APTA Home Health Quarterly Report Vol 58, No. 2

In this Issue: The Quarterly Report SPRING 2023 Vol. 58 | No. 2 Continued on Page 3 “Providing PT in the Home,” 4th Edition Coming in 2023 16 Home Health Academy 20 Platforms CSM 2023 Med Pac - Unified Payment System and Value-Based Incentive Program for Post-Acute Care 14 Best Practice Guide to Supporting Persons Living with Dementia and Their Caregivers 1 Did You Hear? 2 Read All About It! Quarterly Report is Moving to Electronic Mode as Primary Distribution with Optin to Print Available 5 Home Health Physical Therapist as a Pro Bono Volunteer 10 As the size of the U.S. population age 65 and older continues to grow, so too will the number and proportion of Americans with dementia caused by Alzheimer’s disease or other types of dementias.1 The incidence rate of Alzheimer’s is declining while the prevalence is increasing, largely attributable to improvements in lifestyle, healthcare, and education. While these advances positively impact new cases per capita, they also contribute to Americans living to a more advanced age, increasing the risk of developing the symptoms of Alzheimer’s and related dementias with each of those extra years. The current number of Americans living with Alzheimer’s dementia is around 6.1 million; by 2060, that number is projected to reach 13.8 million, with the dramatic increase primarily due Best Practice Guide to Supporting Persons Living with Dementia and Their Caregivers to the aging of America.2 The proportion of the U.S. population age 65 and older is expected to increase from 12% in 2022 to 22% in 2050. The National Institute for Health and Care Excellence (NICE) Quality Standard on Dementia (QS184), published in June 2019, calls for healthcare providers to offer education and skills training to caregivers of people with dementia.3 To that end, this guide is provided for clinicians working with patients and families living daily with one of the many forms of dementia. The intent is to present current information on various topics related to the lived experience, with its joys and challenges, of dementia. Much of the information is from the 2018 Alzheimer’s Association Dementia Care Practice Recommendations.4

Published by APTA Home Health, an Academy of the American Physical Therapy Association Editor Dawn Widmer-Greaves, PT, DPT Managing Editor/Design Don Knox Publications Committee Julie Hardy, PT, MS; Olaide Oluwole- Sangoseni, PT, DPT, MSc, PhD; Amanda Fabozzi, PT, DPT; Brittany Czerw, PT, DPT; Nicole Day, PT, DPT Section Officers: President ...................Philip Goldsmith, PT, DScPT, COS-C Vice President...........................Matt Janes, PT, DPT, MHS Secretary .................................... Monique Caruth, PT, DPT Treasurer .....................................Erin Pazour, MPT, COS-C Executive Director................................................ Don Knox The Quarterly Report is the official publication of APTA Home Health, an Academy of the American Physical Therapy Association. It is published four times per calendar year (Winter, Spring, Summer, Fall). Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion on the part of the officers or the members of APTA Home Health. Article & Content Contributions Guidelines for contributions are available from the APTA Home Health website. If you have materials you would like considered for publication, please email them via attachment to the APTA Home Health Executive Director: [email protected] Advertising Advertising rates and details are available from the Section website, www.aptahomehealth.org, or by contacting the Academy office at 720-459-5559. Electronic subscriptions to APTA Home Health Quarterly Report are available at a rate of $100/year. Order through the Academy’s online store. Copyright ©2021 by APTA Home Health Postmaster: Send address changes to APTA Home Health, PO Box 3406 , Englewood, CO 80155. www.aptahomehealth.org PO Box 3406 • Englewood, CO 80155 • 720-459-5559 Did You Hear? Read All About It! Continued on Page 19 Meet the 2023 Home Health Award Recipients APTA Home Health presented awards to recognize individual excellence at the academy’s business meeting on Friday, February 24, 2023, at the 2023 Combined Sections Meeting in San Diego: The President’s Award, recognizing a member who has provided notable service to the academy, was presented to Christopher Chimenti, PT, Director of Therapeutic Services at HCR Home Care in Rochester, NY, and -up until his term ended at CSM - the academy’s Vice President. Chris’ goal has always been to foster a culture of professional development within his organization with a particular focus on best practice and skill development opportunities. As a leader, he promotes autonomy, job satisfaction, and individual success. His research interests lie in home health care practice, with a particular focus on using evidence to drive successful outcomes. He has conducted several studies throughout his career across a variety of special interest areas including falls prevention, Parkinson’s Disease management, pain management, sepsis screening, and total knee replacement rehabilitation. The Excellence in Home Health Clinical Practice Award, recognizing a physical therapist or physical therapist assistant for outstanding clinical practice in a home health care setting, was presented to Silke Mildenberger, PTA. Silke, has spent the past seven years in home health, specializing in Senior Living and Geriatrics, and working in Senior Communities. Prior to that she specialized in outpatient settings, mostly in Neurological Rehab, Pediatrics and Orthopedics, both in Germany and in the United States. Practicing in Senior Living settings, Silke has focused her training on Parkinson’s Disease, training of the older adult and Community and Family education. She enjoys working in her client’s home and being part of the solution for them to stay and age in place with dignity by collaborating with the client, the family, and the community. Four members received the Home Health Leadership Award, which recognizes the exceptional contribution of an APTA Home Health member in promoting home health physical therapy practice. They are: Dr. Marcie Ganson, PT, DPT, MBA, an active member of the IPTA (Illinois Physical Therapy Association) and the American Physical Therapy Association on a local and national basis since 1995. She has seen our profession change and grow as the health care industry has changed. Dr. Ganson has been in her current role as a clinician and management for the last 20 years. She strives to live out her philosophy of servant leadership as she helps colleagues identify their strengths. Since the start of the COVID-19, Dr. Ganson has assisted the Illinois Critical Access Hospital Networking (ICAHN) Page 2 APTA Home Health

Continued from Page 1 Please consult the resource at the end of this article for additional information. You may also scan this QR code for access to a downloadable version of this resource to share with appropriate patients and their caregivers. Activities Providing and supporting various recreational activities that offer opportunities for meaningful engagement may preserve dignity, prevent excessive stress-inducing demands, and prevent increased dependency, boredom, and learned helplessness.5 Encouraging participation in daily chores and maintaining hobbies and shared past activities can improve mood, reduce agitation, and improve the quality of life for the person living with dementia (PLWD).6 Activities should be tailored to the individual preferences, cognitive and functional abilities, lifelong habits and roles, memories and past experiences.7 Carefully chosen activities can be an integral component of a nondrug approach to preventing behavioral and psychological symptoms of dementia. Changing and Challenging Behavior Behavioral and psychological symptoms of dementia (BPSD) may include agitation, aberrant motor behavior, anxiety, irritability, depression, apathy, disinhibition, delusions, hallucinations, sleep, or appetite changes. Often, persons living with dementia (PLWDs) have difficulty with language, and adverse behaviors are often an attempt to communicate an unmet need.8 These needs may include boredom, hunger, pain or anxiety over their current situation. Medications (antipsychotic and psychotropic medications – see under Medications section for examples) may be needed to treat severe agitation, aggression, or distress from psychotic symptoms such as hallucinations and delusions which may accompany Alzheimer’s disease and other dementias. - However, medications are generally not recommended unless non-drug approaches have been tried without success. Non-drug methods are preferable and do not carry the risk of side effects or adverse drug interactions. Practices to address BPSDs should build from broader dementia care principles which include simplifying tasks (breaking each task into simple steps, using verbal and or tactile prompts), communicating clearly and calmly, and allowing time for the individual’s response; aligning activities with the individual’s preferences and capacity and providing support as needed; and engagement with the individual in a simplified environment that is free from clutter and distractions, using visual cues for orientation.9 Examples of non-drug approaches to changing and challenging behaviors (BPSD)10 • Aromatherapy: There is moderate research evidence that essential oils (examples: lavender and lemon balm) may have a calming effect on the PLWD. • Massage: There is limited research evidence that massage applied to the back, shoulders, neck, hands, or feet by qualified massage therapists, trained staff, or family members may have a calming and positive effect on PLWD. • Bright light therapy: There is moderate research evidence that exposure to light anywhere from five to 30 times brighter than typical office lights during the day may help some PLWD who are restless or active during the night to restore their national sleep-wake cycles. • Validation therapy: There is limited research evidence that a care approach that involves validating the perceived reality and emotional experience of the PLWD (rather than denying, arguing, or re-orienting) can positively affect agitation, apathy, irritability, and night-time disturbances. • Reminiscence therapy: There is moderate research evidence that a care approach that uses objects, sights, smells, sounds from the PLWD’s past can have a positive effect on mood and depressive symptoms. This involves photographs, videos, music, food, and other smells tied to pleasant memories. • Music therapy: There is moderate research evidence that music, especially that which is personalized to the PLWD, can have a positive effect on a range of BPSD, including anxiety, agitation, and apathy. In some studies, music is one of the most beneficial approaches overall. Driving Driving requires the ability to react quickly, both physically and cognitively, to various situations. Because of this, a person with Alzheimer’s will, at some point, be unable to drive. Planning ahead can help ease the transition.11 An Occupational Therapy driving specialist can provide a comprehensive driving evaluation and work with your medical provider to develop a plan to retain the highest level of independence and mobility while reducing risk. Learn more here: AOTA List of Driver Assessment and Rehab Programs AOTA.org.12 An integral part of planning ahead to ensure the highest level of safe community mobility should include a list of local transportation options. To find senior transportation options in your community, call 211, your local Alzheimer’s Association, contact your local Area Agency on Aging, or see the resource at the end of this article. Hydration Persons with dementia may forget to drink water, leading to constipation, dehydration, metabolic problems such as altered sodium levels, and urinary tract infections. It may be helpful to set up a structured drinking program, such as labeling bottles of water with times during the day to finish each bottle by the marked time. Legal Issues Creating a legal plan for the future early in the disease process can empower and ensure that a person’s wishes are known and realized. This allows the PLWD and their family to focus on enjoying life.13 With a plan, including forms that designate a health care power of attorney, times of crisis can be manageable. If the PLWD has yet to have conversations with someone close to them about their healthcare wishes, others will have to guess what they would want. In the absence of a previously determined surrogate, the court system may have to make very personal decisions. Having difficult conversations early in the disease process will avoid these pain points. Medications Antipsychotic and other psychotropic medications are generally not indicated to alleviate BPSDs, so non-drug practices (as noted in the Changing and Challenging Behavior section in this document) should be the first line of approach.14 Research shows that the use of antipsychotic medications is associated with an increased risk of The Quarterly Report | SPRING 2023 Page 3

