APTA Home Health Quarterly Report Vol 57, No. 4

The Quarterly Report

FALL 2022

Vol. 57 | No. 4

In this
Issue:

1 Expanding the
Definition of Home to
Meet our Mission

2 Did You Hear?
Read All About It!

5 OASIS-E:
Ready, set, go!

8 What Can I Do? A
Guide to Affirming
LGBTQIA+ Patients
in Home Health

12 Value Based
Purchasing
Expanding the Definition of Home to
Real World Experience Meet our Mission
from the Demonstration
Lisa VanHoose, PT, PhD, MPH
14 High Intensity Exercise
Programs in People Board Certified Clinical Specialist in Oncologic Physical Therapy
with Dementia
The mission statement of American Physical Therapy Association (APTA) Home Health charges
15 Medication Errors’ the organization, “to provide a means by which Association members having a common interest in the
Causes Analysis in delivery of physical therapy in the home and other alternative settings within the community may meet,
Home Care Setting: confer, and promote these interests.” An etymological investigation of the word ‘means’ revealed defini-
tions such as “a course of action” from the late 14th century or, “wealth, resources at one’s disposal for
A Systematic Review accomplishing some objects” which was a 17th-century definition.1 Those objects to be accomplished
are best defined by our professional organization. APTA states that physical therapists and physical
17 APTA Home therapist assistants improve the ability of persons, “to move, reduce or manage pain, function, and
Health Awards prevent disability…. They help people achieve fitness goals, regain or maintain their independence, and
lead active lives.”2 Mobility and life do occur in our diverse examples of “home”. Home can include a
18 Recognition of patient’s home, family member’s home, independent living facility, assisted living facility or a group
our Recent ACHH or residential home. The Old English term ‘ham’ included a more ecological definition of ‘home’ which
Graduates included a “dwelling place, house, abode, fixed residence, estate, village, region, country”.3

19 A Home Health Question: Could you, we and the Academy expand our definition of “home” to meet the mission of
COVID-19 protecting and increasing movement and function as part of the delivery of care?
Rehabilitation
Program Utilizing Continued on Page 3
High Frequency, Low
Intensity and Short
Duration Activity: A
Case Report

24 Poster Presentations
from the 2022 CSM

Published by APTA Home Health, Did You Hear?
an Academy of the American Physical Therapy Association
Read All About It!
Editor
Dawn Widmer-Greaves, PT, DPT APTA Home Health Debuts Partner Program
APTA Home Health is excited to introduce a new Partner Program
Managing Editor/Design
Don Knox that will appeal to businesses that serve home health PTs and PTAs
nationwide. The program is composed of two types of partnerships.
Publications Committee
Zachary Hampshire, PTA; Julie Hardy, PT, MS; Olaide • Allied Partners are businesses that provide products & services
Oluwole- Sangoseni, PT, DPT, MSc, PhD; Amanda used by PTs and PTAs.
Fabozzi, PT, DPT; Matt Janes, PT, DPT, MHS; Brittany
Czerw, PT, DPT • Provider Partners are Home Health Agencies and other
employers of PTs & PTAs.
Section Officers:
President....................Philip Goldsmith, PT, DScPT, COS-C The first program type, Allied Partnership, enables companies to con-
Vice President................................. Chris Chimenti, PT, MS nect with APTA Home Health’s members across the country. The
Secretary..................................... Monique Caruth, PT, DPT base partner fee of $1,000 includes a ½ page ad in our annual Allied
Treasurer...................................... Erin Pazour, MPT, COS-C Partner Digital Catalog, a listing on our website in the Allied Partner
Executive Director................................................. Don Knox Directory, and a one-time ad in an issue of the academy’s e-HouseCalls
newsletter.
The Quarterly Report is the official publication of APTA
Home Health, an Academy of the American Physical Under this category, there’s also a Premier Allied Partnership for
Therapy Association. It is published four times per $5,000 that includes sponsorship of annual membership meeting or
calendar year (Winter, Spring, Summer, Fall). Statements awards ceremony your choice of one add-on sponsorship and year
of fact and opinion are the responsibility of the authors listing on AHH homepage with logo as a ‘Premier Partner.’
alone and do not imply an opinion on the part of the
officers or the members of APTA Home Health. Add-on sponsorships are:
• Podcast Sponsor - $750/each or $2,000 for series of three.
Article & Content Contributions Includes reading of promotional script (up to 60 seconds)
Guidelines for contributions are available from the • Publication Sponsor - $1,500 - $3,000 (depending on size of
APTA Home Health website. If you have materials you publication) Up to 6 for each publication; printed on inside of
would like considered for publication, please email them front cover
via attachment to the APTA Home Health Executive • Webinar Sponsor - $1,500 each or $4,000 for series of
Director: [email protected] three. Can be hosted by AHH or by Partner and AHH promotes.
Partner responsible for content and presentation. Link to
Advertising recording will be included in e-HouseCalls newsletter and sent
Advertising rates and details are available from the to all members.
Section website, www.aptahomehealth.org, or by
contacting the Academy office at 720-459-5559. The other type of partnership, Provider Partnership, receive benefits
aimed at reaching potential job candidates and helping your physical
Electronic subscriptions to APTA Home Health Quarterly therapy staff to become the best qualified team available.
Report are available at a rate of $100/year. Order
through the Academy’s online store. This partner program has three sizes: Tier 1 (< 25 employees) =
$400/year; Tier 2 (26 – 100 employees) = $800/year; and Tier 3 (101+
Copyright ©2021 by APTA Home Health employees) = $1,600/year.

Postmaster: Send address changes to APTA Home Health, Benefits include membership pricing for all employees (regard-
PO Box 3406 , Englewood, CO 80155. less of individual membership status) for ACHH and OASIS-E
programs OR 10% off membership pricing if 100% of current therapy
www.aptahomehealth.org staff (5 people < ) or at least 25 employees participate in program. 
PO Box 3406 • Englewood, CO 80155 • 720-459-5559
Provider Partners also receive access to APTA Home Health’s
Page 2 bi-weekly e-HouseCall Newsletter  as well as free job board postings:
Tier 1 – Up to 5 free postings a year; Tier 2 – Up to 10 free postings a
year; and Tier 3 – Up to 20 free postings a year.

Here again, there’s also a Premier Provider Level that includes the
same high-level benefits as are available in the Allied Partner Program.


If you are interested in an APTA Home Health Partnership, please
email us at [email protected] with your name, company,
and the program and level you are interested in.

APTA Home Health Section

Continued from Page 1

If we are to protect and increase health and wellness within noise, were another barrier reported by aging adults.11
one’s home, then we must consider built and natural environments. The livable elements identified by aging adults are in alignment
Studies of urban environments have shown that neighborhood
characteristics are positively related to physical activity levels. with the World Health Organization’s eight ‘domains of livability’ or
The difference in physical activity levels between the most and community features. Those domains are categorized as service,
least physical activity-friendly neighborhoods was approximately social or built environments. The home health therapist will need to
20 minutes.4 The disability associated with being homebound, as consider housing, transportation, outdoor spaces and public build-
required for home health services, increases the risk of conditions ings, social and civic participation, employment, social inclusion
and diseases related to immobility and obesity. The Physical Activ- and respect, community support and health services and commu-
ity Guidelines for Adults with Disabilities from the U.S. Department nication and information8 if they are to provide high-quality, holistic
of Health and Human Services are at least 150 minutes of moder- care. Each feature plays a crucial, integrated role in the health and
ate-intensity, 75 minutes of vigorous-intensity or a combination wellness of clients.
of both intensity levels which is similar to the guidelines for the
general population.5 The American College of Sport Medicine developed the Community
Fitness Assessment with support from Anthem Foundation.14 The doc-
With over 85% of home health users over the age of 65,6 addi- ument will assist the home health therapist with the identification and
tional attention must be given to the impact of the environment on assessment of physical activity resources within a community that
the health of aging adults. The 1970s ecological model of aging aligns with the eight domains of livability. The process includes seven
and the expanded bioecological systems theory elucidate the to eight steps as listed below.
interaction between individuals and their environmental contexts.
Each context is interrelated based on one’s immediate environment Step 1: Guides the therapist through the identification of population
(their dwelling place), their neighborhood (mesosystem, which characteristics using the U.S. Census database.
is the connection between the dwelling places) and their city or Step 2: Guides the therapist through the comparison of a community
state (macrosystem, which is the connections between the neigh- of interest with local, state and national data facts.
borhoods).7 Black and Jester (2020) indicated that transportation Step 3: Guides the therapist through the identification of personal health
and housing were the most important community resources for behaviors and outcomes within a community using various public data-
aging adults in the worst health and mental conditions.8 Additional sets (e.g., exercising, food consumption, sleeping behaviors).
environmental influences on healthy aging include social network Step 4: Guides the therapist through the identification of commu-
participation, level of pollution, accessibility of services and facili- nity and environmental indicators within a community using various
ties and community life.9 Although most aging adults want to age in public datasets (livability, air quality, food availability, physical activity
place,10 many do not consider outdoor resources to be part of their resources, walkability and bikeability and policy indicators).
definition of livable.8 The lack of livable accessibility are related to Step 5: Provides the therapist an alternative option of completing a
pedestrian infrastructure, safety, access to facilities, aesthetics Mini Community Fitness Assessment if an abbreviated assessment
and environmental conditions.11 Older adults who choose to age is needed and can sufficiently provide the therapist the contextual
in place feel like community members, governmental officials and information needed to provide holistic person-centered care.
leaders and health care providers are not considering their physical Step 6: Guides the therapist through the interpretation of the findings.
activity and psychosocial needs as evidenced by the quote below. Step 7: Educates the therapist on how to transition from an ally to an
advocate and potentially an activist to improve the patient’s expanded
“They’re not including us! They’re more concerned about the “home” environment to optimize movement and function.
young people, what they’ve got. They’ve got skate parks and all sorts
of things they’re planning for them, but they’re not planning anything As the profession continues to communicate its value proposition
for us.”12 within the health care ecosystem, we must recognize that commu-
nity-based health and community health are necessary elements of
Pedestrian infrastructure includes the availability of complete home health service. The very nature of home health makes it a com-
sidewalk systems with accessible slopes and curbs. Fifty percent munity-based service. However, we can expand this definition of home
or greater of sidewalks and curbs are not accessible even though and broaden our ability to partner with communities for sustainable,
the Americans with Disabilities Act was passed in 1990.13 Older healthy living. The “delivery of physical therapy” is not a question of
adults and those with disabilities are concerned about sharing what we do, but how we do it. Can we provide care in a manner that
existing sidewalks with cyclists and skaters.11 Safety concerns also increases the return of investment from individual health to com-
included the presence of homeless persons, beggars, immigrants munity health? We must practice with a greater understanding of
and youth groups in outdoor settings. The presence of police can the individual’s movement and functional context, also known as the
be viewed as a positive safety element, but some aging adults social, structural and political determinants of health. This context
were concerned about police response when interacting with the drives upwards to 80% of health and wellness outcomes.15 Therefore,
community. Ambulating or mobilizing in one’s community can be we must be active advocates and activists to reduce the barriers to
further hindered by long street crossing distances, inadequate healthy lifestyles in communities. Even for the patient who is home-
signals or crossing times or poor signage indicating pedestrian bound, there needs to be equitable access to community resources
crossing. Access to physical activity resources and well-positioned to support health and wellness which will require changes in policies
rest areas may impact the patient receiving home health services. and social services. The APTA Home Health and its members are
Neglected built and natural environments discourage physical uniquely positioned to respond to this social obligation as a health
activity. Environmental conditions that negatively impact mobility care profession and as professionals.
such as cold weather and high pollutions levels, including air and

The Quarterly Report | Fall 2022 Page 3

About the Author 5. Health.gov. 2022. Current Guidelines | health.gov. [online] Available at:
Dr. Lisa VanHoose describes herself as your <https://health.gov/our-work/nutrition-physical-activity/physical-activity-
intercultural guide. She can help you make the guidelines/current-guidelines> [Accessed 22 March 2022].
uncomfortable situations comfortable and exciting.
She is a Clinical Professor at Baylor University in the 6. Alliance for Home Health Quality and Innovation. 2021. Home Health
Physical Therapy Department. Dr. VanHoose is the Chartbook. [online] Available at: <https://ahhqi.org/research/home-health-
Founder and Executive Director of the Ujima Institute chartbook> [Accessed 21 March 2022].
and Foundation. The mission of the organization is
7. Greenfield, E., 2011. Using Ecological Frameworks to Advance a Field
to improve Black health outcomes and patient/client satisfaction of Research, Practice, and Policy on Aging-in-Place Initiatives. The
through workforce upskilling focused on intercultural development Gerontologist, 52(1), pp.1-12.
and interactions. Dr. VanHoose has investigated workforce
diversification and health disparities since 1995. She is a qualified 8. Black K, Jester DJ. Examining Older Adults’ Perspectives on the Built
administrator of the Intercultural Development Inventory. Dr. Environment and Correlates of Healthy Aging in an American Age-Friendly
VanHoose received her PhD in Rehabilitation Science and MPH from Community. Int J Environ Res Public Health. 2020;17(19):7056. Published
the University of Kansas Medical Center. She completed fellowships 2020 Sep 27. doi:10.3390/ijerph17197056
at the University of Arkansas Medical Sciences; Donald W. Reynolds
Institute on Aging; and the National Heart, Lung, and Blood Institute, 9. Annear M, Keeling S, Wilkinson T, Cushman G, Gidlow B, Hopkins H.
PRIDE Summer Institute with an emphasis in Cardiovascular Genetic Environmental influences on healthy and active ageing: a systematic
Epidemiology. Her Bachelor of Science in Health Science and Master review. Ageing and Society. 2014;34(4):590-622. doi:10.1017/
of Science in Physical Therapy were completed at the University S0144686X1200116X
of Central Arkansas. She is a Board-Certified Clinical Specialist in
Oncologic Physical Therapy. She is a certified Patient Navigator 10. Harrell R., Lynott J., Guzman S., Lampkin C. What is Livable? Community
through the Harold P. Freeman Patient Navigation Institute. She Preferences of Older Adults. AARP Public Policy Institute; Washington, DC,
is a trained facilitator through the Center for the Improvement of USA: 2017. 
Mentored Experiences in Research. She has trained in the Louisiana
Racial and Health Equity Learning Laboratory which focuses on 11. Moran M, Van Cauwenberg J, Hercky-Linnewiel R, Cerin E, Deforche B, Plaut
building capacity of leaders across the state to address systemic P. Understanding the relationships between the physical environment and
barriers and social inequities affecting marginalized and minoritized physical activity in older adults: a systematic review of qualitative studies. Int
communities. She is always excited to learn with and from all J Behav Nutr Phys Act. 2014;11:79. Published 2014 Jul 17. doi:10.1186/1479-
humans. 5868-11-79

