
§§ DON’T:
Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. Good Vibrations Improve Standing Balance in People
with Alzheimer’s Disease.
§§ DO:
Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. Good vibrations improve standing balance in people
with Alzheimer’s disease.
or if book chapter with a number:
Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. Chapter 3: Good vibrations improve standing balance
in people with Alzheimer’s disease.
-- If a chapter of a book is used, and the chapter has authors along with an editor (or editors) for the entire book, then
the chapter authorship and title lead, followed by the editor information and book information (separated by a
period and two spaces)
§§ Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. Chapter 3: Good vibrations improve standing balance
in people with Alzheimer’s disease. In Wilson M, ed. The Smile Sessions.
-- If an entire book, or most of a book, is used, then the book title is cited in italics with all major words beginning
with capital letters (words such as in, an, the do not need to be capitalized unless it is the first word)
§§ Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. The Smile Sessions.

The title of the source material for a journal article or book chapter follows next, in italics, followed by a period and two
spaces

-- Each major word in the title should be capitalized
-- If the source is a chapter in a book, then the entire title of the book must be written out, preceded by “In:”

§§ Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. Chapter 3: good vibrations improve standing balance
in people with Alzheimer’s disease. In: The Smile Sessions.

-- If the source material is a journal, then the Index Medicus abbreviation of the journal title, in italics, must be used
§§ Index Medicus abbreviations are readily available online from multiple sources, simply by searching on “Index
Medicus,” then scroll through the journals until you find the title you seek; if your journal does not appear on
the list, then there is no abbreviation for that journal, and you simply use the full title, followed by a period
• Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. Good vibrations improve standing balance in
people with Alzheimer’s disease. Phys Ther.

• Citations must clearly describe how to locate the source material
-- If the source is a book, then information must include, in order, city of publication, the publisher’s name, copyright
year, and when appropriate, page numbers
-- If the source is a journal, then information must include, in order, the year of publication, volume number, issue
number (when applicable), inclusive page numbers
§§ If material was in a part, supplemental or special issue, that information must be included as well

Additional information for print books
-- If multiple cities are listed for the publisher, then cite the first city listed
-- Page numbers are necessary for chapters of books, or if only a few pages are used
§§ If more than one page or group of pages used, then the pages should be listed in order, then separated by
commas
-- If the bulk of the book is used, or if numerous pages scattered throughout the book are used, the page numbers do
not need to be cited
-- Multiple non-consecutive pages throughout the book, appropriate page numbers in sequential order, separated by a
comma and no space; when a range of consecutive pages is included, indicate the range with a hyphen

Page 20 APTA Home Health Section

-- Spacing and punctuation for book publication information is as follows:
§§ Most or all of book used, no page numbers necessary
• Author A[comma][space]Author BC[period][double space]Title of Book[period][double space]City,
State[semi-colon][single space]Publisher’s name[colon][double space]year[period]
• Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. The Smile Sessions. Hawthorne, CA; 2011.
§§ Single chapter, single page or single grouping of pages
• Author A[comma][space]Author BC[period][double space]Title of Book[period][double space]City,
State[semi-colon][single space]Publisher’s name[colon][double space]year[colon][no space]inclusive page
numbers[period]
• Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. Chapter 3: good vibrations improve standing
balance in people with Alzheimer’s disease. In: The Smile Sessions. Hawthorne, CA; 2011:19.
or:
• Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. Chapter 3: good vibrations improve standing
balance in people with Alzheimer’s disease. In: The Smile Sessions. Hawthorne, CA; 2011:19-42.
§§ Multiple non-consecutive pages throughout the book
• Author A[comma][space]Author BC[period][double space]Title of Book[period][double space]City,
State[semi-colon][single space]Publisher’s name[colon][double space]year[colon][no space]page
number,page number,page number – page number.
• Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. The Smile Sessions. Hawthorne, CA;
2011;11,20,15-20.
§§ Special circumstances
• Subtitles of books should be included along with the main title in italics with main words also capitalized
££ Author A[comma][space]Author BC[period][double space]Title of Book:[single space]Include the Subtitle
[period][double space]City, State[semi-colon][single space]Publisher’s name[colon][double space]
year[period]
££ Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. The Smile Sessions: California is the Place for
Dreaming. Hawthorne, CA; 2011.
• The book is one of several volumes
££ Author A[comma][space]Author BC[period][double space]Title of Book:[single space]Include the Subtitle
[period][double space]Vol number non-italicized[period][double space]City, State[semi-colon][single
space]Publisher’s name[colon][double space]year[period]
££ Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. The Smile Sessions: California is the Place for
Dreaming. Vol 2. Hawthorne, CA; 2011.
• The book is a later edition
££ Author A[comma][space]Author BC[period][double space]Title of Book:[single space]Include the Subtitle
[period][double space]Ed number non-italicized[period][double space]City, State[semi-colon][single
space]Publisher’s name[colon][double space]year[period]
££ Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. The Smile Sessions: California is the Place for
Dreaming. 2nd ed. Hawthorne, CA; 2011.
• The book is one of several volumes and a later edition
££ Author A[comma][space]Author BC[period][double space]Title of Book:[single space]Include the
Subtitle [period][double space]Vol number[period][double space]Ed number[period][double space]City,
State[semi-colon][single space]Publisher’s name[colon][double space]year[period]
££ Author A[comma][space]Author BC[period][double space]Wilson BD, Wilson CD, Wilson DC, Jardine AC,
Love ME. The Smile Sessions: California is the Place for Dreaming. Vol 2. 2nd ed. Hawthorne, CA; 2011.