change should always trigger a search for the cause. Could the PLWD be tired, hungry, cold, hot, frustrated, depressed, withdrawn, or as is often the case, in pain? Knowing the person’s history, for example chronic neck pain caused by osteoarthritis, can give clues as to the source of unusual behavior. Neck pain does not go away just because the PLWD no longer has words to express their discomfort; this expression may take a different form, such as pacing, crying, or even lashing out at others, verbally and, at times, physically. Another example would be observing an increasing frequency of bathroom trips, possibly due to uncommunicated diarrhea or a urinary tract infection. In this example, severe illness and perhaps a hospital stay can be avoided by early detection of the underlying problem. If the source is chronic pain, consider the difficulty in communicating a need for as-needed pain medication. Regular dosing of an over-the-counter pain medication, such as acetaminophen (after consultation with their physician), or regular physical or occupational therapy to relieve chronic musculoskeletal pain may also be beneficial. To overcome problems with communication pain in the PLWD, observational scales that help gauge the level of the person’s pain may be used, such as the PAINAD.19 The PAINAD asks providers to observe and rate the person’s outward behaviors across six domains that correlate with pain: Breathing, negative vocalizations, facial expression, body language, and consolability.20 Such a scale can be used to more accurately assess pain and monitor intervention effectiveness. Planning Ahead PLWD and their caregivers should understand the options available for care during the later stages of Alzheimer’s disease. Having discussions early with the person’s physician and other care providers and communicating the preferences of the person and family across care settings can make the transitions during the progression of dementia more manageable.21 Early attention to advance planning provides greater opportunity for participation of the PLWD and increases the likelihood that they will have their individual preferences and wishes honored. Physical Activity and Exercise Physical activity and exercise have been shown to have benefits at all levels of cognition. It may slow cognitive decline by reducing inflammation, increasing blood flow to the brain, and facilitating neuroplasticity.22 Maintaining or improving strength and balance contribute to fall prevention and decrease risk of head injury with further cognitive decline. Aerobic exercise promoting cardiovascular fitness has a greater impact on slowing decline in cognition23,24 and has been shown to increase the size of the hippocampus (the key brain area involved in memory).22 Exercise programs that are structured, individualized, higher intensity, longer duration, and multicomponent show promise for preserving cognitive performance in older adults.25 Products that Support Living with Dementia Many products are available to support PLWDs. These can range from products that support wayfinding and orientation (e.g., finding one’s way back home from a walk around the block or to their room in an assisted or independent living community) to supporting autonomy in activities of daily living to enhancing safety by exit control to deter elopement. The earlier in the disease process a new piece of equipment is introduced, the easier it is to stroke and death.15,16,17 The FDA has a “black box warning” regarding the increased risks associated with these medications. However, it should be noted that even though a non-drug approach is preferred, there are times when medications are warranted for BPSD when nondrug approaches have failed.18 The CG should always remain vigilant for changes in behavior, especially following the addition of a new medication, which may indicate a side effect or interaction, and to ensure that the PLWD is taking their prescribed medications as prescribed. Examples of common antipsychotic and other psychotropic medications: Risperdal (Risperidone) Largactil (Chlorpromazine) Seroquel (Quetiapine) Fluanxol (Flupenthixol) Zyprexa (Olanzapine) Modecate (Afluphenazine) Zeldox (Ziprasidone) Haldol (Haloperidol) Invega (Paliperidone) Loxapac (Loxapine) Abilify (Aripiprazole) Trilafon (perphenazine) Clozapine (Clozaril) Orap (Pimozide) Nutrition As dementia progresses, nutrition becomes an ongoing and changing challenge. In the early stage, the person with memory problems may forget to eat, putting them at risk for poor nutrition. Or they may forget they have eaten, and overeat, putting them at risk for health challenges, including obesity, diabetes, and high blood pressure. As dementia progresses, anxiety or other causes may lead to pacing or continuous walking, burning excess calories and making it difficult to sit and eat a meal, also leading to possible malnutrition. In this case, finger foods “on the go,” such as putting mashed potatoes in an ice cream cone or handing them a smoothie, may be helpful. About this time, dysphagia (difficulty swallowing or choking) may become an issue. Eating meats or raw vegetables that require adequate chewing before swallowing can be difficult. The caregiver will need to increase their vigilance for choking and be on the lookout for other signs of “silent aspiration”: runny nose, watery eyes, wet cough, or gurgling sound following swallowing may indicate a swallowing problem. Also, if the PLWD runs an unexplained fever, this can indicate an infection brought about by aspiration or having food go into the lungs rather than the stomach. If food choices become limited and nutrition is an issue, consider adding the PLWD’s favorite flavor to the food, for example, chocolate syrup, maple syrup, sugar, or gravy. As dementia progresses, the caregiver may need to discuss with the health care provider of the PLWD how to “balance” managing chronic medical conditions such as diabetes and hypertension with the need for calories and quality of life and pleasure associated with eating. If needed, request a referral to a dietitian for appropriate food suggestions and a speech- language pathologist to evaluate swallowing. Pain Pain is a complex topic for the PLWD. With dementia progression, communication of needs becomes more challenging as body awareness declines. As a result, identifying the source of discomfort and communicating it to others becomes more difficult. This can lead to agitation, frustration, and ultimately, unusual behaviors. A behavior Page 4 APTA Home Health