References: 12. Annear, M., Cushman, G. and Gidlow, B., 2009. Leisure time physical
1. Etymonline.com. 2022. means | Etymology, origin and meaning of means activity differences among older adults from diverse socioeconomic
neighborhoods. Health & Place, 15(2), pp.482-490.
by etymonline. [online] Available at: <https://www.etymonline.com/word/
means> [Accessed 21 March 2022]. 13. Eisenberg, Y., Heider, A., Gould, R. and Jones, R., 2020. Are communities in
2. Apta.org. 2022. Becoming a Physical Therapist. [online] Available at: <https:// the United States planning for pedestrians with disabilities? Findings from a
www.apta.org/your-career/careers-in-physical-therapy/becoming-a-pt> systematic evaluation of local government barrier removal plans. Cities, 102,
[Accessed 21 March 2022]. p.102720.
3. Etymonline.com. 2022. home | Etymology, origin and meaning of home by
etymonline. [online] Available at: <https://www.etymonline.com/word/ 14. American Fitness Index. 2020. Community Fitness Assessment - American
home> [Accessed 22 March 2022]. Fitness Index. [online] Available at: <https://americanfitnessindex.org/
4. Sallis JF, Cerin E, Conway TL, et al. Physical activity in relation to urban community-fitness-assessment/> [Accessed 21 March 2022].
environments in 14 cities worldwide: a cross-sectional study [published
correction appears in Lancet. 2016 May 28;387(10034):2198]. Lancet. 15. Hood, C. M., K. P. Gennuso, G. R. Swain, and B. B. Catlin. 2016. County
2016;387(10034):2207-2217. doi:10.1016/S0140-6736(15)01284-2 health rankings: Relationships between determinant factors and health
outcomes. American Journal of Preventive Medicine 50(2):129-135. https://
doi.org/10.1016/j.amepre.2015.08.024

Page 4 APTA Home Health Section

OASIS-E: Ready, set, go!

Dr. Matt Janes, PT, MHS

Home health agencies and practicing clinicians should already include: Acronym List, Action Plan Worksheet, Resource Guide, Case
be planning for the next iteration of the Outcome Assessment and Study documents and PDF versions of the Training Webinars. Additional
Information Item Set, Version E (OASIS-E). The Centers for Medi- select resources including a link to the video presentations from CMS
care & Medicaid Services (CMS) originally planned for OASIS-E to include:
be effective on January 01, 2021, however, implementation was
delayed allowing additional flexibilities for home health agencies • OASIS-E Updated Instrument @ https://www.cms.gov/files/
to respond to public and patient health care needs related to the document/oasis-e-update-instrument51622.pdf
COVID-19 Public Health Emergency (PHE).1 As mandated in the
CY 2022 Home Health Final Rule, CMS will implement OASIS-E on • OASIS-E Guidance Manual available @ https://www.cms.gov/
January 1, 2023.2 files/document/oasis-e-guidance-manual51622.pdf

Home health agencies using an electronic medical record • PAC Training: Home Health Virtual Training Program Didactic
(EMR) should ensure their documentation system vendor has a deploy- Training @ https://www.youtube.com/playlist?list=PLaV7m2-
ment plan that meets the CMS implementation date of 1/1/2023. zFKpj_ANPy_1VIYM3Fvt_soTw-
In addition, clinician preparedness with any documentation change
allows for a more manageable transition and practice acceptance. In addition to CMS, there are multiple resources available from
There are many low to no cost resources that agencies can use to help vendors and other providers who service home health practice that
train clinicians, clinical managers and other agency staff impacted by can be identified or located via the internet.
OASIS-E. CMS has developed several support items to assist agen-
cies with training and provide reference materials including over 4.5 OASIS-E further aligns quality reporting with cross-setting Post-
hours of content training across a total of 11 recorded presentations. Acute Care (PAC) measures as required by the Improving Post-Acute
Additional training resources are located in a zip file in the download Care Transformation (IMPACT) Act of 2014. Overall, there are 27 new
section on CMS’ Home Health Quality Reporting webpage3 titled 2022_ assessment items as part of OASIS-E. Many of the changes were to ensure
September_HH Virtual Training Program – Part 1 (ZIP). Resources additional inclusion of items of importance such as Social Determinants
of Health (SDoH), health literacy, additional cognitive and depression
screening, pain related to day-to-day activities or in response to performing
therapy-related activities, high-risk medication identification and others.

The Quarterly Report | Fall 2022 Page 5

The 27 new OASIS-E items are shown in Table 1, designated by the applicable timepoint(s): Start of Care (SOC), Resumption of Care (ROC),
Follow-up (FU), Transfer (TRF) or Discharge (DC)

In addition to the new OASIS-E items, there are also several assessment items that have been either replaced or removed at various time-
points. Agencies should review the items that have been removed and determine if alternative assessment strategies may still be beneficial
to practice, safety and overall patient care outcomes.

OASIS-E Item Timepoint
A1005: Ethnicity SOC
A1010: Race SOC
A1110: Language SOC
A1250: Transportation SOC, ROC, DC
A2120: Provision of Current Reconciled Medication List to Subsequent Provider at Transfer TRF
A2121: Provision of Current Reconciled Medication List to Subsequent Provider at Discharge DC
A2122: Route of Current Reconciled Medication List Transmission to Subsequent Provider TRF, DC
A2123: Provision of Current Reconciled Medication List to Patient at Discharge DC
A2124: Route of Current Reconciled Medication List Transmission to Patient DC
B0200: Hearing SOC
B1000: Vision SOC
B1300: Health Literacy SOC, ROC, DC
C0100: BIMS: Should Brief Interview for Mental Status (C0200-C0500) be Conducted? SOC, ROC, DC
C0200: BIMS: Repetition of Three Words SOC, ROC, DC
C0300: BIMS: Temporal Orientation SOC, ROC, DC
C0400: BIMS: Recall SOC, ROC, DC
C0500: BIMS: Summary Score SOC, ROC, DC
C1310: Signs and Symptoms of Delirium SOC, ROC, DC
D0150: Patient Mood Interview (PHQ-2 to 9) SOC, ROC, DC
D0160: Total Severity Score SOC, ROC, DC
D0700: Social Isolation SOC, ROC, DC
J0510: Pain effect on Sleep SOC, ROC, DC
J0520: Pain Interference with Therapy Activities SOC, ROC, DC
J0530: Pain Interference with Day-to-Day Activities SOC, ROC, DC
K0520: Nutritional Approaches SOC, ROC, DC
N0415: High-Risk Drug Classes: Use and Indication SOC, ROC, DC
O0110: Special Treatments, Procedures, and Programs SOC, ROC, DC
Table 1 New OASIS-E Items

Page 6 APTA Home Health Section

Removed OASIS-E Item Timepoint Replacement Timepoint
M0140: Race/Ethnicity SOC
M1200: Vision with corrective lenses if the patient usually wears them SOC, ROC A1005 and A1010 SOC
M1730: Depression Screening SOC, ROC
M1242: Frequency of Pain Interfering with Activity or Movement SOC, ROC, DC B1000 SOC
M1910: Has this patient had a multi factor Falls Risk Assessment using a standardized, validated
assessment tool? D0150, D0160, D0700 SOC, ROC, DC
M1030: Therapies the patient received at home
M2016: Patient/Caregiver Drug Education Intervention J0510, J0520, J0530 SOC, ROC, DC
M1051: Pneumococcal Vaccine
M1056: Reason Pneumococcal Vaccine not received SOC, ROC No Replacement
M2401A: (Diabetic Foot Care as part of Intervention Synopsis)
SOC, ROC, FU K0520 SOC, ROC
TRF, DC No Replacement
TRF, DC No Replacement
TRF, DC No Replacement
TRF, DC No Replacement

Table 2 Replaced and/or removed items

The OASIS-E items in Table 2 were either replaced or removed at defines therapies currently being delivered at time of SOC/ROC.
the noted timepoints. These include cancer treatments such as chemotherapy or radiation.
Respiratory therapies such as oxygen use, suctioning, tracheostomy
Highlights of several new OASIS-E items or those that were care, ventilator or respirator use and non-invasive mechanical venti-
removed/replaced, include changes related to Social Determinants lation such as bilevel positive airway pressure (BiPAP) or continuous
of Health (SDoH) such as increasing specificity to identify race or positive airway pressure (CPAP). Additional items include: IV medica-
ethnic disparities that in turn impact outcomes. Also, potential health tions, transfusions, dialysis, and specificity of IV access sites.
outcome barriers such as language and the ease of communication
or translation services and access to transportation were included to A coordinated clinician/operational task has been added at time
further identify opportunities to foster health equity among all patients. of patient transfer or discharge for the provision and designated route
Additional assessment items include changes to hearing, speech, and of delivery of the patient’s reconciled medication list. Clinicians and
vision, but now include a standard consideration of health literacy agencies will need to develop a timely and consistent operational
and the potential for these areas to be another contributable barrier process to ensure a current medication list is delivered when appli-
for a patient or caregiver to thoroughly understand the care plan and cable to the subsequent provider. The route of delivery however can
negatively impact the patient outcome. be provided by several options including via electronic health record,
health information exchange, verbal (e.g., in-person, telephone, video
Another significant change is the expanded screening of cognitive conferencing), paper-based (e.g., faxed, copies, printouts) or other
decline with the use of the Brief Interview for Mental Status (BIMS) methods (e.g., texting, email, CDs).
including the identification of signs and symptoms of Delirium from
the Confusion Assessment Method (CAM©). Further, mood changes For OASIS-E items that were removed but had no replacement,
can now be more comprehensively assessed using the Patient Health one specific item should be a major consideration for clinicians to
Questionnaire-2 (PHQ2) to 9. consider which is the identification of fall risk factors and prioritizing
relevant interventions based on the level of risk as previously driven
A patient’s self-reported or observed level of pain is a frequent by M1910. Agencies should consider continuing to screen for fall
area to address as part of any care plan. Pain is now divided into 3 risk via an appropriate evidence-based screening instrument and/
question/response items that differentiate the effect of pain and poten- or administration of a test or measure that is valid and reliable in the
tial primary cause. These include pain’s effect on sleep, interference identification of fall risk. As we know, our aging population continues
with therapy activities and interference with day-to-day activities. to be at increased risk for falls and the prevalence and risk of falling
incrementally increases with age.4-6 Agencies should strive to continue
Nutritional approaches now include additional items such as to identify and prioritize appropriate interventions that address fall
a mechanically altered diet that require change in texture of food risk to not only aid in the identification of risks but also to aid in the
or liquids (e.g., pureed food, thickened liquids) or a therapeutic diet justification and provision of skilled therapy as part of the care plan.
(e.g., low salt, diabetic, low cholesterol). These options, along with
parenteral/IV feeding and feeding tube provide a more comprehensive The following OASIS-E items were removed only at FU; all other pre-
understanding of the patient’s abilities related to nutrition at SOC/ROC existing timepoints remain.
as well as any changes noted at time of DC.
• M1610: Urinary Incontinence or Urinary Catheter Presence
Medications and adverse events that potentially impact patient • M1620: Bowel Incontinence Frequency
safety and health are now indicated by increasing awareness in the use • M1630: Ostomy for Bowel Elimination
of high-risk medication classes such as: antipsychotic, anticoagulant, • M1021: Primary Diagnosis
antibiotic, opioid, antiplatelet, hypoglycemic (including insulin). The • M1023: Other Diagnosis
assessing clinician must document which drug class a patient is taking • M1400: Dyspnea
as well as if there is an identification for use of that specific drug class.

Special treatments, procedures, and programs (O0110) that

The Quarterly Report | Fall 2022 Page 7

• M1311: Current Number of Unhealed Pressure Ulcers/Injuries at About the author:
Each Stage Matt Janes, PT, DPT, MHS is a Board Certified
Orthopaedic Clinical Specialist and a Certified
• M1322: Current Number of Stage 1 Pressure Ulcers Strength and Conditioning Specialist. Dr. Janes is
• M1324: Stage of Most Problematic Unhealed Pressure Ulcer/ the Division AVP of Therapy Practice and Quality for
CenterWell Home Health and can be reached at matt.
Injury that is Stageable [email protected]
• M1330: Does this patient have a Stasis Ulcer?
• M1332: Current Number of Stasis Ulcer(s) that are Observable References:
• M1334: Status of Most Problematic Stasis Ulcer that is 1. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Observable Instruments/HomeHealthQualityInits/OASIS-Data-Sets. Accessed 9/20/2022.
• M1340: Does this patient have a Surgical Wound? 2. Centers for Medicare & Medicaid Services (CMS), HHS. Medicare and Medicaid
• M1342: Status of Most Problematic Surgical Wound that is
Programs; CY 2019 Home Health Prospective Payment System Rate Update
Observable and CY 2020 Case-Mix Adjustment Methodology Refinements; Home Health
• M2030: Management of Injectable Medications Value-Based Purchasing Model; Home Health Quality Reporting Requirements;
• M2200: Therapy Need Home Infusion Therapy Requirements; and Training Requirements for
Surveyors of National Accrediting Organizations. Final rule with comment
As with any change that impacts the clinical assessment, subse- period. Fed Regist. 2018 Nov 13;83(219):56406-638. PMID: 30457255.
quent documentation and administrative support, OASIS-E will bring 3. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
about many needed changes to promote a more comprehensive view Instruments/HomeHealthQualityInits/Home-Health-Quality-Reporting-
of the patient. With these changes however, agencies should ensure Training accessed 9/20/2022.
all assessing clinicians have the appropriate training and resources 4. Moncada LVV, Mire LG. Preventing Falls in Older Persons. Am Fam Physician.
available to ensure OASIS accuracy for both new and old patient 2017 Aug 15;96(4):240-247. PMID: 28925664.
assessment items. Assessment accuracy not only provides an iden- 5. Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged
tification of the most accurate clinical representation of the patient ≥65 Years — United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65:993–
but drives the collaborative conversation of multidisciplinary providers 998. DOI: http://dx.doi.org/10.15585/mmwr.mm6537a2
aimed at meeting the goals of the patient as well as those established 6. Institute of Medicine (US) Division of Health Promotion and Disease
as part of the comprehensive patient plan of care. Prevention; Berg RL, Cassells JS, editors. The Second Fifty Years: Promoting
Health and Preventing Disability. Washington (DC): National Academies Press
(US); 1992. 15, Falls in Older Persons: Risk Factors and Prevention. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK235613/. Accessed 9/20/2022.