Additional information for print journal
-- Spacing and publication in a journal; please note, no spaces between publishing information from year of
publication on:
§§ Author A[comma][space]Author BC[period][double space]Title of article[period][double space]Journal Title
in Index Medicus Abbrev[period][double space]Year[semi-colon]Volume number[colon]page number-page
number[period]
§§ Do not include any other date information (i.e., do not include month or day)
§§ DON’T:
Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. Good vibrations improve standing balance in people
with Alzheimer’s disease. Phys Ther. May, 2011;3:19-43.
§§ DO:
Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. Good vibrations improve standing balance in people
with Alzheimer’s disease. Phys Ther. 2011;3:19-43.

The Quarterly Report | Summer 2019 Page 21

-- Include a volume number or supplement information when available:
§§ Author A[comma][space]Author BC[period][double space]Title of article[period][double space]Journal Title in
Index Medicus Abbrev[period][double space]Year[semi-colon]Volume number(issue number in parentheses)
[colon]page number-page number[period]
§§ Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. Good vibrations improve standing balance in people
with Alzheimer’s disease. Phys Ther. 2011;3(4):19-43.
§§ Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. Good vibrations improve standing balance in people
with Alzheimer’s disease. Phys Ther. 2011;3(suppl 4):19-43.

Additional information for online resources:
-- For books and journals that are published online only, you must provide information to indicate how you found
them. Either the DOI (preferred by AMA) or the exact URL may be used, and the date of access must be provided
§§ For The Quarterly, the URL is fine
-- Access information is the last piece of information cited
§§ Author A[comma][space]Author BC[period][double space]Title of Book[period][double space]City, State[semi-
colon][single space]Publisher’s name[colon][double space]year[period][double space]URL or DOI[period][double
space]Accessed Month[space]Date[comma][space]Year[period]
££ Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. The Smile Sessions. Hawthorne, CA; 2011.
http://www.surfiniseasy.com. Accessed August 2, 2018.
££ Wilson BD, Wilson CD, Wilson DC, Jardine AC, Love ME. Good vibrations improve standing balance in
people with Alzheimer’s disease. Phys Ther. 2011;3(4):19-43. http://www.surfiniseasy.com
-- Website citations vary depending on the material
§§ If the source cited is a “page” or “article” of a website with authors, cite it as you would an online journal,
using the title of the overall website in place of the journal title
££ No italics or title abbreviations necessary
££ If a volume, issue or date of publication are available, cite as you would for an article
££ Lennon JW, McCartney JP, Harrison G, et al. The use of the tops of mops (“mop tops”) for smooth gait.
The British Incursion website. https://www.britinvas.com. Accessed May 8, 2005.
££ Jagger MB, Richards K, Watts CR, Wood RD, Jones LBH, Wyman WG. Access to physical therapy
improves patient satisfaction. In Stewart I, ed. The KMoon website. http://blueandlonesome.com.
Accessed June 24, 2019.
§§ If no authors listed, begin with the title of the page or article
££ Access to physical therapy improves patient satisfaction. The KMoon website. http://blueandlonesome.
com. Accessed June 24, 2019.
§§ If it is a site that does not have pages or separate articles, then cite as you would a book
££ If location, date of publication, etc., are available, cite as you would for publication information for a
book.
££ The British Incursion website. https://www.britinvas.com. Accessed May 8, 2005.