incorporate it into the person’s daily life. For example, a walking aid such as a cane or walker can be an intimidating foreign object to someone living in the later stages of dementia; however, when introduced early and processed into long-term procedural memory, it is more likely to become a helpful mobility support. Recommended Reading For many, comfort and support can be found through shared experiences. The Alzheimer’s Association provides a wide variety of reading resources for those experiencing the joys and challenges of living with cognitive decline. Alzheimer’s Association Recommended Reading26 Safety and Risk Reduction Planning for risk reduction in one of the most valuable types of support for PLSDs and care partners. Persons living with dementia in the early to middle stages are at increased risk for harm related to financial mismanagement, medication-related adverse events, driving, falls, wandering, elopement, and getting lost.27,28,29,30,31 It is important to remember that risk-averse approaches that discount threats to personhood and dignity may threaten the person’s integrity.32 Frank discussions about risk tolerance and risk mitigation are essential.32 Supporting Activities of Daily Living Dementia is a progressive disease, accompanied by a progressive need for support in the conduct of activities of daily living (ADLs); from first to last, the need for supportive care generally follows the order of bathing, dressing, grooming, toileting, walking, and eating.33 The 2018 Alzheimer’s Association Dementia Care Recommendations provide a comprehensive Review Article entitled “Progressive Support for Activities of Daily Living for Persons Living with Dementia”.34 Below are five practice recommendations from that article. The reader is directed to the entire article for a full explanation with examples. 1. Support for ADL function must recognize the activity, the individual’s functional ability to perform the activity, and the extent of cognitive impairment. Dementia is a progressive disease, accompanied by progressive loss in the ability to independently conduct ADLs. Needs for supportive care increase over time – such as beginning with support needed for dressing, and later toileting, and later eating – and must address both cognitive and functional decline and remaining abilities. 2. Follow person-centered care practices when providing support for all ADL needs. Not only are dignity, respect, and choice a common theme across all ADL care, but the way support is provided for functionally specific ADLs must attend to the individualized abilities, likes and dislikes of the person living with dementia. 3. When providing support for dressing, attend to dignity, respect and choice; the dressing process; and the dressing environment. In general, people living with dementia are able to dress independently if, for example, they are provided selective choice and simple verbal instructions, and if they dress in comfortable, safe areas. 4. When providing support for toileting, attend to dignity and respect; the toileting process; the toileting environment; and health and biological considerations. In general, people living with dementia are more able to avoid incontinent episodes if, for example, they are monitored for signs of leaking, have regularly scheduled bathroom visits, have clear access to a well-marked bathroom, and avoid caffeine and fluids in the evening. 5. To provide support for eating, give attention to dignity, respect and choice; the dining process; the dining environment; health and biological considerations; adaptions and functioning; and personal preferences, food, beverages, and appetite. In general, people living with dementia are more likely to eat if, for example, they are offered choices, dine with others and in a quiet, relaxing, and homelike atmosphere, maintain oral health, are provided adaptive food and utensils, and offered nutritionally and culturally appropriate foods. Conclusion In conclusion, physical therapists and assistants working in the home setting have access to, as well as an obligation to provide quality information and support to PLWD and their caregivers. As the 65 years and older population continues to swell in the coming 30-40 years, this will be ever more essential as part of a comprehensive plan of care. The Quarterly Report | SPRING 2023 Page 5

Best Practice Guide to Supporting Persons with Dementia Topic Description Resources Activities Driving Hydration Legal Issues Having Alzheimer’s doesn’t mean that the PLWD and their CG cannot have fun and experience joy. Experiences that are shared can be especially meaningful and allow the relationship to find expression in new ways. Activities to do with a friend or family member who has Alzheimer’s (nia.nih.gov) Adapting Activities for People who have Alzheimer’s (nia.nih.gov) 50 Activities (alz.org) The Alzheimer’s Association and the American Occupational Therapy Association provide tools and resources to prepare for the eventuality that the PLWD will one day no longer be safe to drive. Early discussions and planning may help prevent worry, frustration, and potential tragedy. Find a Driving Rehab Provider (aota.org) Dementia and Driving (Alz.org - Includes sections on Having the conversation, Planning ahead/Transportation options, Signs of unsafe driving, and driving evaluation) Driving Fact Sheet and Contract (Alz.org) Remembering to drink water can be a problem for the PLWD and lead to secondary problems such as constipation and altered electrolytes. Drinking, Hydration and Dementia (dementiauk.org) Here are some helpful websites to assist the PLWD and their loved ones with legal issues that may arise involving competency and legal forms. Legal Planning (alz.org) Legal Documents (alz.org) Legal Capacity (alz.org) Caring for Dementia: Legal and Financial Planning (va.gov) Pain The PLWD may lose their ability to identify, localize and/or communicate the presence of pain. Many tools are available to help caregivers to understand pain in the PLWD and to learn to investigate for underlying problems when BPSD are observed that may be communicating pain. Pain Assessment in Advanced Dementia - PainAD scale (missouri.edu) Alzheimer's Disease: Common Medical Problems (nia.nih.gov) Pain in Advanced Dementia (scie.org.uk) BPSD = Behavioral and Psychological Symptoms of Dementia CG = Caregiver PLWD = Person Living with Dementia Page 6 APTA Home Health

Nutrition Physical Activity Planning Ahead Nutrition is essential to health and wellbeing. However, mealtimes can become strained and difficult as dementia advances. Check out these resources with helpful suggestions. Food and Eating (alz.org) Healthy Eating and Alzheimer's Disease (nia.nih.gov) Dementia and Nutrition Fact Sheet (nutrition.va.gov) Dementia: Challenges with Chewing, Swallowing, and Self-Feeding (nutrition.va.gov) Dementia: Challenges with Constipation, Dehydration, and Changes in Taste and Smell (nutrition.va.gov) There are multitude of benefits to staying physically active. Check out these websites to learn more. Stay Physically Active (alz.org) Physical Activity and Exercise (alzheimers.org.uk) Staying Physically Active with Alzheimer’s (nia.nih.gov) Making care decisions early in the disease can provide for a more peaceful progression. These are a few of the resources available to guide the PLWD as they and their caregivers make a plan. Alzheimer’s Navigator (alz.org: A comprehensive planning guide for creating a personalized action plan) Lanny Butler’s My Way (vhca.org: A document to record personal preferences for daily activities) The Conversation Project (theconversationproject.org: A free guide for sharing a person’s wishes for care through the end of life.) Products that Support Living with Dementia Safety & Risk Reduction There are many sources for products that support living with cognitive impairment. Here are a few examples to browse. Alzheimer’s Store (alz.org) Independent Living Aids (independentliving.com. search “Persons living with dementia” and/or similar terms.) The Mind Care Store (mindcarestore.com) Amazon.com and Pinterest also have “Alzheimer’s Store” sections on their websites with items curated for PLWD. Persons living with dementia should have access to an environment that does not put unnecessary restrictions on the individual while helping them feel comfortable and secure and ensuring their safety. These resources provide helpful suggestions. Wandering (alz.org) Home Safety (alz.org) Medication Safety (alz.org) Preventing Elder Scams, Fraud, and Other Crimes Targeting the Elderly (alz.org) 24/7 Wandering Support for a Safe Return (alz.org) Technology 101 - Location Systems (alz.org) Travel Tips (alz.org) Preparing for Emergencies (alz.org) Abuse and Neglect (alz.org) The Quarterly Report | SPRING 2023 Page 7