Page 8 What Can I Do? A Guide
to Affirming LGBTQIA+
Patients in Home Health

Chris W. Condran, PT, DPT, EdD, MBA-HCM, MS, and
Cindy Lane Moore, PT, DPT, PhD, MPH

According to Gallup’s latest poll, the United States LGBTQIA+
population has increased substantially in the past ten years, up to 5.6%
in 2022 from 3.5% in 2012.1 In Generation Z, one in six adults is part
of the LGBTQIA+ communities.1 As this population continues to grow,
physical therapists, physical therapist assistants and other providers
have been challenged to address these individuals’ unique healthcare
needs. In the past, providers have performed poorly when tasked with
delivering high-quality care to members of the LGBTQIA+ population.2

Based on research themes derived from patient experiences,
physical therapists make assumptions regarding the gender and sexu-
ality of their patients, discriminate based on gender and sexuality and
lack knowledge of specific transgender health issues.3 Additionally,

APTA Home Health Section

patients fear discrimination and are uncomfortable with the proximity as race or ethnicity) epidemiological, intervention and implementa-
and touch of therapists as well as with the undressing and observa- tion research is needed.6 Disparities in lesbian communities include
tion of their bodies which are often components of care provision in increased rates of heart disease, stroke, chronic pain, arthritis, obesity,
physical therapy.3 mental health challenges and emotional stress.7 Lesbians have less
frequent routine preventative health screenings compared to het-
Recent research findings suggest this problematic care may be erosexual peers.7 Additionally, lesbians have higher rates of intimate
related to LGBTQIA+ cultural competency. Nowaskie et al4 found that partner violence and substance use than their heterosexual peers.7
student physical therapists receive on average less than one hour
of LGBTQIA+ cultural competency training in their academic degree In gay communities, disparities manifest as increased incidences
programs. This lack of training is reflected in these students’ Lesbian, of headaches, sexual health conditions, chronic pain, heart disease,
Gay, Bisexual, Transgender- Development of Clinical Skills Scale (LGBT- prostate cancer, colon cancer, testicular cancer and eating disorders
DOCSS) score. When compared to other helping professions (medical, when compared to their heterosexual peers.7 Gay individuals experi-
dental, occupational therapy, pharmacy, social work and physician ence greater rates of violent victimization and harassment and more
assistant), physical therapy students score in the bottom third in intimate partner violence than their heterosexual peers.7
the basic knowledge and attitudinal awareness subscale as well as
fifth out of six professions on the overall LGBT-DOCSS.4 This study Bisexual individuals experience an increased risk for heart dis-
suggests a greater number of education hours is likely to increase ease, cancer and mental health conditions than their heterosexual
LGBTQIA+ cultural competency. These educational hours will be well peers.7 Bisexual folks are more likely to experience intimate partner
spent developing empathy and a deep understanding of the lived violence.7 Bisexual women are more likely to be underweight, while
experiences of those in the LGBTQIA+ communities. Let’s unpack bisexual men are more likely to experience sexual health conditions
some of these experiences next. compared to their respective heterosexual peer groups.7

What Can I Do? Transgender people experience higher rates of headaches, chronic
pain, cardiovascular conditions, neurologic conditions, endocrine con-
Understand and Empathize with the Unique Experiences of ditions, chronic pulmonary disease, anemia, liver disease, renal failure,
LGBTQIA+ Folks rheumatoid arthritis, cancer, peptic ulcer disease, mental health and
sexual health conditions than their cisgender peers.7 Transgender
In order to fully empathize with our patients’ experiences, we individuals are more likely to use substances.7 Transgender women
must try to envision ourselves in their shoes. If walking their path, of color experience the highest rates of violent victimization.7 Lastly,
we may consider the issues facing them each day. For LGBTQIA+ transgender individuals experience disproportionately high rates of
Americans, this list of issues is substantial: housing discrimination, violence and harassment.7
fair and inclusive workspaces, access to health insurance, access
to competent healthcare, access to gender-affirming care, identity Creating empathy regarding these unique experiences of political,
document changes, gender marker changes, freedom from discrimi- societal and personal adversity broadens the ways in which we can
nation, hate crimes legislation, equitable education, anti-bullying and engage our patients. In addition to empathy, delivering care utilizing
safe schools, equitable athletic competition policies, secure legal ties affirming behaviors can establish a channel to quality therapeutic
between parents and children, access to welcoming faith communities, encounters.8
conversion therapy, hospital policies for caring for a sick partner or
child, freedom to marry and public access to the bathrooms or locker Develop and Deliver Inclusive, Affirming Behaviors
rooms.5 The interconnectedness of legal protections and the pursuit When providing care to members of the LGBTQIA+ communities,
of health and wellness is one often overlooked by those of privileged
experience. For example, without fair and inclusive workspaces, free- an essential component of successful care delivery is to display inclu-
dom from discrimination and employment protections a patient of sive, affirming behaviors. Let’s begin prior to the first encounter. Before
LGBTQIA+ identity may experience difficulties securing insurance and/ engaging with patients, set your mindset to maintain confidentiality.
or affording to pay for physical therapy care. A patient of transgender You may hear information that is outside your comfort zone and want
identity may not pursue necessary care because their identity does to discuss it with your colleague. Remember that unless your colleague
not match their identity documents due to being unable to legally tran- is participating in their care, you are not to share. Also, set your mind to
sition in their municipality. These are just a couple of examples of the be open and free from assumptions. Be mindful to recognize the wide
complex issues LGBTQIA+ patients may face when trying to access variety of identities and practices. There is no “right” or “wrong” way
care. Due to these complexities, LGBTQIA+ individuals experience to express gender identity or to transition. Now that the encounter is
greater health disparities than their cisgender heterosexual peers.2 framed in your mind, consider the first engagement with the patient.

Groups within the LGBTQIA+ communities have unique dispari- During the first encounter, introduce yourself by using your name
ties profiles and additional community- and subgroup-specific (such and disclosing your pronouns. Sharing your pronouns with your patients
conveys the value and importance of those words as well as sets the
tone so patients will feel safe sharing theirs. Table 1 provides details
regarding pronouns and narratives. After the initial encounter, as you

Pronouns Example

She, her, hers This is my friend Sam. She came to my house today. I borrowed this book from her. This book is hers.

He, him, his This is my friend Sam. He came to my house today. I borrowed this book from him. This book is his.

They, them, theirs This is my friend Sam. They came to my house today. I borrowed this book from them. This book is theirs.

Ze, Zir, Zirs This is my friend Sam. Ze came to my house today. I borrowed this book from zir. This book is zirs.

TABLE 1. Pronouns and Narratives

The Quarterly Report | Fall 2022 Page 9

Less Gendered Language… In Lieu of… transparency, collaboration and mutuality, empowerment/voice/choice
and the awareness of cultural, historical and gender acknowledgment.8
• People with vaginas • Women, men, females, males
• People who menstruate Home care physical therapists and physical therapist assistants
• People with ovaries • Biologically male or male bodied can take steps to incorporate trauma-informed care within their clinical
• People with penises • Biologically female or female bodied practices. Figure 1 shows tips for doing so within clinician-patient inter-
• People with prostates • Pregnant woman actions. Implementation of healthcare improvements also requires
• People who produce sperm • Breasts actions at organizational and societal levels.13,14 The Fenway Guide
• Breastfeeding describes institutional and community/societal steps for applying
• Assigned male sex at birth • Period trauma-informed care principles to optimize care for transgender and
gender diverse patients.8
• Assigned female sex at birth
Create and Foster an Inclusive Environment
• Pregnant person In clinical settings, an inclusive environment can be fostered

• Chest by providing gender-neutral bathrooms, non-discrimination policies,
and representative media. In home health, although the setting is
• Chestfeeding already constructed by the patient, there are still things in the built
environment that can be done to signal to patients that safety, equity
• Menstruation and inclusion are our goals. On forms and documentation, recognize
there may be incongruence and provide space for the name a patient
TABLE 2. Alternatives to Gendered Language* uses and name as it is on legal documents (photo ID and insurance).
*Adapted from Table 12-1, O’Banion D, Barr SM. Obtaining a gender- Providing space for current gender identity, sex assigned at birth and
affirming sexual history. In: Keuroghlian A, Potter J, Reisner SL. an inclusive anatomical inventory also creates an inclusive experience.
Transgender and Gender Diverse Health Care: The Fenway Guide. Documentation space for communication between providers should
McGraw-Hill; 2022: 130-142. be prioritized with names, pronouns and additional considerations
to ensure safe hand-offs between staff.11 This prevents the patient
build your rapport, remember to listen and mirror the patient. Patients from having to repeat their entire history to each new provider and
may use different words to describe their anatomy than the anatomically potentially relive any associated trauma or incur additional trauma
correct words. Follow their lead and use the words they use. Another related to disclosing sensitive information.
aspect of language is to de-gender your language. Table 2 provides
language samples you may utilize when engaging in conversations to Our built environment in home health is our outward appearance
keep the content less gendered.9 Table 3 contains words you should to the patient. LGBTQIA+ pins or badges and pronoun badges can
avoid at all costs and if used accidentally warrant an apology to the send a strong message to patients they are safe with you. With these
patient. Many of these words have historical significance and negative badges comes an important responsibility to educate oneself, par-
connotations that could be harmful to those in LGBTQIA+ communities. ticipate in training and routinely unpack your implicit biases using an
intersectional lens to mitigate harming others.
As we move from opening the conversation to deeper investiga-
tion into the patient’s medical history, the rule to follow is necessity Conclusion
not curiosity.10 If you are in a direct access pelvic health situation, In addressing the unique needs of the growing LGBTQIA+ patient
this conversation may look completely different than in an orthopedic
home health scenario. Use your best judgment regarding the depth of population, several key strategies are necessary to achieve optimal
your inquiry. The Fenway Guide recommends utilizing the following patient outcomes. By seeking education and understanding of the
language to open up communication regarding anatomical inventory: political, societal and personal adversity the LGBTQIA+ communi-
“To provide good clinical care, I will need to know if you have certain ties face, clinicians can acquire knowledge regarding these health
body parts. Is it OK if we talk through a list of body parts, and you can disparities and increase empathy for their patients. Developing and
let me know whether you have these, and also what language you use delivering affirming behaviors during patient encounters will improve
to describe these for yourself?”11(p28) care and patient outcomes. Utilizing trauma informed care practices
will facilitate a therapeutic environment likely to reduce gender dyspho-
As you progress into the physical examination, the risk of trigger- ria, trauma triggers and unintentional patient harm.8,12 Promoting an
ing trauma and gender dysphoria increases.12 Due to the higher levels inclusive therapeutic environment signals to patients that they are safe,
of trauma experienced in their lives, home health patients of LGBTQIA+
identity may feel especially vulnerable to having a stranger in their
home. Consider the following principles of trauma-informed care
when framing your physical examination: safety, trustworthiness and

Outdated or Defamatory Term Acceptable Term
• “transgenders” or “a transgender” • “transgender people” or “a transgender person”
• “transgendered” • “transgender”
• “transgenderism” • “being transgender”
• “sex change” or “sex reassignment surgery” or “pre-operative” or “post-operative” • “transition” or “gender affirmation surgery”
• “passing” or “stealth” • “visibly transgender” or “not visibly transgender”
• “tranny” “she-male” “he/she” “it” or “shim” • “Transgender person”

TABLE 3. Appropriate language to use to refer to transgender people*
*Adapted from https://omh.ny.gov/omhweb/resources/publications/language-matters-gender.pdf.