This reference guide only covers the types of sources that are more commonly used. For other types (government
documents, theses, unpublished researched, etc.), please do an internet search on “ama style citation” and the type of
reference you are using.

Hear continued from Pg. 2

Coming to NAHC? Visit Us at the Home Care and Hospice In other news…
Conference and Expo
APTA’s Combined Sections Meeting 2020 is being
The 2019 Home Care and Hospice Conference and Expo on held February 12-15, 2020, in Denver, Colorado, which
October 13-15 at the Washington State Convention Center happens to be the home of the Home Health Section’s new
is just steps from the waterfront and the world-famous headquarters office. CSM registration opened Sept. 18.
Pike Place Market. This conference allows you to be in the If you haven’t yet registered, please visit: https://www.
center of the home care and hospice world while you’re in apta.org/CSM/Registration/ … By the time you read this,
the center of one of the world’s greatest cities. And it allows APTA Home Health’s new mobile-friendly website will have
you to connect with Home Health Section leaders, including launched. We want your comments! Email us at admin@
President Diana ‘Dee’ Kornetti, PT, MA, HCS-D. homehealthsection.org!
NAHC says don’t worry about missing anything while
you’re in the Expo because the Expo will be open for over
eight hours during the Conference when no other events
are scheduled.

Page 22 APTA Home Health Section

New Website Carries APTA Home Health Section Into Future

By Don Knox

The APTA Home Health Section is excited to unveil its new,
mobile-friendly website and membership platform. This
website – the address of which remains
www.homehealthsection.org – will help us keep our
membership connected.

Professionals say that one of the biggest reasons they join
their association is the opportunity to collaborate and
network with fellow members. With social networking
tools for staying in touch and a space dedicated to sharing
materials, our members can form new, professional
connections with fellow colleagues. Member groups can be
formed based on geographic region, issues, etc.

To get started on the new site, you’ll first need to set up
your password.

We’ve already sent you an email explaining how to log in for
the first time. But if you don’t remember receiving it, here’s
what you need to know:

• Your User ID is the email under which you joined APTA.
• You’ll need to set up a Password. Go here to set/update

your Password: https://aptahhs.memberclicks.net/
login#/reset-password
• Once your Password is set/updated, you can login to the
website at homehealthsection.org

Once you sign into the new site, you’ll find a wealth of
forums, discussion circles and more. We’ll be emailing you
frequently about the newest resources, and we encourage
your comments at [email protected].

What’s New About The Website?

• UPDATED FORMS: Many forms have been updated Mobile Friendly
from PDF or Word documents to electronic forms,
which will make interacting with the section easier for • ‘BANDED’ HOME PAGE: The new home page is
members. Examples: Award Nomination Submission presented in a series of bands instead of the previous
Form, ACHH Certification Registration Form, ACHH sliders, which again simplifies presentation for mobile
Certification Completion Form, Course Submission phones and tablets.
Form, and the Article Topic Submission Form.
• COMMUNITY FORUMS & DISCUSSION CIRCLES:
• UPDATED PAGES: Many pages that were in PDF format APTA Home Health staff will begin communicating to
have been converted to HTML, which means they’ll be members and subsets of members through community
easy to read in the mobile format. Examples: Awards forums and topic discussion forums. Please look for
Pages, Award Histories, ACHH Requirements Pages. more information on these in your email box!

• NEWS PRESENTATION: News is also now presented We’re excited! We hope you will be, too!
in a mobile-friendly format and is available for the first
time in an RSS format, which means members who use Don Knox, based in Denver, has been the executive director of the
web feeds can incorporate our news into their viewing APTA Home Health Section since March.
feeds. It also simplifies distribution of our weekly APTA
Home Health email, House Call.

The Quarterly Report | Summer 2019 Page 23

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