References 1. Alzheimer’s Association. 2022 Alzheimer’s disease facts and figures. Alzheimers Dement. 2022;18(4): 19. doi:10.1002/alz.12638 2. Alzheimer’s Association. 2022 Alzheimer’s disease facts and figures. Alzheimers Dement. 2022;18(4): 28. doi:10.1002/alz.12638 3. Quality Standard (QS184) https://www.nice.org.uk/search?q=QS184. Accessed online 3.18.2023. 4. Fazio S, Pace D, Maslow K, Zimmerman S, Kallmyer B. Alzheimer’s Association Dementia Care Practice Recommendations. Gerontologist. 2018: 58(suppl_1). doi:10.1093/geront/gnx182. Accessed Feb. 2023. 5. Fazio S, Pace D, Maslow K, Zimmerman S, Kallmyer B. Alzheimer’s Association Dementia Care Practice Recommendations. Gerontologist. 2018: 58(suppl_1):S39. doi:10.1093/geront/gnx182. Accessed Feb. 2023. 6. Fazio S, Pace D, Maslow K, Zimmerman S, Kallmyer B. Alzheimer’s Association Dementia Care Practice Recommendations. Gerontologist. 2018: 58(suppl_1):S52. doi:10.1093/geront/gnx182. Accessed Feb. 2023. 7. Han A, et al. The benefits of individualized leisure and social activity interventions for people with dementia: A systematic review. Activities, Adaptation and Aging. 2016;40: 219-265. DOI: 10.1080/01924788.2016.1199516. Cited in The Gerontologist. 2018; 58(1):S96. 8. Fazio S, Pace D, Maslow K, Zimmerman S, Kallmyer B. Alzheimer’s Association Dementia Care Practice Recommendations. Gerontologist. 2018: 58(suppl_1):S2. doi:10.1093/geront/gnx182. Accessed Feb. 2023. 9. Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behavioral symptoms in dementia. JAMA. 2016, 308:2020-2029. ):S89. 10. Fazio S, Pace D, Maslow K, Zimmerman S, Kallmyer B. Alzheimer’s Association Dementia Care Practice Recommendations. Gerontologist. 2018: 58(suppl_1):S91-92. doi:10.1093/geront/gnx182. Accessed Feb. 2023 11. Dementia and Driving. https://www.alz.org/help-support/caregiving/safety/ dementia-driving. Accessed Feb. 2023. 12. Driving Practitioner Directory. https://www.aota.org/practice/clinicaltopics/driving-community-mobility/driving-practitioner-directory. Accessed Feb. 2023. 13. Legal planning. https://www.alz.org/help-support/i-have-alz/plan-for-yourfuture/legal_planning. Accessed Feb. 2023. 14. Fazio S, Pace D, Maslow K, Zimmerman S, Kallmyer B. Alzheimer’s Association Dementia Care Practice Recommendations. Gerontologist. 2018: 58(suppl_1):S6. doi:10.1093/geront/gnx182. Accessed Feb. 2023. 15. Douglas IJ, Smeeth L. Exposure to antipsychotics and risk of stroke: Self controlled case series study. BMJ (Clinical Research ed.). 2008; 333:1227. Cited in The Gerontologist. 2018; 58(1):S53. 16. Gill SS, Et al. Antipsychotic drug use and mortality in older adults with dementia. Annals of Internal Medicine. 2007;146:775-786. Cited in The Gerontologist. 2018; 58(1):S53. 17. Schneeweiss S, et al. Risk of death associated with use of conventional versus atypical antipsychotic drugs among elderly patients. [published correction appears in CMAJ. 2007 May 22;176(11:1613]. CMAJ . 2007;176(5):627-632. Doi:10.1503/cmaj.061250. Cited in The Gerontologist. 2018; 58(1):S53. 18. Fazio S, Pace D, Maslow K, Zimmerman S, Kallmyer B. Alzheimer’s Association Dementia Care Practice Recommendations. Gerontologist. 2018: 58(suppl_1):S52. doi:10.1093/geront/gnx182. Accessed Feb. 2023 19. Fazio S, Pace D, Maslow K, Zimmerman S, Kallmyer B. Alzheimer’s Association Dementia Care Practice Recommendations. Gerontologist. 2018: 58(suppl_1):S51. doi:10.1093/geront/gnx182. Accessed Feb. 2023. 20. PAIN AD. https://geriatricpain.org/painad. Accessed Feb. 2023. Cited in The Gerontologist. 2018; 58(1):S51. 21. Fazio S, Pace D, Maslow K, Zimmerman S, Kallmyer B. Alzheimer’s Association Dementia Care Practice Recommendations. Gerontologist. 2018: 58(suppl_1):S5. doi:10.1093/geront/gnx182. Accessed Feb. 2023. 22. Ahlskog JE, et al. Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging. Mayo Clin Proc. 2011;86(9):876-884. doi:10.4065/mcp.2011.0252. 23. Law CK, Lam FM, Chung RC, Pang MY. Physical exercise attenuates cognitive decline and reduces behavioural problems in people with mild cognitive impairment and dementia: a systematic review. J Physiother. 2020;66(1):9-18. doi:10.1016/j.jphys.2019.11.014. 24. Liu IT, Lee WJ, Lin SY, Chang ST, Kao CL, Cheng YY. Therapeutic effects of exercise training on elderly patients with dementia: A randomized controlled trial. Arch Phys Med Rehabil. 2020;101(5):762-769. doi:10.1016/j. apmr.2020.01.012. 25. Kirk-Sanchez NJ, McGough EL. Physical exercise and cognitive performance in the elderly: current perspectives. Clin Interv Aging. 2014;9:51-62. doi:10.2147/CIA.S39506. 26. Alzheimer’s Association Recommended Reading https://www.alz.org/media/ documents/books-magazines-rl-2019.pdf. Accessed online Feb 2023. 27. Dong X, Chen R, Simon MA. Elder abuse and dementia: A review of the research and health policy. Health Affairs (Project Hope). 2014; 22: 642-649. Cited in The Gerontologist. 2018; 58(1):S42. 28. Wucherer D, et al. Potentially inappropriate medication in communitydwelling primary care patients who were screened positive for dementia. JAD. 2016;55:691-701. Cited in The Gerontologist. 2018; 58(1):S42. 29. Rapoport MJ, et al. Canadian Consortium on Neurodegeneration in Aging Driving and Dementia Team. A systematic review of intervention approaches for driving cessation in older adults. International Journal of Geriatric Psychiatry. 2017;32:484-491. Cited in The Gerontologist. 2018; 58(1):S42. 30. De Ruiter S, et al. Cognitive impairment is very common in elderly patients with syncope and unexplained falls. J Am Med Dir Assoc. 2017;18:409-413. Cited in Gerontologist. 2018; 58(1):S42. 31. Ali N, et al. Risk assessment of wandering behavior in mild dementia. Int Psychogeriatr. 2016;31:367-374. Cited in The Gerontologist. 2018; 58(1):S42. 32. Fazio S, Pace D, Maslow K, Zimmerman S, Kallmyer B. Alzheimer’s Association Dementia Care Practice Recommendations. Gerontologist. 2018: 58(suppl_1):S41. doi:10.1093/geront/gnx182. Accessed Feb. 2023. 33. Cohen-Mansfield J, et al. Dressing of cognitively impaired nursing home residents: Description and analysis. Gerontologist. 2006;46:89-96. Cited in Gerontologist. 2018; 58(1):S74. 34. Fazio S, Pace D, Maslow K, Zimmerman S, Kallmyer B. Alzheimer’s Association Dementia Care Practice Recommendations. Gerontologist. 2018: 58(suppl_1):S74-87. doi:10.1093/geront/gnx182. Accessed Feb. 2023. Author Julie Hardy, PT, MS, CDP, COS-C Julie is a long-time clinical educator, recently retired from a nationwide home health and hospice provider, with expertise in the areas of dementia and heart failure. She has presented at APTA CSM and her works have been published in the Academy of Home Health’s Quarterly Report, and the Academy of Geriatric Physical Therapy’s Geri-Notes. She has been very active in the APTA serving on district boards, as a delegate in the APTA House of Delegates, and currently on the Home Health Section’s Publications Committee. Page 8 APTA Home Health

Dear Members: For many years, members of APTA Home Health have been receiving the Quarterly Report in their mailbox like clockwork (mostly!) every three months. The APTA Home Health executive committee, along with Dawn Greaves, the editor of this fine publication, have had several conversations about what the Quarterly Report should look like moving forward. In the mini-survey last year, about twenty to thirty percent of members who responded felt strongly that receiving the Quarterly Report on paper in the mail was a vital aspect of their Academy membership. We take that feedback quite seriously. At the same time, many of our members have moved on to other forms of media (non-print), and digest information in new ways. We have heard particularly clearly those who want podcasts—look for that to start later this year. In some cases, our podcasts will be separate from the QR, and sometimes they will supplement information in the QR. Beginning with this issue, members of APTA Home Health will have several months to let us know that you want to continue to receive a print edition of the Quarterly Report. If we do not hear from you by July 15th, 2023, you will no longer receive a print copy of the QR, and beginning with the summer issue you will receive your copy via e-mail as a web-viewable magazine. We will be sending a variety of communications around this choice between now and July 15th, in addition to a QR code and link provided here. Again, if we do not hear from you by July 15th, you will no longer receive a printed copy of the Quarterly Report. Why are we doing this? In addition to giving our membership a choice in how they receive content, we are trying to be better stewards of our environment. The less paper used, the better. Twenty-eight pages times 1,500 copies is, well, a big number. Also, the leadership of APTA Home Health are doing our best to be good stewards of your dues and other funds that we receive. Due to unprecedented increases in paper costs and postage, the Quarterly Report now represents a third of your annual dues. We feel, and we hope that you agree with us, that we can do a better job than that of providing you with value for your dues and your membership. If you have any questions, please do not hesitate to reach out to us at [email protected] or to me directly at pgoldpt@ gmail.com. I thank every one of you for your membership and continued support of APTA Home Health. Phil Goldsmith, PT, DScPT, COS-C President, APTA Home Health SCAN HERE TO OPT-IN Quarterly Report is Moving to Electronic Mode as Primary Distribution with Opt-in to Print Available The Quarterly Report | SPRING 2023 Page 9