Page 10 APTA Home Health Section

valued and respected. These key strategies ultimately will promote 8. Grossman S, Berman S, Potter J. Basic principles of trauma-informed and
high quality, patient-centered care and improved patient outcomes.9 gender-affirming care. In: Keuroghlian A, Potter J, Reisner SL. Transgender
and Gender Diverse Health Care: The Fenway Guide. McGraw-Hill; 2022:
Additional Resources 111-129.
• Gender Spectrum https://www.genderspectrum.org/
• GLMA: Health Professionals Advancing LGBTQ Equality 9. O’Banion D, Barr SM. Obtaining a gender-affirming sexual history. In:
(previously the Gay & Lesbian Medical Association) https:// Keuroghlian A, Potter J, Reisner SL. Transgender and Gender Diverse Health
www.glma.org/ Care: The Fenway Guide. McGraw-Hill; 2022: 130-142.
• GLSEN (formerly the Gay, Lesbian & Straight Education
Network) https://www.glsen.org/ 10. Hill F, Condran C, Pluss A, Fons L, Bell K. Introduction to LGBTQ+
• Human Rights Campaign https://www.hrc.org/ Competency: Handbook for Physical Therapy. 2019.
• National Center for Transgender Equality (NCTE) https://
transequality.org 11. Grasso C, Keuroghlian AS. Harnessing information technology to improve
• LGBT MAP (Movement Advancement Project) https://www. clinical care. In: Keuroghlian A, Potter J, Reisner SL. Transgender and Gender
lgbtmap.org/ Diverse Health Care: The Fenway Guide. McGraw-Hill; 2022: 26-36.
• PFLAG https://pflag.org/
• Pride in Practice https://www.prideinpractice.org/ 12. Elliseou S, Potter J. Performing a trauma-informed physical examination. In:
• PT Proud, a Committee of the Health Policy and Administrative Keuroghlian A, Potter J, Reisner SL. Transgender and Gender Diverse Health
Section of the APTA https://www.aptahpa.org/page/ Care: The Fenway Guide. McGraw-Hill; 2022: 143-155.
PTProudLead
• Substance Abuse and Mental Health Services Administration 13. Perry NS, Elwy AR. The role of implementation science in reducing sexual
(SAMSHA), Center for Substance Abuse Prevention, U.S. and gender minority mental health disparities. LGBT Health. 2021;8(3):169-
Department of Health and Human Services https://www. 172. doi:10.1089/lgbt.2020.0379
samhsa.gov/
• transathlete https://www.transathlete.com/ 14. Eliason MJ, Fogel SC. An ecological framework for sexual minority
• TransGenderPartners.com https://www.transgenderpartners. women’s health: factors associated with greater body mass. J Homosex.
com/ 2015;62(7):845-882. doi:10.1080/00918369.2014.1003007
• Transhealth https://transhealth.org/resources-list/
About the Authors:
REFERENCES: Chris W. Condran, PT, DPT, EdD, MBA-HCM, MS,
1. Jones JM. LGBT Identification Rises to 5.6% in Latest U.S. Estimate. Politics. ACSM-EP, NSPA-CS
Pronouns: he/him/his
Gallup. February 24, 2021. Accessed August 20, 2022. https://news.gallup. Chris Condran is an outpatient orthopedic physical
com/poll/329708/lgbt-identification-rises-latest-estimate.aspx therapist with nearly 10 years of clinical experience.
2. Lambda Legal. When Health Care Isn’t Caring: Lambda Legal’s Survey of He also has experience as faculty in graduate
Discrimination Against LGBT People and People with HIV (New York). 2010. education and guest lectures on topics related to
Accessed April 29, 2016. https://www.lambdalegal.org/publications/when-
health-care-isnt-caring LGBTQIA+ inclusion in PT, fitness, and athletic settings.
3. Ross, MH, Setchell J. People who identify as LGBT+IQ+ can experience Dr. Condran’s educational background includes a BS in Exercise
assumptions, discomfort, some discrimination, and a lack of knowledge while
attending physiotherapy: a survey. J Physiother. 2019;65(2):99–105. https:// Science (East Stroudsburg University, 2006) MS in Exercise
doi.org/10.1016/j.jphys.2019.02.002 Physiology (West Chester University, 2009) MBA in Business
4. Nowaskie DZ, Patel AU, Fang RC. A multicenter, multidisciplinary evaluation Administration (Widener University, 2014) DPT in Physical Therapy
of 1701 healthcare professional students’ LGBT cultural competency: (Widener University, 2013) and an EdD in Kinesiology (University
comparisons between dental, medical, occupational therapy, pharmacy, of North Carolina Greensboro, 2022). He also holds certificates
physical therapy, physician assistant, and social work students. PLoS One. in Healthcare Management (Widener University, since 2013)
2020;15(8). doi:http://dx.doi.org/10.1371/journal.pone.0237670 as Certified Exercise Physiologist (American College of Sports
5. Movement Advancement Project. An Ally’s Guide to Issues Facing LGBT Medicine, since 2006) and as Certified Conditioning Specialist
Americans. 2012. Accessed August 20, 2022. https://assets2.hrc.org/files/ (National Strength Professionals Association, since 2004).
assets/resources/Allys-Guide-Issues-Facing-LGBT-Americans-Dec2012.pdf
6. McDowell A, Streed Jr CG. Health disparities. In: Keuroghlian AS, Potter J, Chris’s research and advocacy interests are centered in providing
Reisner SL, eds. Transgender and Gender Diverse Health Care: The Fenway inclusive clinical environments for all patients, transgender health
Guide. McGraw-Hill; 2022: 16-23. issues and the intersections of PT clinical practice, eliminating health
7. Substance Abuse and Mental Health Services Administration. Top Health disparities in the LGBTQIA+ populations, and establishing a curriculum
Issues for LGBT Populations Information & Resource Kit. HHS Publication No. for LGBTQIA+ cultural competency in the classroom and beyond.
(SMA) 12-4684. Rockville, MD: Substance Abuse and Mental Health Services Chris has found an outlet for these interests as a board member of PT
Administration, 2012. Accessed August 20, 2022. https://store.samhsa.gov/ Proud the LGBTQIA+ Catalyst Group/Committee of the Health Policy &
sites/default/files/d7/priv/sma12-4684.pdf Administration Section of the American Physical Therapy Association,
where he serves as the treasurer and webinar subcommittee mentor.

Cindy Lane Moore, PT, PhD, DPT, MPH, GCS is Staff
Development Coordinator for Therapy at Redeemer
Home Health and has over 30 years of home care
experience.

She was a 2021 APTA Centennial Scholar and she
presented on DEI at APTA CSM 2022. Cindy’s research
interests include knowledge translation into clinical
practice, fall prevention, shared decision making and health equity.

The Quarterly Report | Fall 2022 Page 11

Value Based Purchasing

Real World Experience from the Demonstration

With the Home Health Value-Based Purchasing (HHVBP) focus over the next few months, what would you say are some of the
nationwide expansion set to roll out in 2023, two members of the most important things that someone should consider?
Publications Committee. Matt Janes and Amanda Fabozzi sat
down to discuss lessons learned during the demonstration and Fabozzi: I would say one of the things to really focus on is to fine tune
operational considerations as home health providers navigate the processes to ensure utmost OASIS accuracy. There will be 12 OASIS
pre-implementation year. measures that make up 35% of the HHVBP total performance score.
It starts with ensuring timely completion of start of care and add on
You can also access this content in a Podcast by following this link: evaluation visits as well as timely documentation. The sooner that
https://aptahhs.memberclicks.net/hhvbp-podcast gets done, the sooner the team can collaborate to make sure that the
OASIS is as accurate as possible. Also, it will be important to really
Janes: I know everyone is planning value-based purchasing especially analyze your OASIS review processes for opportunities to improve.
during this pre-performance year. Amanda, tell me a little bit about Who is performing your OASIS review and what steps are they currently
your background and why you are here today to talk about value-based taking to ensure OASIS accuracy? Is there a structured process to
purchasing. review OASIS details and are these individuals educated on the things
that are going to change under the HHVBP model? The remainder of
Fabozzi: Absolutely. My name is Amanda Fabozzi, PT and I had the the pre-implementation year can be used to provide education and
experience of practicing in two demonstration states from 2017 to ensure that the OASIS review process is seamless.
2020, Florida and Tennessee. During that time, I held various clinical
and operational roles including field clinician, Area Rehab Director and Janes: I agree that education is so important especially when we talk
Executive Director of a home health branch. With each of these roles, about the accuracy of the OASIS. This is one of the continued themes
I spent a good bit of time tracking outcomes, goal setting and action that we all speak of in the home health space. In thinking about staff
planning and educating the clinical teams. I am here today to share education, tell me why it’s so important to educate your staff, especially
some lessons learned since we are mid pre-implementation year with knowing that education is never “one and done.” Why is ongoing staff
the first performance year quickly approaching in 2023. education so important?

Janes: Alright. Thank you, Amanda. That’s great information about Fabozzi: You are right in that education must be ongoing and certainly
your background. Really relevant, of course, since you’ve already lived cannot be “one and done.” There are multiple drivers of the HHVBP
it. When we think about the day-to-day processes that should be a total performance score including OASIS measures, claims-based

Page 12 APTA Home Health Section

measures and patient satisfaction results. This is too much to educate Regarding education during orientation, you have to teach the intent
on all at once, so I recommend ongoing education while focusing of each OASIS item which is completely unique to the home health set-
first on the area with the most immediate need. I would also suggest ting. Supervisory visits are critical to ensure the orientee understands
choosing a couple of specific areas for education at a time so that the scoring based on observed patient performance with emphasis on
information is digestible for the audience. Repeating the same edu- safety. Debriefing after the visit to discuss the patient scenario and
cation topic every so often may be necessary to keep the information give the employee opportunity to ask questions can help them learn
fresh. I found that it was helpful to identify or appoint an education and retain information to apply to the next situation.
lead within the organization to really own the education delivery and
follow-up monitoring. The employee must be monitored closely for a period until proving
competence with OASIS understanding and scoring accuracy. It takes
Janes: How do you identify an education leader and define their roles repetition. Assigning a peer or a mentor that they can reach out to if
and responsibilities? they have questions can be a useful strategy. These training efforts
during orientation require extensive time and resources and it is crit-
Fabozzi: This is going to vary by organization based on how roles and ical to have the time and resources allocated because turnover is
responsibilities are assigned. In some cases, the education leader may happening at such a high rate.
be one person while in other cases education duties may be shared.
Regardless, education leaders need to be well-versed on the HHVBP Janes: Yes, turnover seems to be an issue affecting all of health
drivers and the scoring methodology so that they can develop a train- care, especially regarding nursing shortages. In thinking of outcome
ing program. They need to have access to monitor performance while monitoring, which is clearly important now but also with the HHVBP
recognizing that results and evidence of performance improvement expansion, what are some of the strategies that you would recommend
are not immediate, especially when trying to improve functional out- personally to monitor outcomes?
comes. It is important that education leaders have a way to test or
gauge competency following education to ensure that education was Fabozzi: Constant monitoring and action planning is going to be com-
effective. Leaders must be prepared to redeliver education as needed pletely necessary. I would recommend using the PDSA approach which
and change the strategy of education delivery to accommodate dif- means to plan, do, study then act. Let’s walk through an example. Say
ferent learning styles. for instance that your goal is to reduce your acute care hospitalization
(ACH) rate because we know that ACH makes up over 26% of total per-
Janes: In thinking about education delivery including different training formance score under HHVBP. You might start by formulating a plan
methods using technology, audio, video and different communication to perform a retrospective chart audit for all hospitalized patients over
strategies, what have you found to be effective when educating or the next month. From there, you would execute the plan and analyze
training? the results. In this case, you find that half of all hospitalized patients
had a cardiopulmonary diagnosis and that the majority of them were
Fabozzi: I think that multiple forms of education delivery can be effec- hospitalized in the first 30 days of the episode. This information can
tive, and it may be worth trying different things to see what works be used to determine the next action which may include identifying
best. Though it takes time and diligence, it is important to deliver the these patients as high risk at the time of referral, front loading visits
education at a regular cadence, say maybe monthly. You can educate and eliminating gaps in care during those first 30 days. The PDSA
on a couple of topics at once followed up by monitoring to ensure real method is cyclical where action planning is ongoing based on moni-
life application. I have found that supervisory visits can be an effective toring and assessment.
way to educate on OASIS scoring and accuracy based on a patient’s
case. When developing an OASIS training strategy, it is important to Janes: Thank you Amanda. PDSA is so important when we think about
train all OASIS clinicians which likely includes occupational and speech QAPI performance improvement and what needs to be done to ensure
therapists. These disciplines may perform fewer start of care visits that we’re delivering the best care.
but must understand how to score the OASIS accurately at other time So here is the final question. Regarding the value of physical therapy
points. For instance, under HHVBP, the accuracy of functional scores as a profession, what is the value of the Physical Therapy perspective
at discharge are equally as important as at start of care when looking as it relates to HHVBP?
at overall performance improvement.
Fabozzi: Physical Therapists are uniquely positioned to be able to
Janes: That is so true and often I find agencies that forget about the assess and accurately score OASIS functional measures which is so
discharge component. It is so important to think about not only start important under HHVBP. PTs are trained to assess functional perfor-
of care but resumption of care and discharge as well to focus on the mance with the highest precision and recognize deficits and safety
patient specific outcome change. concerns that may be otherwise overlooked. As mobility experts, it
Regarding orientation, what have you found to be important to create makes sense for the PT professionals to be involved in the OASIS
a successful orientation experience to set up a new home health scoring process whenever possible.
clinician to score OASIS accurately?
Janes: I completely agree that function is what we do and we certainly
Fabozzi: I will start by saying that employee turnover is a huge pain appreciate our occupational therapy, speech therapy and nursing
point in the industry right now. And when you have employee turnover, colleagues as everyone is important to helping patients achieve their
it can hurt quality efforts because new employees are often starting goals. We all make an impact and what we do as a team is so important
from square one with significant training and on-boarding needs. for success under HHVBP.

The Quarterly Report | Fall 2022 Page 13

About the Authors: Amanda Fabozzi, PT, DPT has held multiple roles in
Matt Janes, PT, DPT, MHS is a Board Certified home health including field clinician, Rehab Director
Orthopaedic Clinical Specialist and a Certified and Executive Director. She is currently the Director of
Strength and Conditioning Specialist. Dr. Janes is Clinical Transformation with Medalogix and serves on
the Division AVP of Therapy Practice and Quality for the APTA Publications committee. She can be reached
CenterWell Home Health and can be reached at matt. at [email protected].
[email protected]

High Intensity Exercise Programs
in People with Dementia

Critically Appraised Topic (CAT) 

Julie Hardy, PT, MS

Clinical Question: How effective is high intensity exercise in people 3. The Umea Dementia and Exercise (UMDEX) study. A total
with dementia? sample size of 456 participants had dementia, 227 of them
received a HIT intervention and 229 control activities.
Clinical Bottom Line: There is a huge body of evidence suggesting
that a higher amount of physical activity, and specifically high intensity Procedure: Each of the nine studies compared a high intensity train-
training, is associated with a reduced risk of cognitive impairment ing program with light and stimulating control activities in a sitting
throughout the life span and that physical activity counteracts brain position. Outcomes with sufficient quantitative data were analyzed
atrophy. However, only limited data exists about the most effective meta-analytically. If any heterogeneity was present, the random-ef-
exercise dose. fects model for statistical analysis was applied.