Pro bono is the Latin word for “public good.” While it may connote different things to different people, professionals, or situations, there is a consensus that pro bono is the act of dispensing professional services voluntarily at no cost to the recipients with no remuneration.1 Thus, when pro bono is seen as a public health initiative, it is necessary to explore pro bono practice as a means of meeting the healthcare needs of all. As a physical therapist (PT) whose practice focuses on providing care for individuals in their homes, I am acutely aware of the many challenges of our type of practice and the misunderstanding others have about home health physical therapy (HHPT) practice. These challenges include HHPT being undervalued and underpaid despite documented cost-effectiveness.2 Outside the home health practice environment, few healthcare professionals understand the scope of diagnosis and conditions we manage in this environment. Home health practice encompasses acute, post-acute, and preventive care in the person’s home. Most of the care we provide in the home is indeed interventional, but a small percentage is geared towards prevention or early detection for health promotion and wellness. I am a clinician who has had the good fortune of being a home health PT for the past three decades on a part-time basis while working in other settings, such as hospital-based, rehabilitation facilities, and outpatient clinics at the same time. I observed that the common thread in all these practice settings included a prescription for a home exercise program for ongoing maintenance and preventive care. I am also aware that the extent of care provided by HHPT is not always based on the patient’s needs but significantly on the payer’s determination of the patient’s need, which in turn determines how much of our services are reimbursed. I have a passion for the underserved and underinsured among us and feel drawn to making sure individuals that need PT are not left behind in the care they need. This passion is what drew me to volunteerism and what keeps me volunteering. Getting Started Providing pro bono PT care started for me as continuing care visits even when the payor would deny or unauthorize the visit. This means I provided health promotion, maintenance or wellness consult, or community education even when I was not being remunerated. First, I familiarized myself with my state’s PT act regarding pro bono visits. Doing so helped me to establish guidelines and communicate expectations regarding adherence to the home program, cancellations, expectations for continuing care, and discharge criteria. When providing pro bono as “continuing care” in home health, the patient is not responsible for the costs of the care supplied beyond authorized visits by the third-party payors. However, it does not mean less care, different care, or sub-standard care; it just means I continue to see the patient for a few more visits before discharge cost-free. Charity begins at home with local mission I expanded into community volunteer care when I noticed that the Home Health Physical Therapist as a Pro Bono Volunteer by Dr. Olaide Oluwole-Sangoseni, DPT, PhD, MSc, FNAP Page 10 APTA Home Health

health (parish nurse) committee at my church consisted of nurses, physicians, surgeons, dentists, deacons, and pastors. Even though the committee activities included health fairs within the local community and international medical missions, there was no mention of or invitation for a physical therapist. We had many PTs that attended the church. As an academic faculty member and a home health PT, I contacted the church health committee to become a committee member. I offered to conduct a fall screening and prevention day for church and community members on the occasion of “Falls Free” day, a statewide event. They enthusiastically accepted and informed me of their support. Many of them told me they did not realize PTs can conduct a fall screening independently of nurses and physicians. They also did not know that PTs can partake in health fairs since we only work with people who are sick or post-surgery. The event was advertised in the church bulletin and on a local radio event website. Other PTs at the church volunteered their time, skill, and energy, and PT students from my university offered to help with the event. The event focused on fall screening and prevention and posture education. The church is a multi-generational church, and a significant number of members attended and reported that they benefited greatly from the information they received at the event. The church leaders were encouraged by the event’s success, which led to the leadership ensuring that the event became annual and part of the church health fair. The leadership also asked if PT could be part of the international medical mission. International Missions Even though I continue with pro bono activities in my immediate community, I have also been encouraged and taken advantage of the opportunity to establish a partnership with a local non-profit. The collaboration led to my being part of medical missions’ trips to countries in Latin America and East and West Africa. PT is now part of the medical team that provides intervention and preventive care. The care is usually offered at a makeshift “clinic” at a church or school location. Still, some visits are conducted in the home, especially for people who cannot travel to the bigger location. The inter-professional team is usually of six to fifteen people for a trip that may last eight to twelve days, including travel time. The actual care days may range from four to seven consecutive days. The clinic usually runs for 10 to 12 hours but visit days may run longer because of travel time. Although fewer people are seen on home-based visits days because they are usually people with stroke or intense disabilities. The visit time typically consists of actual one-on-one treatment with a heavy emphasis on family/caregiver education. The PT focuses on self-management, positioning, posture reeducation, and home exercise programs with readily available, easy-to-use equipment – such as resistance bands. Exercise therapy for someone with back pain may include assessment and prescription of McKenzie exercises because this program is geared towards self-management.3 Modalities include cryotherapy and water-based activities with written instructions. Pictures and demonstrations augment patient education, which is usually conducted through an interpreter. Locally sourced honey is used for wound care,4 although the debridement kit is brought from the United States. Manual therapy and exercise therapy are preferred approaches in low-resource environments. Reward of unpaid service is intangible and invaluable My favorite experiences encompass utilizing resources from the local environment for physical therapy, teaching stretching and range of motion exercises to someone with a frozen shoulder and observing decreased pain instantaneously. The joy on their face when they realize they can experience some pain relief without medication. One feels fulfillment after teaching “positioning” to someone with a chronic stroke of about seven months using a simple proprioceptive neuromuscular facilitation pattern of the “reach and chop” method5 daily for four days, then seeing them with small but significant improvement with their being able to show off with the help of family members how they are now able to facilitate the paralyzed arm using the stronger arm. Or teaching how to scoot using “ball play” with pediatric-age children with developmental delays due to cerebral palsy or other neurological conditions. Or the immeasurable joy of finding out that new immigrants from Nicaragua could qualify for healthcare in Costa Rica by presenting the HHPT evaluation report generated by me as a PT volunteer. Conclusion Home health physical therapists interested in pro bono volunteering, whether locally or internationally, should consider what interests them most and their unique skill set. Most of our practice in home health is based on our adaptability and creativity. HHPTs are adept at using unconventional objects as therapeutic tools or exercise therapy facilitators. PTs interested in volunteering their time and skill should expand on their understanding of primary care and preventative health approaches. HHPTs conduct home safety risk assessments, and taking vitals is routine for us. Still, we need to delve deeper into educating other professionals on the implications of our findings and how such information can be integrated into care. Usually, home health PTs work alone, but we are good communicators and interprofessional collaborators; this is a strength we need to highlight. Get involved by first identifying areas of need in your community, schools, and worship place, or find out from agencies in your community that serve special populations. Explore whether your home health agency can offer free monthly visits to screen for impairments and educate community members. Partner by reaching out to faith communities and see if you can be of help at a place where they have mission trips. Examine your own finances to see if you can afford international trips. Ask yourself, “are you comfortable setting up a crowdfunding page with the transparency that comes with the purpose of the fundraising?” “Are you comfortable with fulfilling other non-PT roles as needed?” Such as medical aides, food service packing, or distributing lunch bags and backpacks to school kids. These are all types of help that may allow us to get visibility as invaluable health promotion and wellness team members before we can provide our PT. References 1. Goupil K, Kinsinger FS. Pro Bono Services in 4 Health Care Professions: A Discussion of Exemplars. J Chiropr Humanit. 2020;27:21-28. Published 2020 Dec 7. doi:10.1016/j.echu.2020.10.001 2. Collins TL, Yong KW, Marchetti MT, Miller KL, Booths B, Falvey JR. The Value of Home Health Physical Therapy. Home Healthc Now. 2019;37(3):145-151. doi:10.1097/NHH.0000000000000760 3. Physiopedia. McKenzie method. https://www.physio-pedia.com/McKenzie_ Method Accessed March 18, 2022 4. Molan P, Rhodes T. Honey: A Biologic Wound Dressing. Wounds. 2015;27(6):141-151. PMID: 26061489. 5. Al Dajah SB. Soft Tissue Mobilization and PNF Improve Range of Motion and Minimize Pain Level in Shoulder Impingement. J Phys Ther Sci. 2014;26(11):1803-1805. doi:10.1589/jpts.26.1803 The Quarterly Report | SPRING 2023 Page 11

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 mandated the development of a unified prospective payment system (PPS) for post-acute care (PAC). The specific provision in that law “Directs the Medicare Payment Advisory Commission (MedPAC) to: (1) evaluate and recommend to Congress features of PAC payment systems that establish, or a unified PAC payment system that establishes, payment rates according to characteristics of individuals instead of according to the PAC setting where the Medicare beneficiary involved is treated; and (2) recommend to Congress a technical prototype for a PAC prospective payment system.1 ” A company called Research Triangle Institute (RTI) has been working with CMS and the U.S. Department of Health and Human Services (HHS) Assistant Secretary for Planning and Evaluation (ASPE) to develop the prototype. By law, The Medicare Payment Advisory Commission (MedPAC) reports to Congress each March on the Medicare fee-for-service (FFS) payment systems, the Medicare Advantage (MA) program, and the Medicare prescription drug program (Part D). The March 2022 MedPAC report, as mandated by Congress in the Consolidated Appropriations Act of 2021 also included a report on a prototype value-based payment program under a unified prospective payment system (PPS) for postacute care (PAC) services and analyzes the impacts of the prototype’s design.2 This payment system has not yet been implemented. However, MedPAC published a separate Report to Congress on this prototype unified payment system in July 2022. Post-acute care (PAC) providers – skilled nursing facilities (SNFs), home health agencies (HHAs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs) – provide a wide array of services to Medicare beneficiaries. The services range from recuperation and rehabilitation to hospital-level services.2 Authors have documented overlap of types of patients treated in the four settings.3 One study concluded, “because each PAC PPS uses different case-mix measurement items, it has been difficult to compare the populations admitted to each site and the costs and outcomes associated with treatment in the four PAC sites. These issues are further complicated by the different episode patterns, which may include several types of PAC service use during an episode of care and, depending on local availability, may use alternative types of settings for similar services.”2 Despite this overlap in patients, CMS currently uses separate prospective payment systems for each setting which result in very different payments for similar patients. In response to the Congressional mandate for a unified PAC payment system, in 2016 MedPAC recommended design features and concluded that a unified payment system was feasible.4 The recommended design elements include a uniform unit of service (a stay), outlier policies for unusually short or unusually highcost stays, and a common risk adjustment method that would raise or lower payments depending on the patient’s condition, comorbidities, and other factors. The Commission noted one design feature that cannot be uniform: The base payment rate for home health care needs to be lower to reflect this setting’s considerably lower cost. Otherwise, HHAs would be substantially overpaid, and institution-based care would be substantially underpaid. An adjustment would help ensure that placement decisions are based on a patient’s care needs, not payment incentives. After the 2016 MedPAC report, the Commission recommended that a unified PAC PPS be phased in over multiple years and that aggregate payments be lowered to more closely align payments with costs. Because a unified PAC PPS would establish a common payment system, Medicare’s existing setting-specific regulations would need to be aligned before the new PPS is fully phased in. PAC providers would be required to meet a common set of requirements that would establish the basic provider competencies to treat the average PAC patient. Providers opting to treat patients with specialized or very high care needs—such as those who require ventilator support or high-cost wound care—would need to meet a second tier of requirements that would vary by the specialized care need. The basis of provider requirements would thus shift from the setting of care to Med Pac - Unified Payment System and Value-Based Incentive Program for Post-Acute Care Page 12 APTA Home Health

the care needs of the patients a provider opts to treat.4 The MedPAC March 2022 mandated report focuses on a possible value-based payment program that MedPAC feels should be a component of an overall unified payment for post-acute care. This article will provide a summary of the Commission’s work on the key design elements for a PAC value-based incentive program (VIP). The term value-based purchasing (VBP) has become broadly recognized in healthcare reimbursement. At a basic level, VBP refers to a broad set of performance-based payment strategies that link financial incentives to health care provider performance on a set of defined measures in an effort to achieve better value. Both public and private payers are using VBP strategies to drive improvements in quality and to slow the growth in health care spending. CMS has been advancing the implementation of VBP across an array of health care settings in the Medicare program in response to requirements in the 2020 Patient Protection and Affordable Care Act.5 VBP programs have proven to be effective in reducing the overall Medicare spend per beneficiary (MSPB) as noted in the Home Health Value-Based Program (HHVBP) demonstration program that initially included only 9 states. This original HHVBP model resulted in an average 4.6 percent improvement in HHAs total performance scores and an average annual savings of $141 million to Medicare without evidence of adverse risks driven by reductions in unplanned acute care hospitalizations and skilled nursing facility spending.4 As a result, On January 8, 2021, CMS announced the certification of the HHVBP Model for expansion nationwide effective January 1st, 2023.6 The commission feels that a VIP is an essential complement to the implementation of a unified PAC PPS. Typically, VIPs adjust a provider’s Medicare payments based on performance measures tied to clinical quality, patient experience and resource use. The adjustment is then applied to all Medicare payments for the provider during a subsequent fiscal year. Ideally, in a uniform PAC VIP, performance would be compared across settings using the same measures for a core set of measures. However, the Commission realizes that because the payment systems and regulatory requirements are distinct for each setting, current practice patterns vary considerably across settings. Therefore, at least initially, performances under a PAC VIP would need to be compared within each setting using a uniform set of measures. Once practice patterns (such as length of stay) converge, comparisons across settings could be made.4 Relying on the Commission’s principles for quality measurement and their previous work on redesigning Medicare quality incentive programs, the commission report lists key design elements of a PAC VIP. The design elements include: • a small set of performance measures; • strategies to ensure reliable measure results; • a system to distribute rewards with minimal “cliff” effects; • an approach to account for differences in patients’ social risk factors using a peer-grouping mechanism, if necessary; and • a method to distribute the entire provider-funded pool of dollars. The commission report speaks in general terms and acknowledges that policymakers at the Centers for Medicare and Medicaid Services (CMS) will need to fill in gaps and details for full development and implementation.2 Let’s take a detailed look at each of the noted design elements. Small set of performance measures The commission report states that performance measures should be tied to outcomes, patient experience, and resource use. Should all providers be scored on the same set of measures? The report posits that the PAC VIP could score all providers on the same set of performance measures, such as hospitalizations during the stay, successful discharge to community. and MSPB. Alternatively, the report states that the PAC VIP could include a combination of common measures and measures tailored to specific patient populations. The report cautions, however, that using different measures for different providers would limit the ability to compare performance across providers and settings. In the illustrative model described in the report, the commission suggests three measures – all-condition hospitalizations within a stay, successful discharge to community and MSPB. They state these measures are important to beneficiaries and to the Medicare program, have uniform definitions and risk adjustment across the PAC settings, can be calculated using already reported claims data and have considerable variation in performance within each setting, suggesting opportunities for providers to improve and the ability to differentiate among providers. The report suggests that CMS needs to fill in gaps as to the availability of data for two other key performance measures – maintenance or improvement in function and patient experience. The report encourages CMS to explore utilizing existing Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys as the basis for uniform PAC patient experience survey. Strategies to ensure reliable measure results The report emphasizes that the measure results used in the PAC VIP should be reliable, meaning that they should reflect true differences in performance and not be attributable to random variation. The report suggests that key decisions will need to be made. An example is determining the minimum number of stays required for a provider’s performance to be scored. The report states that setting a minimum case count to ensure reliability inevitably means excluding some (low volume) providers from the quality measurement program. It suggests that one way to include as many providers as possible is to pool data across years. Such pooling is consistent with other quality payment program designs and measures.7 System to distribute rewards with minimal “cliff” effects The report suggests that the PAC VIP should reward or penalize a provider using a continuous, prospectively set scale for each measure recognizing every level of performance versus using preset numeric thresholds or cut points. The commission suggests that the performance scale for each measure should be set nationally and apply the same performance scale to all providers. The scale should be prospectively set so providers know how their performance on a measure translates to points before the payment year. The commission acknowledges that providers could be compared within each setting. Should a provider meet some sort of minimum performance standard before it earns a reward? The report suggests that this is a key decision for policymakers. Such a criterion would prevent relatively poor performance from earning a reward for ‘improvement’. It suggests that one way to do this would be to set a performance-to-points scale such that no points are awarded below a minimum threshold. The report does however list several points to consider in support of NOT setting such a threshold such as it would essentially create a cut point between providers who fall just below and those that fall just above; and that it could penalize providers who treat a disproportionate high number of patients at high social risk because they are more likely to The Quarterly Report | SPRING 2023 Page 13