Summary of Key Evidence:  Outcome Measures:
1. Berg Balance Scale (BBS)
Study Design: Systematic review of high intensity training studies in 2. 6-meter Gait Speed (GS) test
people with dementia with special regard to physical performance, 3. 30 second chair stand test
mental and cognitive health, ADLs and quality of life (QoL). 4. Mini-Mental Status Exam
5. Neuropsychiatric Inventory Questionnaire (NPI-Q)
Sample: Initial database search yielded 1484 articles from five data- 6. Philadelphia Geriatric Center Morale Scale
bases. After removing duplicates and applying eligibility and screening 7. Observational analysis of ADL ability, Quality of life in
criteria, 9 articles were included. These articles were solely based on late-stage dementia (QUALID) scale.
the following three large-scale studies:
Results: The data supports that high intensity training regimens led
1. The Frail Older People-Activity and Nutrition in Umea to greater improvements in balance performance and the ability to
(FOPANU) perform ADLs independently than seated control activities. The mean

2. The Exercise and Dementia (EXDEM) study

Page 14 APTA Home Health Section

change in the BBS was 2.38+/- 5.25 pts from baseline to first follow-up. 2. No common definition of high intensity training in patients
There was evidence of superior effects on GS in favor of the high inten- can be deduced from the literature which limits the
sity training groups. There were no treatment effects in favor of high comparability of study results; however, in this SR, all high
intensity training interventions on cognitive functioning and depressive intensity training interventions were based on the same
symptoms, and the data indicated that QoL was not affected by high HIFE program.
intensity training. However, there was evidence that psychological
well-being as well as specific dementia-related behavioral disorders 3. The lack of reporting of the type of dementia (e.g.,
were positively influenced by high intensity training. Alzheimer’s vs Lewy Body) can also be considered a limiting
factor for the application of the information.
Critical Appraisal 
4. Due to the multi-modal nature of the high intensity training
Strengths: In all studies, group allocation was randomized and con- programs, it cannot be determined if one training modality
cealed. The mean PEDro score was 7.6 +/- 0.7 ranging from 6 to 8 was superior to the other.
which indicates an overall good methodological study quality. Each
of the studies compared a high intensity training program with light 5. It is unclear whether the HIFE program is superior over other
and stimulating control activities in a sitting position. The 9 articles types of exercise training, as it was only compared to seated
that were included were based on three large scale studies as noted ex in this study.
previously. All exercise programs conducted in these studies were
based on the High-Intensity Functional Exercise (HIFE) program).  
Intervention duration ranged from 12-16 weeks, the average training Citation: Russ J, Weyh C, Pilat C. High-intensity exercise programs
frequency was 2-3 sessions per week and all studies incorporated in people with dementia – a systematic review and meta-analysis.
multi-modal exercise programs. German Journal of Exercise and Sport Research. 2020;51(1):4-16.
doi:10.1007/s12662-020-00688-1.
Limitations:
1. The dropout rate could not be clearly determined due to a  
lack of information in two studies. About the Author: 

Julie Hardy, PT, MS, is an independent clinical
consultant with a specialty in the area of dementia.
She was formerly with Encompass (now Enhabit)
Home Health and Hospice, and currently serves on
the Publications Committee of the Academy of Home
Health of the APTA. She can be reached at jahpt@
icloud.com

Medication Errors’ Causes
Analysis in Home Care Setting:
A Systematic Review

Critically Appraised Topic (CAT)

Amanda Fabozzi, PT, DPT

Clinical Question: What factors contribute to the generation of medication reconciliation exacerbated by poor communication tenden-
medication errors in the home care setting, and what are possible cies between home health practitioners. Implementing strategies and
solutions to reduce and prevent occurrences? technology to improve communication as well as involving a pharma-
cist in care transitions are potential solutions to address medication
Clinical Bottom Line: Research on medication errors has largely errors in home care.
focused on the hospital setting with very few studies analyzing risk
factors for medication errors occurring in home care. Evidence sum- Summary of Key Evidence:
marized in this systematic review indicates that medication errors • Study Design: Systematic Review performed according to the
in the home care setting most frequently occur during care transi- Preferred Reporting Items for Systematic Reviews and Meta-
tion due to poor interdisciplinary communication and insufficient Analyses (PRISMA) statement.
transfer of patient health information. This can result in inadequate

The Quarterly Report | Fall 2022 Page 15

• Procedure: Databases PubMed, CINAHL and Cochran maintain primary responsibility of medication management challeng-
Library were searched using the following keyword phrases: ing the limits of their professional autonomy.
medication errors, adverse drug reaction, medication
reconciliation, home care nurses and home health care. Strategies to reduce risk of medication errors may include utilizing
Inclusion criteria included: 1) all primary quantitative and a coordinating nurse and/or technological solutions to improve inter-
qualitative studies analyzing the phenomenon of medication disciplinary communication and medication reconciliation during care
errors in the home 2) studies dealing with transitional care transitions. In addition, inclusion of a pharmacist as part of the care
from any setting to the home setting and 3) studies where transition team to provide post-discharge medication management
nurses and/or nurses in conjunction with other healthcare can reduce risk and improve continuity of care.
professionals represent the reference population. Exclusion
criteria included: 1) grey literature 2) studies concerning Critical Appraisal
hospital readmissions where home care is not the care setting • Strengths: Grey literature was excluded but bibliographies were
3) studies where the patient and/or caregiver represent the thoroughly evaluated to identify primary studies for inclusion
reference population and 4) studies related to disease-specific criteria. The review included a “certainty assessment” for
treatment. The study date range was January 1, 2009 to each study noting risk of bias, inconsistency, indirectness and
September 30, 2021. Two authors independently analyzed each imprecision.
study for inclusion, and quality of evidence was analyzed using • Limitations: Only a small number of studies met eligibility
the Grading of Recommendations, Assessment, Development as medication errors in the home care setting has been
and Evaluations (GRADE) method. scarcely studied. A criterion for inclusion was that nurses
be represented as the reference population, which excludes
• Results: Seven hundred and twelve records were identified, and analysis of risk and incidence of medication errors in cases
a total of 17 studies met inclusion criteria. Of the 17 studies, where nursing care is not provided. Further studies are
6 were qualitative, 1 was mixed method, 9 were observational needed regarding standardized electronic tools and how the
and 1 was a quasi-experimental pilot. Results revealed that the implementation of such technology can impact communication
phenomenon of medication errors in the home care setting is and drug reconciliation.
relevant and potentially more widespread than in the hospital
setting. Citation: Dionisi S, Di Simione E, Liquori G, De Leo A, Di Mizio M,
Giannetta N. Medication errors’ causes analysis in home care setting:
Medication errors most often occur when a patient first transi- A systematic review. Public Health Nursing. 2021; 1-22. DOI: 10.1111/
tions to the home care setting due to a lack of unique and complete phn.13037.
documentation and documentation inaccuracies. The exchange of
information during a care transition is frequently ineffective due to About the Author:
technology constraints and lack of accessible patient health infor- Amanda Fabozzi, PT, DPT has held multiple clinical
mation. The lack of an accurate, single source of documentation to and operational roles in the home health industry
store clinical and medication history contributes to problems with including field clinician, Rehab Director, and Executive
medication reconciliation. Furthermore, there are challenges with Director. She is currently a Director of Clinical
communication between practitioners who care for the patient at Transformation with Medalogix and serves on the
home, particularly between home care nurses, general practitioners APTA Publications committee. She can be reached at
and pharmacists. As a result, home care nurses may be required to [email protected].

Page 16 APTA Home Health Section

APTA HOME HEALTH AWARDS

APTA Home Health Awards are presented annually for deserving individuals recognized by peers and colleagues through
an award nomination process.  The deadline for all award nominations to be considered for 2023 is 11:59pm ET on December
16, 2022.  Take a moment and consider an impactful individual to home health practice worthy of recognition.  You may submit
award nominations through the form below. 

• President’s Award: Recognizes an APTA Home Health member who has provided notable service to the Academy.
Award criteria and details.

• Emerging Leader in APTA Home Health: Recognizes and honors one Physical Therapist or Physical Therapist Assistant
who has demonstrated extraordinary service and clinical passion early in his or her home health career. The individual
should have made exceptional overall accomplishments and
contributions to the APTA and/or APTA Home Health mission
and vision, and to the physical therapy profession to advance
quality and evidenced‐based care in the home. Award
criteria and details.

• Excellence in Home Health Clinical Practice
Award: Recognizes a physical therapist or physical
therapist assistant for outstanding clinical practice in a
home health care setting. Award criteria and details.

• Excellence in Home Health Leadership
Award: Recognizes the exceptional contribution of an
APTA Home Health member in promoting home health
physical therapy practice. Award criteria and details.

• Dr. Carol Zehnacker Friend of the Academy
Award: Acknowledges an individual, group or
organization that has made an enduring contribution
to the home health industry and that has been an
advocate of the profession of physical therapy in
the home, as is relates to clinical practice and/or
regulations. This award is dedicated to the late Dr.
Carol Zehnacker who passed away in November 2021.
Dr. Zehnacker was a physical therapist and a member
of the APTA for 56 years. She served our profession
in many ways at both the state and national levels as a
leader, mentor and advocate. She served as the Federal
Affairs Liaison and Government Affairs Committee Chair for
the Home Health Academy. In this role she advocated fiercely
against administrative burden and regulations that hamper PTs
ability to provide quality care. Award criteria and details.

The Quarterly Report | Fall 2022 Page 17

Recognition of
our Recent ACHH
Graduates

APTA Home Health’s Advanced Competency in Home
Health (ACHH) certification program synthesizes current
evidence-based practice and tailors it to the unique physical
therapy setting of home health. This program enables home
health agencies, outpatient practices that provide home health
physical therapy and individual clinicians to enhance efficacy
and efficiency of treatment of their home health patients
and clients.

The program is for licensed physical therapists and physi-
cal therapist assistants. A list of recent graduates, in alphabetical
order by state, follows:

Name City State Professional Designations Name City State Professional Designations

Patricia Hendrix Montgomery AL PT, BSPT Kathleen Donaldson Crofton MD PTA

Joshua Kilpatrick Florence AL PT, DPT Pamela Farnsworth-Martin Northfield MN MSPT

Leanne Raymond Opelika AL PTA Daniela Pelayo Duluth MN PTA

Stephanie Pantaleo Tucson AZ DPT Stefani Birkenmeier Ballwin MO DPT

Petra Williams Flagstaff AZ PT, PhD, NCS Dylan Callier Perryville MO DPT

Linda Badillo Cerritos CA PT Christina Peters Missoula MT PT, DPT

Jichelle Bandoquillo Canoga Park CA DPT Megan Curran Charlotte NC MPT

Susan Bemis Newhall CA PT, DPT, GCS, CBE Doreen Heyward Charlotte NC MS PT

Kasey Boyce San Diego CA PT, DPT Matthew Reckinger Fletcher NC DPT

Roseann Chingcuangco Van Nuys CA DPT Denise Roberts Weaverville NC PTA

Elijah Freeman Fresno CA PT, DPT, OCS Kelly Sandstedt Bennington NE PT, DPT

Uma Gulvady Santa Clarita CA RPT,MS PT Michelee Ratcliff Bunzel Rio Rancho NM PT, WCC

Lee Ann Hayes Arroyo Grande CA MPT Daniel Huddart Henderson NV DPT, GCS

Ashley Hernandez Sacramento CA PT Megan Bush Niagara Falls NY PT, DPT

Robert Macasaet Canyon Country CA PT Lindsay Silver Rochester NY PT, DPT

Maurine Manning Sacramento CA BS, MPT Christy Tanton Vestal NY PT, DPT, MS, GCS

Miguel Ochoa Sacramento CA PT, DPT, CEEAA Jill Schwartz Maplewood OH LPTA, LSVT-Big

Sarah Pinasco Lincoln CA PT, DPT, NCS Tyler Schmiedeberg Edmond OK PT, DPT

Christal Potter-Tosch Roseville CA PT, DPT Melissa Cencetti Pittston PA PT, DPT, EdD, MS

Myriam Sababa Sunland CA PT Gerald Geiger Phoenixville PA DPT

Sangeeta Sahni Valley village CA PT Mary Jones Wellsboro PA PT, DPT

Lilibeth Say Anaheim CA DPT, GCS Antonio Sciulli Pittsburgh PA PT

Dillon Traynor Belmont CA PT, DPT Mohammed Alsulaiman Dhahran SA Certified Home

Diana Turley Simi Valley CA DPT Healthcare Director

Maryann Markes Durango CO DPT Julie Allison Spokane WA PTA

Brandie Laird Bear DE DPT Shana Allred Bothell WA DPT, OCS

Ian King Hartwell GA PT, DPT, Board Certified Nancy Burns Seattle WA PT,CEEAA

Geriatric Clinical Specialist Gregorio Daez Lake Stevens WA PT, DPT

Angela Thomas Richmond Hill GA PT Jake Hanson University Place WA PT, DPT, NCS, CEEAA

Terrilyn Fiedler Honolulu HI PTA Susan Hatheway Bow WA PT, DPT

Jaime Fortier-Jones O Fallon IL PT, DPT Seth Rohde Tumwater WA PT, DPT, Board-Certified

Lee Ann Hulteen Oak Brook IL PT, Cert. MDT Clinical Specialist in

Sharon Mink Bloomington IL PTA Geriatric Physical Therapy

Marie Edlyn Rose Fort Wayne IN PT Lindsey Rohde Tumwater WA PT, DPT, Geriatric

Daniel Laochinda Wichita KS DPT Certified Specialist

Anne Rutherford Wichita KS DPT Kim Saito Lynnwood WA PTA

Anne Rutherford Wichita KS DPT Danielle Shafer Arlington WA DPT

Samantha Guichet New Orleans LA MS, PT Laura Vaughn Seattle WA PT, DPT

Sean Gimler North Attleboro MA PTA, B.S. Debra Carpenter Aniwa WI PT

Sharon Kuebler Dudley MA PT, BSPT, MS Craig Tomaszewski Eagle River WI DPT

Jennifer Waterman Sharon MA MPT, GCS, CEEAA

Page 18 APTA Home Health Section

A Home Health COVID-19
Rehabilitation Program Utilizing
High Frequency, Low Intensity
and Short Duration Activity:
A Case Report

Elena Newland, PT, DPT, NCS, MSCS, CSRS Therapy Professional
Development Specialist, Penn Medicine at Home, University of
Pennsylvania Health System

Sara Kate Frye, OTD, MS, OTR/L, ATP, CAPS, Assistant Professor,
Widener University; Occupational Therapist, Penn Medicine at Home

Abstract leaving the hospital and preventing new hospital admissions.1 Surges
in COVID-19 led acute care hospitals to expedite discharges and lower
Purpose: Individuals diagnosed with COVID-19 often require home the discharge home criteria.2 Meanwhile, the provision of home reha-
health care to support their post-hospitalization recovery. The purpose bilitation has been uniquely challenged by the need for complex
of this case report is to report on a high frequency, low-intensity home infection control protocols to limit exposure and to closely monitor
health rehabilitation program that used a combination of virtual and vital signs and safe activity progression among individuals infected
in-person visits and improved activity tolerance for an individual with with COVID-19. Those experiencing functional limitations may face
COVID-19. difficulty obtaining an in-patient rehabilitation admission due in-patient
rehabilitation facilities limiting admissions to patients with COVID -19.
Methods: An individual with multiple chronic health conditions was Limited in-patient rehabilitation placements are reserved for those with
diagnosed with COVID-19 and referred for home health services after home accessibility barriers, limited caregiver support, or cognitive
an acute care hospitalization. She received 5 days a week of telehealth deficits impacting safety.3 These factors have positioned home health
high frequency, low intensity and short duration home health physical at the center of COVID-19 rehabilitation and raised the need for home
and occupational rehabilitation therapy for 4 weeks followed by twice health agencies to develop guidelines for patients with higher acuity
weekly in-person physical and occupational rehabilitation therapy for and greater functional impairments.
5 weeks.
Before beginning home rehabilitation for patients with COVID-19,
Results: This approach allowed the patient, who required assistance clinicians should thoroughly understand the patient’s medical and
for ambulation and activities of daily living on evaluation, to regain social history to develop a safe and effective intervention plan. The
her independence. patient’s occupational profile should be understood, including how
social distancing or quarantine has limited physical and social activ-
Conclusion: This case report highlights how home health physical and ities, potentially leading to pre-infection deconditioning.4 In addition
occupational therapy might mitigate the potentially profound impacts to considering COVID-19 infection transmission from the patient, the
of COVID-19 for those with pre-existing conditions. clinician must be aware that other residents of the home may be at
earlier stages of the infection and pose a higher risk for transmission.