have lower performance on quality measures. Approach to account for differences in patient’s social risk factors using a peer-grouping mechanism, if necessary The report makes it clear that providers that treat a large share of patients with social risk factors may be relatively disadvantaged in a quality payment program because it may be harder for them to achieve good outcomes for their patients. Thus, the report suggests, a quality payment program should account for differences in the providers’ patient populations to counter the disadvantages they could face in achieving good outcomes. Rather than adjusting performance measures for patients’ social risk factors, which can mask disparities in performance, the report suggests that Medicare should adjust payments based on a provider’s performance compared with its peers. With peer grouping, each provider’s performance is compared with providers with similar mixes of patients at high social risk (that is, its “peers”) to determine rewards or penalties based on performance. How should the social risk of a provider’s patient population be defined and measured? The report educates us that The National Academies of Sciences, Engineering, and Medicine (NASEM) outlined considerations to determine whether a social risk factor (measure) should be accounted for in a Medicare quality payment program. The social risk factor should have a conceptual relationship with the outcome of interest (that is, there should be a reasonable hypothesis positing how the social risk factors could affect a Medicare beneficiary’s health outcome) and empirical association (that is, there should be verifiable evidence of an association between the social risk factor and the outcome of interest). This consideration is consistent with the Commission’s principle that the Medicare program should take into account, as necessary, differences in a provider’s patient population, including social risk factors.8 The report clearly emphasizes that social determinants of health have been shown by many authors to impact access to health care and health outcomes. It raises the question about how to appropriately account for differences in the context of a VIP. The report does site evidence that dual eligibility for Medicare and Medicaid remains a powerful predictor of poor outcomes in Medicare’s value-based purchasing (VBP) programs.9 It goes on to state that beneficiary eligibility for Medicare and Medicaid status is readily available in administrative data. Using a provider’s share of fully dual-eligible beneficiaries is consistent with prior Commission work on other VIPs (hospital, Medicare Advantage, and SNF). The report cautions, however, that it is an imperfect measure and more investigation is needed. Method to distribute the entire provider-funded pool of dollars MedPAC is clear in the report that Medicare quality programs should not attempt to achieve Medicare savings but rather should fully distribute the provider-financed pool of incentive payments as rewards and penalties. A PAC VIP would distribute the entire provider-funded pool of dollars within each peer group based on providers’ quality performance during the performance period. The report suggests that a key decision for policymakers is how large potential rewards and penalties need to be to motivate providers to improve performance and avoid poor performance. They suggest that the program could begin with a 2 percent withhold and scale up to a larger withhold amount (perhaps 5 percent) over two or three years. The MedPAC illustrative model and potential results In the illustrative PAC VIP model described in the report, providers gain more points for better performance on the three performance measures. For each measure, points are assigned on a performance-to-points scale from 0 to 10 based on the continuous and setting-specific national distributions of providers’ scores. Providers earn more points for lower within-stay hospitalization rates, lower MSPB, and higher rates of successful discharge to the community. Table 14-1 from the report illustrates how the three measures are converted into PAC VIP points by PAC setting (only a subset of points is shown).2 To illustrate this, focus on the upper left quadrant of the table. The best-performing SNFs, with a hospitalization rate of about 8 percent, would earn 10 points for that measure, while the worst-performing SNFs (hospitalization rate of about 23 percent) would not earn any points for that measure. SNF and HHA settings had the most variable performances for all three measures, so the 10-point scale spans larger differences in performance compared with the range in points for IRFs and LTCHs. For every PAC provider, after the points for each quality measure are determined, the total PAC VIP points are calculated by averaging the points for each measure (0 to 10 points). This calculation effectively weights each measure equally, although policymakers could weight them differently. Page 14 APTA Home Health

Dual Eligibility and potential impact by setting Across PAC settings, the model found that the share of fully dual eligible beneficiaries was not uniformly related to performance. Using a provider’s share of fully dual-eligible beneficiaries treated as the measure of social risk, the report highlights that SNFs and IRFs with high shares of fully dual-eligible beneficiaries had worse performance than those with low shares. The association between performance and this measure of social risk was strong for SNFs and relatively weak for IRFs, as indicated by the size of the negative correlations (Table 14-2). In contrast, for HHAs and LTCHs, as a provider’s share of fully dual-eligible beneficiaries increased, average performance improved, though the relationships were relatively weak. HHAs and LTCHs Because the empirical analysis found that HHAs and LTCHs with higher shares of fully dual-eligible beneficiaries generally had better performance than providers with lower shares, MedPAC modeled a PAC VIP without peer groups. About equal shares of providers gained and lost under a PAC VIP, and the average adjustment was about zero (Table 14-8). Adjustments to payments ranged from –5 percent to 5 percent (after the 5 percent withhold). Regression analysis found that the share of fully dual-eligible beneficiaries was not a significant factor in explaining LTCH performance but was for HHAs: Agencies with higher shares of fully dual-eligible patients had better performance. HHAs with high shares of beneficiaries admitted from the community had worse performance compared with other HHAs.2 Though a conceptual relationship exists between treating more dual-eligible beneficiaries and providers’ poorer performance on the measures, the empirical analysis of the illustrative model found that HHAs’ and LTCHs’ dual-eligible patient shares were positively associated with performance.2 That is, as the share of fully dual-eligible beneficiaries increased, provider performance improved, though the increases were small. Because the empirical finding conflicts both with the conceptual relationship posited for these settings and with the empirical findings in other PAC settings, the report suggests that more work is needed on the definition of social risk and the measurement of performance. MedPAC indicated that further analysis of this issue is beyond the scope of the report but posited some possible influences that should be investigated.2 • Definitions of fully dual eligible vary across states. The differences in Medicaid eligibility likely contribute to differences in the shares of beneficiaries who are fully dual eligible. • Extent of home- and community-based services (HCBS) varies across states. HHAs in states with higher proportions of their Medicaid spending devoted to HCBS had, on average, better performance on each of the PAC VIP measures compared with HHAs in other states. • Small number of providers. Nationwide, there are fewer than 400 LTCHs which may prevent meaningful identification of peer groups. • Community risk factors likely play a bigger role in outcomes for HHAs. Thus, communities’ social risk factors can be particularly important in understanding differences in HHA performance, yet these factors are not captured by the dualeligibility measure. Conclusions The MedPAC report concludes by stating that a PAC VIP involves many steps and will take years to fully implement. First and foremost, the report is strong in the opinion that a PAC PPS needs to be implemented. Additionally, it suggests that regulatory requirements for the four PAC settings need to begin to converge and align. Until then, the report concludes, provider performance can only be compared within settings – and the existing setting-specific value-based purchasing programs will continue.2 Final Notes The June 2019 MedPAC Report to Congress concluded that a unified PAC prospective payment system (PPS) is feasible but would require CMS to work to establish uniform participation requirements across the four major PAC settings – Home Health, IRF, LTCH and SNF. The June 2022 MedPAC Report to Congress provided details on a value incentive program which MedPAC feels is an important component to a unified PAC PPS. The March 2023 MedPAC report to Congress did not provide any update on progress in development of the unified prospective payment system for PAC nor the VIP that would complement such a system. The APTA Government Affairs Department continues to monitor this initiative including attendance at MedPAC meetings and will continue to do so. The next MedPAC mandated Report to Congress to include this topic is due in June 2023. Currently, there are no definitive steps towards actual implementation of a unified PAC PPS. 1. Improving Medicare Post-Acute Care Transformation Act of 2014. HR 4994. Public Law No: 113-185. October 6, 2014. Accessed 1/4/2022. 2. Medicare Payment Advisory Commission. Report to the Congress - Medicare Payment Policy; March, 2022; Chapter 14. https://www.medpac.gov/wp-content/ uploads/2022/03/Mar22_MedPAC_ReportToCongress_v3_ SEC.pdf. Accessed 3/22/2023. 3. Medicare Payment Advisory Commission. June 2019. Report to the Congress: Medicare and health care delivery system. https://www.medpac.gov/document/march2019-report-to-the-congress-medicare-payment-policy/. Accessed 3/29/2023. 4. Arbor Research Collaborative for Health and L&M Policy The Quarterly Report | SPRING 2023 Page 15