Impact Statement: People with COVID-19 are at risk for lasting Home health rehabilitation considerations for patients with COVID-19
respiratory, central nervous system, cognitive function impairments,
psychiatric problems, deconditioning and muscle weakness, critical People with COVID-19 who have been discharged from an acute
illness myopathy, neuropathy, dysphagia, joint stiffness and pain. care hospital to rehabilitation in home health may experience diffi-
Pre-existing medical conditions increase the risk of COVID-19 adverse culties related to their hospitalization. In the hospital, supportive care
effects. This case report illustrates how home health rehabilitation may include supplemental oxygen for individuals with dyspnea and
using both virtual and in-person interventions might mitigate the mechanical ventilation in critical cases, and patients are often dis-
lasting effects of COVID-19 using a prescriptive high frequency, low charged home with supplemental oxygen.5 Anticoagulation therapy,
intensity and low duration program for exercise-based interventions a COVID-19 acute care standard due to the high risk of thromboembo-
and functional activities. lism, requires monitoring.6,7 Hospitalization may also have negatively
affected function, as one week of bed rest can impair muscle strength
Introduction: The COVID-19 pandemic has changed the landscape by as much as 20%, and this loss increases with longer lengths of
in delivering rehabilitation service and has shifted how healthcare stay.8 Individuals treated for COVID-19 in an intensive care unit (ICU)
is provided across the care continuum, particularly in the home setting may experience post-intensive care syndrome (PICS) with
health setting. Since early in the pandemic, home health services cognitive, psychiatric and physical impairments.9 Longer ICU stays,
have contributed to public health goals during the crisis by providing mechanical ventilation, sedation, age, hypoxia, hypotension, sepsis,
comprehensive patient care services to support recovery in people glucose dysregulation and premorbid functional limitations increase

The Quarterly Report | Fall 2022 Page 19

the risk of PICS.9 Lasting impacts on the respiratory, central nervous reduce the effort of daily activities.
system and cognitive function, psychiatric problems, as well as decon- Nutrition and hydration support should not be overlooked as a
ditioning and muscle weakness, critical illness myopathy, neuropathy,
dysphagia, joint stiffness and pain have been observed in individuals component of COVID-19 rehabilitation. Speech and language pathol-
who have been hospitalized for COVID-19.5 ogy services are indicated for the 50% of people who experience
dysphagia after orotracheal intubation.17 Those who experience gas-
One of the challenges in home rehabilitation is determining the tro-intestinal symptoms of COVID-19 may experience higher levels of
appropriate exercise prescription for individuals who are recovering dehydration, food aversion, and weight loss.17 In these instances, a
from COVID-19. Early mobility programs are considered a standard registered dietician can be brought in to support the patients’ intake
across the continuum of care. The home rehabilitation program and potentially recommend the appropriate supplements.17
incorporates mobility out of bed, sit-to-stand practice, timed and
multi-directional ambulation and simple therapeutic exercises.8,10,11 Developing a COVID-19 home health rehabilitation program
Survivors of COVID-19 should avoid exercise >3 METS or equivalent
for 2-3 weeks after symptom onset such as severe sore throat, dys- We developed a high frequency, low intensity and short duration
pnea, body aches and cough.12 Despite precautions against intense home health rehabilitation program to meet the needs of individuals
exercise, periods of immobility should also be avoided to maintain referred to our home health agency after hospitalization for COVID-
muscle mass, promote pulmonary function and prevent thrombo- 19.Participation in exercise and functional activities is completed in
embolism. Moderate activity is recommended to promote a healthy a short amount of time until a self-reported score of 3-4 (moderate to
immunological response.12 When developing an exercise program somewhat hard) and are completed multiple times throughout the day.
for patients with COVID-19, the most demanding exercises should
be completed first before moving on to less strenuous exercises as We based the program on interventions shown to be effective
tolerated during the same session.13 A higher frequency, low intensity for rehabilitation of conditions with clinical similarities to COVID-19,
and shorter duration of interventions and activities approach benefits including Severe Acute Respiratory Syndrome (SARS), Middle East
this population.12,13 Home health therapists can work with the patient Respiratory Syndrome (MERS), Acute Respiratory Distress Syndrome
to develop a sustainable and progressive home exercise and mobility (ARDS) and sepsis.2,5,9,12 People with COVID-19 who are discharged
program with short activity sessions incorporated daily. directly home from the hospital demonstrate significantly impaired
activity tolerance. A rehabilitation program structured with a high level
Exercise intensity should be adjusted based on the patient’s report of intervention frequency, low intensity and short duration allows this
and vital signs monitoring. This approach is defined as “Response- patient population to recover function faster than a traditional model
dependent management”, where the physiological response to exercise of home rehabilitation. This program consisted of frequent clinician
and activity is carefully monitored to challenge the patient appropri- contact guiding a home program of frequent short bouts of exercise
ately.14,15 For safe and effective activity, vitals should be maintained and functional activities completed throughout the day. The program
as follows: oxygen saturation ≥94%, respiratory rate <30 breaths per was initiated via synchronous telehealth sessions to prevent exposure
minute, heart rate <100 beats per minute, blood pressure within 90/60 to COVID-19, and then transitioned to in-person intervention after the
mmHg to 140/90 mmHg.11 Subjective reports of dyspnea, fatigue, patient and other residents of their household were no longer at risk
dizziness and headache are indicators of exercise intolerance and of transmitting the infection. Daily therapist contact (physical, occupa-
should be assessed regularly during therapy sessions. The Modified tional or speech therapist) at least 5 days per week was a hallmark of
Borg Rating of Perceived Exertion scale (Modified Borg RPE) can be the intervention program to provide frequent touchpoints for medical
used to measure activity tolerance. The patient participates in activ- monitoring and activity progression. This frequency also provided a
ity until a self-reported score of 3-4 (moderate to somewhat hard) is higher level of rehabilitation intensity as inpatient rehabilitation place-
achieved and then rests until their score is 1-2 (very easy to easy).16 ments were inaccessible.

Pulmonary rehabilitation is a key component of a rehabilitation This case report describes a person with multiple pre-existing
program for people with COVID-19. Weak muscles generate an increase health conditions who benefited from this high frequency, low intensity
in oxygen demand, adding complexity to recovery.8 If the patient has and short duration home health rehabilitation program after hospital-
dyspnea, impaired oxygen saturation or impaired activity tolerance, ization for COVID-19 infection.
then pulmonary rehabilitation interventions such as body position
management, adjustment of respiratory rhythm, incentive spirometry Case History
exercise, positive expiratory pressure device use, pursed lip breathing,
cough exercises, diaphragmatic training using light weight on the abdo- Ms. H. is a 54-year-old African-American female with a past
men in supine and trunk/chest stretching are indicated.10,11 Because medical history of hypertension, obstructive sleep apnea, autoim-
of the pulmonary component of COVID-19, exercises that combine mune hepatitis, diabetes mellitus type 2, peripheral neuropathy and
breathing with movement are a good fit for this population. Exercises anemia. She presented to her local emergency department with upper
such as Qi Gong and Tai Chi that pair breathing with movement and respiratory infection symptoms, multi-focal pneumonia, hypertension
can be completed with remote or video instruction and offer promise and tachypnea and was diagnosed with COVID-19. Ms. H. received
for self-paced progression.4,10 physical therapy during her 8-day hospitalization. She used 1 liter
of supplemental oxygen but was weaned prior to discharge home.
Chronic medical conditions place individuals at higher risk of Ms. H was discharged directly home from the hospital because she
COVID-19 with longer recovery trajectories. Therefore, self-manage- was unable to obtain an inpatient rehabilitation admission due to her
ment education should be embedded throughout the rehabilitation COVID-19 diagnosis.
program. Energy conservation and adapted strategies for activities
of daily living and instrumental activities of daily living are essential. Ms. H. lives in a two-story row home with her sister, daughter and
Assistive devices, such as walkers, shower chairs, and grab bars, can granddaughter. Prior to hospitalization, she was ambulating with a

Page 20 APTA Home Health Section

Intervention Area Telehealth Strategies In-Person Strategies
Mobility Training
• Provide activity recommendations based on patient-report (energy- • Gait training
Therapeutic Exercise conservation, durable medical equipment) • Balance challenges
Self-Care Training • Tub transfer training
Self-Management • Sending a video demonstration of bed mobility • Transfer training
Education • Family members provide supervision during mobility and exercise for safety • Stair training
• Family members hold patient’s telephone during videoconference so therapist • Bed mobility training
• ADL and IADL training
can observe mobility skills
• Assess pre/post activity vitals (ambulation, stair climbing) • Observe exercises and progress based on
• Education on modified Borg as activity guide clinical judgement

• Exercises e-mailed or texted using subscription website and reviewed verbally • Demonstration of adaptive equipment
• Select standing exercises with upper extremity support to reduce fall risk • Self-care training

• Education on energy conservation • Meal preparation training
• Equipment recommendations • Assessing process for storing, retrieving

• E-mailing a packet on diabetes management and providing verbal education and taking medications
• Creating a food shopping list
• Medication Reconciliation

Table 1. Sample telehealth and in-person interventions

rollator and receiving outpatient physical therapy for gait dysfunction visits per week shared between physical and occupational therapy. At
due to her pre-existing medical conditions. Prior level of function was that point, she was transitioned to in-person sessions twice a week for
modified independent with her activities of daily living, and she was both physical and occupational therapy for 5 weeks. Telehealth visits
a caregiver for her granddaughter. were completed using a secure synchronous 2-way video and audio
platform through the patient’s smart phone, or an organization-pro-
Ms. H. provided informed consent for her de-identified information vided telehealth tablet with vitals monitoring capability. The telehealth
to be used in this case report. team completed patient education on use of the vitals monitoring
system via phone. The telehealth system included an automatic blood
Assessment: Ms. H. reported her goal was to return to her pre-hospi- pressure cuff, pulse oximeter, thermometer and scale connected to
talization level of function including completing her activities of daily the telehealth device, which wirelessly logged the results into the
living without assistance, resuming outpatient physical therapy and medical record. The telehealth device had a screen that prompted
caring for her granddaughter during the day. the patient to take her vitals and also conducted a short daily health
screen questionnaire. The telehealth system is monitored by a nursing
On initial physical therapy evaluation, Ms. H was only able to team who contacts the patient based on alarms from vitals readings
ambulate 10 feet via rollator with contact guard assistance. While or the daily health screen questionnaire.
ambulating, she scored 4-5/10 on the Modified Borg RPE, her oxygen
saturation reading was 90%, and she required a 3-minute rest in Physical Therapy Intervention: Included a structured high frequency,
between each activity. She required contact guard assistance for low intensity and short duration home program executed across virtual
transfers and moderate assistance for bed mobility. She was unable and in-person sessions (Table 1). Ms. H was instructed to maintain a
to negotiate stairs due to poor activity tolerance and required a first- Modified Borg RPE score of less than 5/10 during all activities. A walk-
floor setup. ing program was initiated with a goal of three 10-minute walks per day.
In addition, a standing therapeutic exercise program was prescribed
Ms. H required moderate assistance for her activities of daily to be completed daily to Ms. H’s tolerance. The physical therapist
living. She was observed to tolerate only 45 seconds of standing before developed a personalized exercise program (obtained from an exer-
her oxygen saturation dropped to 93%. In sitting, her activity tolerance cise subscription website) delivered to Ms. H via text or e-mail. Ms.
for self-care or meal preparation tasks was limited to 20 minutes. A H preferred receiving the exercises via text, where she could log into
falls assessment via the Missouri Alliance for Home Care Tool (MAHC- the website app and view the written instructions and video demon-
10) revealed a score of 5, indicating she was at risk for falls 18. strations. Exercise tolerance was measured and progressed by timing
and counting rest breaks, and timing sustained activity. In the virtual
Ms. H also presented with a new cough from COVID-19 that wors- rehabilitation phase, simple standing exercises (such as heel lifts) were
ened with activity. The cough disrupted her daily activities, particularly provided that were easy to explain and could be completed with upper
her ability to sleep. She experienced blood sugar instability, even extremity support to reduce fall risk. Once the transition was made to
though her blood sugar was controlled prior to COVID-19 infection. in-person visits, balance challenges and more complex exercises were
added. The structure for high frequency, low intensity and short dura-
Intervention: Home rehabilitation was initiated on the day of her tion interventions consisted of simple activities such as mini squats.
discharge from acute care. A nursing start of care for home health The patient would complete as many reps until she reached a Modified
services and physical therapy evaluation were completed on the same Borg RPE score of 3-4/10 and then rest until she returned to baseline.
day and completed in person. Nursing followed the patient for 2-3 Standing therapeutic exercise consisted of: hip flexion, hip abduction,
in-person visits per week throughout her course of care. For the first hip extension, heel raises, mini squats and heel lifts. This strategy
3 weeks, the telehealth nursing team completed a daily check-in call was carried over to all functional activities and then patient education
and monitored her vital signs remotely. Home health aide services was completed on repeating the exercises and activities throughout
were started during her second week. For therapy, she received virtual
occupational and physical therapy for 4 weeks, and then transitioned
to in-person therapy.

The first 4 weeks of rehabilitation consisted of 5 telehealth therapy

The Quarterly Report | Fall 2022 Page 21

each day up to 3 sessions per day. The patient was able to progress Outcomes: Ms. H had good adherence to the program in both the
herself since she understood that she could do as many exercises/ virtual and in-person components. After the initial 4 weeks of vir-
repetitions and functions but she had to stop when the Modified Borg tual rehabilitation, Ms. H was making progress toward physical and
RPE score reached 3-4/10. Active breathing, incentive spirometry and occupational therapy goals. She was able to ambulate 50 feet with
close monitoring of vital signs were completed during the activity. supervision with a Modified Borg RPE of 3-4, ascend and descend a
full flight of steps once per day with supervision to sleep in her bed
Bed mobility training: Training was completed on rolling right and left and was modified independent with bed mobility using a bed rail. She
using parts to whole training, assuming hook-lying, rolling onto the side required minimal assistance for dressing. She still required moderate
and then pushing up to sit. Physical therapy recommended a portable assistance for bathing, but was able to progress to showering seated
bed rail to improve independence, ease and safety of this transfer. on a shower chair and was able to stand for 3 minutes in her kitchen
while completing a light kitchen task.
Transfer training: Ms. H’s sitting surface was raised to improve effi-
ciency and safety of sit-to-stand transfers. Transfer practice was At discharge from home health, she progressed to ambulating up
completed from various sitting surfaces including bed, chair, sofa and down the stairs in her home with a 3-4/10 on the Modified Borg RPE
and steps. scale. She returned to being the caregiver for her granddaughter and was
able to ambulate in her home with modified independence with a rollator.
Stair training: Stairs were completed in segments and progressed She was also able to use a narrow-based quad cane for ambulation on
as tolerated until a full flight was achieved. Vitals signs and Modified the second level of her home with supervision and had no falls during
Borg RPE scale were used to determine safe progression. this course of care. She was able to achieve independence in feeding,
grooming, upper body bathing and dressing modified independence in
Occupational Therapy Intervention: The high frequency, low inten- toileting and toilet transfers and modified independence in lower body
sity and short duration approach began with short bouts of self-care activities of daily living with adaptive equipment. She still required setup
activities and was later expanded to include upper body exercise as and occasional minimal assistance for bathing for energy conservation
the patient’s activity tolerance improved. Self-pacing through the showering in a combination of sitting on her shower chair and standing.
Modified Borg RPE scale guided activity progression. Intervention She could complete light cooking tasks with modified independence to
initially focused on problem solving how to maximize Ms. H’s inde- prepare meals for herself and her granddaughter.
pendence in activities of daily living while coping with her profound
activity intolerance. Ms. H. had limited support from the other adults Discussion
in her family because they also experienced COVID-19 infections.
Therefore, a home-health aide was added to the interdisciplinary care COVID-19 has the potential to have a profound impact on the daily
team to provide assistance with activities of daily living. Adaptive function of individuals with pre-existing health conditions. Physical
equipment and techniques, such as a shower chair, were implemented rehabilitation is needed to mitigate these impacts and can potentially
to allow her to complete more activities at a seated level for energy be implemented via both telehealth and traditional in-person models.
conservation and to maximize participation. As her symptoms resolved We believe that a high frequency, low intensity, short duration program
and activity tolerance improved, an upper extremity home exercise has the potential to maximize functional recovery, reduce hospital
program using a resistance band and a weighted 5lb bar was initiated. re-admissions and improve the quality of life for patients who are
rehabilitating after COVID-19.
Breathing strategies were incorporated into all functional activ-
ities, including pursed-lipped breathing and self-monitoring posture. Ms. H. was an active participant in her home rehabilitation pro-
An incentive spirometry program was implemented for pulmonary gram but struggled to balance rehabilitation with daily living tasks. Her
rehabilitation. Patient education centered on fall prevention, energy profound activity intolerance impacted all domains of occupational
conservation, vital sign monitoring, managing diabetes and self-mon- performance. Ms. H. reported stairs, bathing and meal preparation
itoring for complications was incorporated in all sessions. were the most significant challenges for her. She was so deconditioned
that the act of bathing left her exhausted with no energy reserve for
In home health, managing chronic medical conditions is incorpo- any other activities that day. Although introducing a home health aide
rated into all aspects of care. One challenge for Ms. H. was identifying was a potential concern because of additional staff exposure to the
foods that were nutritious, easy to prepare, and compatible with her virus, aide support was essential for Ms. H considering her functional
diabetic diet. Additionally, since her family members were also experi- limitations and limited family support.
encing fatigue while recovering from the virus, opportunities to travel
to the store were limited and food with a significant shelf-life was Mrs. H. experienced significant physical impairments from
needed. Ms. H. received education from PT, OT and nursing to identify COVID-19 due to her pre-existing medical conditions. A lesson for all
foods that met her dietary needs and were easy to prepare given her therapists treating vulnerable individuals with pre-existing conditions
endurance limitations. is to provide education focusing on smoking cessation, regular exer-
cise, good nutrition and stress management to optimize recovery in the
Nursing Intervention: In-person nursing care was required because event of a COVID-19 infection.19 Ms. H. may not have experienced the
Ms. H required twice weekly blood draws. Initial focus was on the man- same impacts of COVID-19 had she received pre-habilitation looking
agement of COVID-19 symptoms, including fever and cough, as well as at her global health status.
diabetes education and management. Prior to her COVID-19 infection,
Ms. H had been able to control her blood sugar, but while recovering, An interdisciplinary approach provides the best outcomes via
she experienced both hyper- and hypo-glycemia and required nursing a comprehensive care plan addressing both medical and functional
support to monitor her blood sugar and address fluctuations. needs. Additionally, this approach provides more contact points with
the patient for more in-depth medical monitoring. This case identi-
fied one opportunity for improvement which was the need for more

Page 22 APTA Home Health Section

structured interdisciplinary communication. Although the multidisci- This report highlights the effectiveness of home-health reha-
plinary team communicated regularly through the electronic medical bilitation for an individual with COVID-19. Although this case report
record messaging platform, we feel that a weekly, multidisciplinary shows a benefit of a prescriptive high frequency, low intensity and
case conference would have provided more comprehensive care. short duration rehabilitation home program, larger trials are needed
on this approach for people with COVID-19 in the home health set-
Telehealth rehabilitation has significant advantages and disadvan- ting to develop evidence-based standards of care. We recommend
tages. Telehealth alone, or in conjunction with in-person visits, allows large-scale trials of hybrid virtual and in-person rehabilitation models
the clinician to provide rehabilitation while minimizing the risk of virus in the home health setting. Data gathered in these larger trials will
exposure 11. However, telehealth may not be appropriate for those indi- support home-health telehealth reimbursement, guide treatment
viduals with low literacy skills or those who do not have access to or protocols and facilitate the development of prescriptive clinical prac-
are not skilled with technology use.20 An additional barrier is limited tice guidelines.
reimbursement for home health telehealth rehabilitation sessions.
Telehealth rehabilitation allows for more frequent touch points with Conclusion: Rehabilitation after COVID-19 must be individualized to
the patient thus improving monitoring and follow up when needed. include physical, cognitive and psychosocial principles. Emphasis
Clinicians reported the frequency of contact, and the ability to view on health management of current and pre-existing health conditions
facial expressions without masks, fostered therapeutic rapport with is needed. For those recovering from COVID-19 in the home health
the patient. Conversely, because of the ease of access to the patient, setting, an interdisciplinary high frequency, low intensity and short
the patient was at times overwhelmed by multiple contacts from the duration home program combining in-person and telehealth sessions
agency. She reported sometimes she received so many phone calls, 5 days a week shows promise for regaining independence and may
it was difficult to rest. Drawbacks include: difficulty determining if the be applicable to other cardiopulmonary conditions.
patient was performing interventions as prescribed due to poor visual-
ization of exercises and activities and an increased burden on the patient Disclosure: The authors report no conflicts of interest.
to monitor their vital signs independently. For a patient who requires
physical assistance, tactile cues, or guarding during higher level chal- About the Authors:
lenges or needs more physical assistance, it would be difficult for the Elena Newland PT, DPT, NCS, MSCS
therapist to implement safe and effective interventions via telehealth, Elena Graduated from Thomas Jefferson University
and the recommendation would be for in-person visits. Hybrid telehealth in 2001 with her MSPT and then completed a
and in-person models allow the therapist to conduct evaluations and transitional DPT program through Jefferson in 2006.
select treatment activities in person but still maintain the accessibility She then went on to achieve specialty certifications
of telehealth for follow-up sessions to assess carryover and activity in neurology through the APTA, Multiple sclerosis
tolerance.21 In this report, telehealth was used exclusively before tran- through the MS consortium and stroke through
sitioning to in-person visits based on our knowledge of transmission
risk at the time, but combining both methods by alternating visit types Neurorecovery Unlimited.
throughout care would likely offer greater benefits. In addition to her clinical expertise, education and advanced

Another opportunity was the potential for additional referrals on certifications, at Penn Medicine at Home, she is actively developing
this case. Speech therapy would have provided an in-depth cogni- the neurological rehabilitation program. Highlights include:
tive assessment as a standard of care, knowing the risk of cognitive Therapy Professional Developmental Specialist, development of
impairment.12 Social workers or psychologists could have provided interdisciplinary care plans for multiple sclerosis and creation of a
support to address anxiety and depression related to COVID-19. A BPPV/Vestibular Therapy Competency.
dietician could have provided more in-depth dietary education. To
ensure that the number of contacts Ms. H. received throughout the Sara Kate Frye OTD, MS, OTR/L, ATP, CAPS is an
day was not overwhelming, interdisciplinary communication could be assistant professor in the Institute for Occupational
used to develop an overarching plan and coordinate visits throughout Therapy Education at Widener University in Chester,
the week. For example, occupational therapy could have played a larger PA. Dr. Frye continues to practice occupational therapy
role in implementing an upper body conditioning program, but phys- with Penn Medicine at Home. She is a current member
ical therapy took the lead in implementing pulmonary rehabilitation of the American Occupational Therapy Association’s
techniques and progressing activity tolerance because the patient Rehabilitation & Disability Special Interest Section’s
found it easier to deal with one primary therapist throughout the week. standing committee. Dr. Frye’s research focuses on an occupational
approach to self-management of chronic health conditions.
The primary limitation of this case report is that it represents
the progress of a single individual during a single episode of care. Bibliography
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Poster Presentations from the 2022 CSM

Last years Combined Sections Meeting in San Antonio presented ABSTRACT BODY:
an opportunity for abstract submissions to APTA Home Health.
Presented here are those accepted as poster presentations. Purpose/Hypothesis: To survey home health physical therapists
regarding the rationale for selecting fall assessment/screening tools.
TITLE: Factors Influencing a Home Health Physical Therapist’s
Decision Regarding What Fall Assessment Tools to Utilize Number of Subjects: 68

Author: Christopher Howard Voltmer Materials and Methods: This was an exploratory research study

Page 24 APTA Home Health Section

using an internet-based survey to collect data from home health 3. Curry SJ et al. Interventions to Prevent Falls in Community-Dwelling Older
physical therapists (PTs). The survey consisted of 31 questions Adults - US Preventive Services Task Force Recommendation Statement.
and took approximately 10 minutes to complete. Participants were JAMA. 2018;319(16):1696-1704. doi:10.1001/jama.2018.3097
recruited via email through a large home health agency. Participants
were licensed PTs who are currently providing home-based phys- 4. STEADI Helps Physical Therapists Incorporate Older Adult Fall Prevention
ical therapy. All survey data was analyzed using SPSS v25 and in Routine Care. CDC website. https://www.cdc.gov/steadi/stories/routine.
Microsoft Excel. html. Updated September 19, 2016. Accessed April 2, 2020.

Results: Sixty-eight participants completed the survey. Participants 5. Older People Projected to Outnumber Children for First Time in U.S. History.
were primarily females (53.0% [36/68]) between the ages of 26-35 US Census Bureau website. https://www.census.gov/newsroom/press-
(45.6% [31/68]). Participants with a Doctor of Physical Therapy degree releases/2018/cb18-41-population-projection
made up 77.9% (53/68) of the total while 11.8% (8/68) had American
Board of Physical Therapy Specialty certifications. Most participants
(85.3% [58/68]) reported learning about fall risk screening as part of
their physical therapy education. TITLE: Implementation of the Activity Measure for Post-Acute Care
(AM-PAC) in Home Care
In the 2 years prior to the study, 29.4% (20/68) participants
reported taking CEUs regarding fall assessment. 72.1% (49/68) of Authors: Tyler James, Weston A. Lindsay, Bill Bates, Pamela
participants reported spending 0-5 hours per year on education related Balla Dibblee
to fall assessment tools. 4.4% (3/68) were members of special interest
groups related to falls. The age of patients predominantly treated in ABSTRACT BODY:
the home care setting were between 66-75 (30.9% [21/68]) followed
by 76-85 (27.9% [19/68]). Purpose/Hypothesis: As the rehabilitation industry continues to shift
to value based care, our integrated not-or-profit health system needed
The most utilized outcome measures used to assess balance to implement quantifiable tools to measure mobility, activity and cog-
included the TUG (80.9% [55/68]) followed by the 30-second chair- nition in the home care setting to assist in developing a way to track
stand-test (53% [36/68]). The 3 most common factors influencing the standard outcomes across the rehabilitation continuum of care. The
TUG were ease of administration (64.7% [44/68]), clinical judgment AM-PAC is a tool that can be used to compare mobility, activity and
(55.9% [38/68]) and time to administer (52.9% [36/68]). cognition using t-scores across different settings. The purpose of this
quality improvement project was to implement the use of the AM-PAC
Participants selected a history of falls (89.7% [61/68]), fear of fall- short forms for Home care in this health care system.
ing (82.4% [56/68]), and medical diagnosis (79.4 [54/68]) as the most
common factors leading to a fall risk screen. Polypharmacy was the Number of Subjects: 185 therapists
seventh leading factor prompting a fall risk screen (61.8% [42/68]. 59%
(40/68) of participants answered that cognitive impairments would Materials and Methods: Training of therapists occurred 4th quarter
prompt a fall risk assessment. 2020 with the ask for immediate implementation. Training included
information about “why” there was a need to standardize outcome
Conclusions: Participants did not put a strong emphasis on educa- tracking. Training also included education on the AM-PAC short forms
tion regarding falls, as less than 30% of participants had taken CEUs, for Home Care, how to administer the AM-PAC and how the assess-
between 0 and5 hours per year was spent on education related to falls ment can guide clinical decisions. A discrete field was created in
and less than 5% were members of special interest groups related the electronic medical record for therapists to document a score so
to falls. The TUG and the 30-second chair-stand-test were the most that data could be extracted. Reports were built to capture AM-PAC
utilized outcome measures secondary to their ease of administration. scores for each patient and each visit. Managers provided feedback
Participants put less importance on polypharmacy and cognition than to therapists on compliance with data collection.
other potential risk factors for falls.
Results: Initial training occurred December, 2020 with clinical
Clinical Relevance: The aging adult, with the help of a physical thera- champions facilitating training. The measurement period was from
pist, can significantly lower their risk for falls. Based on the results of January 1st, 2021-May 31st, 2021. There were 2141 unique therapy
this study, PT’s need to spend more time on professional education cases. A documented AM-PAC score was found on 24% (16,829
related to fall and balance assessment tools. Education should include of 70169) of therapy visits. On evaluation, the AM-PAC home care
the significance of factors such as cognition and polypharmacy which short form is collected 42% (3907 of 9235) of the time. In addition
are strong predictors of future falls. This will improve patient manage- to the early implementation results, the following average initial
ment by reducing fall risk, improving health outcomes and lowering mobility scores by patient population have been identified: ortho-
overall healthcare costs. pedic (N=367) average raw score 17.1, t-score 47.98; neurologic
(N=43) average raw score13.6, t-score 43.0 cardiac (N=81) average
References: raw score 21.5, t-score 54.07 and other general medical (N=294)
1. Florence CS, Bergen G, Atherly A, Burns ER, Stevens JA, Drake C. Medical average raw score 16.6, t-score 47.4.

Costs of Fatal and Nonfatal Falls in Older Adults. Journal of the American Conclusions: Implementation included leadership support, EMR
Geriatrics Society, 2018 March, DOI:10.1111/jgs.15304 resources to modify content to increase ease of data extraction and
2. Medicare Payment Advisory Commission. Report to Congress: Medicare analyst support to assist in providing feedback on compliance with col-
payment policy. 2020. http://medpac.gov/documents/reports/march-2016- lection measures. Ongoing training is planned to encourage behavior
report-to-the-congress-medicare-payment-policy.pdf?sfvrsn=2.

The Quarterly Report | Fall 2022 Page 25

change not only increasing data collection but in utilization of scores rehabilitation requirements, visit utilization and discharge disposition
to assist in clinical decision making. of patients following acute COVID hospitalization who were referred
for Home Health Care identified. Thoughtful discharge planning is
Clinical Relevance: Implementing a process for collecting the AM-PAC imperative for this complex patient group.
in a home care setting in a large not-for-profit healthcare system was
established. Collection rates have improved and training is ongoing. References:
Implementing the AM-PAC in the home care setting is a step in devel- 1. Smith JM, Lee AC, Zeleznik H, Coffey Scott JP, Fatima A, Needham DM, Ohtake
oping a means of tracking patient outcomes across the continuum. We
are not aware of other organizations looking to utilize AM-PAC scores PJ. Home and Community-Based Physical Therapist Management of Adults
to track outcomes across an integrated continuum. There is further with Post-Intensive Care Syndrome. Phys Ther. 2020 Jul 19;100(7):1062-1073.
opportunity to formally analyze AM-PAC data in the homecare space. doi: 10.1093/ptj/pzaa059. PMID: 32280993; PMCID: PMC7188154.
2. Rooney S, Webster A, Paul L. Systematic Review of Changes and Recovery
References: in Physical Function and Fitness After Severe Acute Respiratory Syndrome-
1. Association of AM-PAC “6-Clicks” Basic Mobility and Daily Activity Scores Related Coronavirus Infection: Implications for COVID-19 Rehabilitation.
Phys Ther. 2020 Sep 28;100(10):1717-1729. doi: 10.1093/ptj/pzaa129. PMID:
with Discharge Destination Meghan Warren, PT, PhD, Jeff Knecht, PT, DPT, 32737507; PMCID: PMC7454932.
Joseph Verheijde, PhD, MBA, PT, James Tompkins, PT, DPT Physical Therapy, 3. Demeco A, Marotta N, Barletta M, Pino I, Marinaro C, Petraroli A, Moggio
Volume 101, Issue 4, April 2021, pzab043, https://doi.org/10.1093/ptj/ L, Ammendolia A. Rehabilitation of patients post-COVID-19 infection: a
pzab043. literature review. J Int Med Res. 2020 Aug;48(8):300060520948382. doi:
2. A Community-Wide Quality Improvement Project on Patient Care Transitions 10.1177/0300060520948382. PMID: 32840156; PMCID: PMC7450453.
Reduces 30-Day Hospital Readmissions from Home Health Agencies Markley, 4. Belli S, Balbi B, Prince I, Cattaneo D, Masocco F, Zaccaria S, Bertalli L, Cattini
Jennifer RN, BSN; Sabharwal, Karen MPH; Wang, Ziyin PhD; Bigbee, Cindy F, Lomazzo A, Dal Negro F, Giardini M,
RN, MSN; Whitmire, Linda BA Home Healthcare Nurse: March 2012 - Volume
30 - Issue 3 - p E1-E11 doi: 10.1097/NHH.0b013e318246d540
TITLE: Telecare Pain Management: Are Booster Sessions Required
for Maintenance of Long-Term Outcomes?
TITLE: Home Health Rehabilitation Interventions and Outcomes
Following Hospitalization for COVID 19 Authors: Raveenn S. Smith Mowbray, Shana D. Bergal, Matthew S.
Bailey, Marnin Joseph Romm, Lawrence P. Cahalin
Authors: Denise Tillery Wagner, Sharon Renee Siegel, Eileen Marcie
Reinhard, Michael Joseph Markowski, William Weakland, Stacee ABSTRACT BODY:
Minyard, Allison Madden
Purpose/Hypothesis: To investigate the medium to long-term effec-
ABSTRACT BODY: tiveness of a telecare group-based pain management program (GPMP)
for chronic pain conditions. The study aimed to examine the effects of
Purpose/Hypothesis: Analyze the rehab disciplines required by and GPMP on an exposed group (more ready to change maladaptive pain
outcomes of a sample of the 645 patients discharged from hospital behaviors) and unexposed group (less ready to change maladaptive
to home health care after diagnosis of COVID from 4/1/20 to 7/1/21. pain behaviors) pain experiences.

Number of Subjects: 120 Number of Subjects: 31

Materials and Methods: chart review Materials and Methods: 42 subjects participated in the GPMP. 5 groups
of 8-11 subjects met once a week, for 6 weeks, for 3–4-hour ses-
Results: 67% of those referred to home health care received Physical sions. The intervention consisted of a biopsychosocial approach to
Therapy, 28% received Occupational Therapy and 5% received Speech self-management. Questionnaires were distributed at pre-, post-, and
Therapy. Visit utilization, discharge disposition and functional out- at 2 months post-intervention. Analyses were performed on the data
comes as represented by AMPAC and OASIS data are presented from the 31 participants who responded at the 2-month follow up. The
demonstrating value of home health care rehab services. outcome measures assessed included the pain Visual Analog Scale
(VAS), Tampa Scale of Kinesiophobia (TSK) and Pain Self-Efficacy
Conclusions: AMPAC and OASIS data demonstrate functional improve- Questionnaire (PSEQ). Repeated measures ANOVA was used to ana-
ments during the home health rehabilitation services episode of care. lyze the data with statistical significance set at p<0.05.
The value of Home Health Care rehabilitation to post-acute COVID
patients is demonstrated through these trends. Persistent functional Results: For both, the exposed and unexposed group, VAS, TSK and
limitations at home health discharge highlight the need for continued PSEQ improved from pre- to post-intervention and 2-month follow
interventions through individualized home exercise programs; outpa- up scores were significantly different (p<0.05) for between groups
tient PT, OT, SLP and/or outpatient cardiac or pulmonary rehab. effect for VAS, TSK and PSEQ. Wilk’s lambda showed a statistically
significant difference (p<0.05) based on time for both PSEQ and TSK.
Clinical Relevance: Value of Home Health Care rehab to post-acute At 2-month follow up, VAS scores returned to baseline values in the
COVID patients supported through trends in AMPAC and OASIS exposed group and had the following mean±SD scores for baseline and
assessment Value Based Purchasing outcome measures. Trends in 2 months follow up 49.4±17.9 and 49.1±31.3, respectively, with 18.3%

Page 26 APTA Home Health Section

variance in scores explained by the groups. At 2-month follow up, the osteoarthritis’) AND (‘physical therapy’ OR ‘physiotherapy’). Titles
mean±SD VAS scores of the unexposed group decreased from baseline and abstracts were screened to determine inclusion. Peer reviewed
(69.5±18.4 to 61.7±20.7). Mean±SD PSEQ scores decreased slightly studies published in English since 2010 involving patients ages 18
in both the exposed and unexposed groups at 2 months follow up years or older with shoulder disorders treated via TR were included.
(44.9±9.7 and 38.3±9.8, respectively), but remained greater than base- Study quality was assessed by two authors using the EPHPP Quality
line scores (36.5±10.9 and 25.6±10.3, respectively), with 19.2% variance Assessment Tool for Quantitative Studies. Data on study character-
in scores explained by the groups. TSK scores remained the same istics and details of TR were extracted and tabulated.
post-GPMP to 2 months follow-up for the unexposed group (35.9±6.6
and 35.7±8.5, respectively), decreased slightly in the exposed group Results: Out of 14 eligible studies, nine met the inclusion criteria.
post-GPMP to 2 months follow up (29.8±7.5 and 31.3±7.9, respectively) Pathologies included shoulder joint replacement, rotator cuff related
and were improved from baseline (43.4±5.1 and 35.0±7.1, respectively) pain, subacromial impingement, frozen shoulder, arthroscopic sub-
with 22.0% variance in scores explained by the groups for this measure. acromial decompression and proximal humeral fractures. Study
designs included case reports, cohort studies, RCT’s and qualitative
Conclusions: Both the exposed and unexposed groups improved studies, ranging from weak to strong evidence. The most common
scores of VAS, TSK and PSEQ at post- assessment. Improvements form of TR delivery was synchronous in five studies. One study deliv-
from pre-intervention to 2 months follow-up were maintained but were ered TR asynchronously, and two studies were a mix of both types.
slightly less than at post-intervention. Seven out of nine studies did not have a control group, and only two
studies compared TR with in-person physical therapy (PT). The most
Clinical Relevance: Booster sessions may be required once a month for commonly used outcome measures were Visual Analog Scale (VAS),
a few months following a final GPMP session to potentially maintain or Disabilities of Shoulder, Arm and Hand (DASH), and Constant Murley
even further improve post-intervention scores. Further research should (CM). VAS and CM were shown to have the most change in the majority
incorporate booster sessions to examine their potential impacts on of studies. No statistical analysis was possible because of variability
pain outcome scores. in pathologies, TR delivery, intervention protocols and outcome mea-
sures and lack of studies that compared telerehabilitation to in-person
References: treatment.
1. Romm MJ, Ahn S, Fiebert I, Cahalin LP. A Meta-Analysis of Therapeutic Pain
Conclusions: Telerehabilitation seems to be a feasible means of
Neuroscience Education, Using Dosage and Treatment Format as Moderator delivering PT treatment to patients with shoulder disorders. However,
Variables. Pain Pract. 2021;21(3):366-380. doi:10.1111/papr.12962. studies are inconsistent in terms of defining telerehabilitation, delivery
2. Romm MJ, Ahn S, Fiebert I, Cahalin LP. A Meta-Analysis of Group-Based Pain modes, duration and whether telerehabilitation was used as a way
Management Programs: Overall Effect on Quality of Life and Other Chronic to deliver treatment or assessments. Furthermore, there is a need
Pain Outcome Measures, with an Exploration into Moderator Variables that to validate the outcomes for use in telerehabilitation. Future studies
Influence the Efficacy of Such Interventions. Pain Med. 2021;22(2):407-429. looking into PT treatment for shoulder disorders delivered via TR
doi:10.1093/pm/pnaa376 should aim to utilize validated outcome measures, include control
3. Romm MJ, Ahn S, Fiebert I, Cahalin LP. A Meta-Analysis of Group-Based Pain groups, provide clear dosages and intensity of exercises and improve
Management Programs: Overall Effect on Quality of Life and Other Chronic consistency among the methods of TR delivery to synthesize evidence
Pain Outcome Measures, with an Exploration into Moderator Variables that of its effectiveness.
Influence the Efficacy
Clinical Relevance: We enumerate factors that clinicians may want
to consider when deciding the feasibility of using telerehabilitation.
TITLE: Telerehabilitation in the Treatment of Shoulder Disorders: A
Systematic Review References:
1. Choi Y. Effect of smartphone application-supported self-rehabilitation for
Authors: Kristen Mihalich, Nguyen Thao Nguyen, David Newell, Nick
Oliveira, Amitabh Dashottar frozen sAhoulder: a prospective randomized control study. Clin Rehabil. 2019
Apr;33(4):653-660. doi: 10.1177/0269215518818866. Epub 2018 Dec 10. PMID:
ABSTRACT BODY: 30526016.
2. Levy CE, Silverman E, Jia H, Geiss M, Omura D. Effects of physical therapy
Purpose/Hypothesis: The purpose of this systematic review is to syn- delivery via home video telerehabilitation on functional and health-related
thesize the available evidence regarding the use of telerehabilitation quality of life outcomes. J Rehabil Res Dev. 2015;52(3):361-370.
(TR) in the treatment of common shoulder pathologies. 3. Macias-Hernandez S. Proposal and Evaluation of a Telerehabilitation
Platform Designed for
Number of Subjects: Studies included patients ages 18 years or older
with shoulder pathologies receiving PT via telerehabilitation.

Materials and Methods: MEDLINE, Pubmed, EBSCO and Google Scholar
were searched for eligible studies using combinations of the following
keywords: (‘telehealth’ OR ‘telerehabilitation’ OR ‘telemedicine’) AND
(‘shoulder’ OR ‘shoulder disorders’ OR ‘shoulder impingement’ OR
‘rotator cuff’ OR ‘shoulder bursitis’ OR shoulder fracture’ OR ‘shoulder

The Quarterly Report | Fall 2022 Page 27

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