Research. Evaluation of the Home Health Value-Based Purchasing Model. Third Annual Report. https://innovation. cms.gov/data-and-reports/2020/hhvbp-thirdann-rpt. Accessed 1/2/2023. 5. Damberg C, Sorbero M, et al. Measuring Success in Health Care Value-Based Purchasing Programs. RAND Health Quarterly. 2014; 4(3):9. https://www.rand.org/ pubs/periodicals/health-quarterly/issues/v4/n3/09.html . Accessed 12/29/2022. 6. CMS Takes Action to Improve Home Health Care for Seniors, Announces Intent to Expand Home Health ValueBased Purchasing Model. January 8, 2021. www.cms.gov/ newsroom/press-releases/cms-takes-action-improvehome-health-care-seniors-announces-intent-expand-homehealth-value-based. Accessed 12/29/2022. 7. Gage B, Morley L, Smith L, et al. Post-Acute Care Payment Reform Demonstration: Final Report, Volume 1 of 4. March 2012. https://www.cms.gov/Research-Statistics-Dataand-Systems/Statistics-Trends-and-Reports/Reports/ Downloads/PAC-PRD_FinalRpt_Vol1of4.pdf. Accessed 3/29/2023. 8. National Academies of Science, Engineering, and Medicine. Accounting for social risk factors in Medicare payment: Identifying social risk factors. Washington, DC: The National Academies Press; 2016. 9. Assistant Secretary for Planning and Evaluation, Department of HHS. 2020b. Report to Congress: Social risk factors and performance under Medicare’s value-based purchasing programs: A report required by the IMPACT Act of 2014. https://aspe.hhs.gov/sites/default/files/private/ pdf/253971/ASPESESRTCfull.pdf . Accessed 3/29/2023. About the Author: Mark Besch, Mark Besch is a Physical Therapist by training and holds a Bachelor of Science degree in Biology and a certificate in Physical Therapy from the University of Iowa. Besch has extensive clinical and operational management experience in a variety of settings, including acute care. He has held positions in operations, clinical supervision, and staff training and development. He currently serves as the Sr Specialist for Government Affairs and Analytics for Aegis Therapies. Prior to his current position, he served as Chief Clinical Officer for Aegis. Since 1987, Besch has specialized in senior health and wellness in home care, long term care and senior housing settings and has broad experience with clinical program development, training and implementation. He is actively involved in Legislative and Regulatory advocacy with ADVION, a trade association whose member companies provide care and services to long-term and post-acute care settings. Besch has done numerous presentations on local, state and national levels. He is a member of the American Physical Therapy Association and its Academy of Geriatric Physical Therapy and Academy of Leadership and Innovation. The Home Health Academy has remained committed to supporting the practice of physical therapy with the publication of resources to assist in service delivery aligned with the highest standards of care. Providing Physical Therapy in the Home” is one such publication that has been a resource for many years. The 3rd edition was published in 2014 and the 4th edition is being finalized and is projected to be available in 2023. The latest iteration will provide greater details and depth as it “Providing PT in the Home,” 4th Edition Coming in 2023 Page 16 APTA Home Health

expands on Physical Therapist’s (PT) and Physical Therapist Assistant’s (PTA) role in administration and case management. Although seasoned clinicians will find this expansion useful, the primary audience for the book remains new PTs entering the home health field. The 4th edition is divided into two main sections. The first half expands on the roles of home health team members, reimbursement, rules specific to home care, safety in the home, documentation, and general assessment. Each chapter includes scenarios of PTs and PTAs working through situations related to the chapter’s main topic. The revised version also addresses new subjects with the introduction of clinical chapters focusing on clinical aspects of the musculoskeletal, neurologic, cardiopulmonary, integumentary, and endocrine systems relative to home health. These chapters provide system and diagnostic-specific clinical pearls and standardized outcome measures to utilize in the home. Clinical case studies are included specific to musculoskeletal, neurologic, cardiopulmonary, and integumentary system impairments commonly seen in the home health setting. Patient-centered care is a cornerstone of healthcare, and the 4th edition emphasizes this by including a chapter on patient rights and the importance of cultural diversity and health literacy in the home health setting. As the US population becomes increasingly diverse, it is crucial for healthcare providers to recognize and respect cultural diversity and inclusion to provide patient-centered care. According to the US Census Bureau, in 2020, there was a 61.1% chance that two people chosen at random would be from different racial and ethnic groups, compared to 54.9% in 2010.1 The authors acknowledge the increasing prevalence of cultural diversity and have therefore incorporated resources aimed at assisting clinicians in navigating cultural differences. These resources can aid healthcare providers in gaining a better understanding of their patients’ distinct requirements while providing care that is culturally sensitive and responsive. In this 4th edition, the authors highlight the importance of patients’ right to make informed health decisions, particularly when faced with limited health literacy. Unfortunately, less than 2 in 10 US adults are considered to have proficient health literacy, according to a 2006 study.2 To address this issue, the book provides several examples of tools that can be used to determine patients’ health literacy, including Ask Me 3, REALM (Rapid Estimate of Adult Literacy in Medicine), The Newest Vital Sign, SAHL-E Test (Short Assessment of Health Literacy-English), and the Single Item Literacy Screen. These tools can help clinicians communicate more effectively with patients who may have limited health literacy, ensuring that patients understand their treatment plans and instructions. By emphasizing the importance of health literacy and providing tools to assess it, the 4th edition aims to improve patient outcomes and promote patient-centered care for individuals with diverse health literacy levels. In this edition, the authors have included a chapter that will facilitate the role of medication review performed by the PT in the home. Here is an excerpt from that Chapter. Medications In this ever-evolving healthcare setting, physical therapists assume a key role in primary care. Oftentimes, the homecare patient’s first contact may be with a PT. The Guide to PT Practice states that the PT initial evaluation must be thorough and include a review of systems, objective tests and measures, and a patient’s medical history, including a review of current medications.3 The Joint Commission outlines five patient safety goals, two of which relate to medication safety–use medicines safely and prevent patients from falling.5 In reviewing medications, a PT can analyze if the patient is taking any medication that makes him/her feel weak, dizzy, or sleepy. The Joint Commission recognized the importance of patients following an appropriate medication regimen and the value of the homecare worker in identifying negative side effects of medications that affect patient safety and function.4 Due to an aging population and an increased number of medications available to treat certain conditions, polypharmacy in homecare patients is commonplace.6 While polypharmacy may be appropriate for some patients with multiple comorbidities, it can lead to adverse drug events, drug interactions, decreased adherence to taking medications prescribed, increased risk for falls, cognitive disruption, and mortality.5 Physical therapists play a key role in helping patients work toward adherence with their medication regimen and recognizing medication issues when they arise. Patients should have a current list of prescription medications, and it should include the following details: • Dosage • Timing schedule • Route of administration (e.G., Injection, by mouth) • Indications • Special instructions related to how the medication is taken (e.G., Thyroid medication that must be taken a half hour prior to eating) or when to hold the medication (as in the case with bp medications when a patient’s readings are too low) • Any supplements, creams, eye/ear drops, and over-the-counter medications the patient is using • Any changes in the medications from one visit to the next The medication list from the referring physician or facility should match information on the bottles present in the home. If there is a discrepancy between the medication list and the prescription label(s), then the clinician in the home needs to know how to rectify this inconsistency. In some states, a PT would need to reach out to the nurse or case manager covering the case and in other states, the PT should call the physician directly for clarification. If there are recent medication adjustments, these changes should be well understood by the patient and the PT should conference with others on the care team if appropriate. Collaborating with patients on solving some of their concerns with taking specific medications will help with better medication compliance. During a medication review the following items should be discussed with all patients: • Dosing guidelines as set forth by physician(s) • Any patient discontinued medications, why? - medication cost - pills too large to swallow - intolerable side effects Other safety considerations: • Medications should be stored appropriately, in the refrigerator if needed, or in a cool, dry location, as is common for most drugs. - Note that some prescriptions need to be kept out of the light and should be kept in a suitable container. • Check drug labels for any special instructions related to their storage or use. The Quarterly Report | SPRING 2023 Page 17

• Medications should be out of reach of those who should not have access to them. • Expired medications should be disposed of properly. • If a patient has an injectable medication, appropriate disposal of sharps should be done by using a container made specifically for sharps or a hard, plastic receptacle. For quick reference the Beer’s Criteria has been added to the 4th edition. In keeping with the practice of the past edition, case scenarios are provided. This is a case scenario from the book highlighting the practice of drug review and medication reconciliation using the Brown Bag Review strategy. Case Scenario: Tom is performing a Physical Therapy Start of Care (SOC) admission to home health services and has reviewed the patient’s medical record. Tom uses the Brown Bag Review strategy, so when calling to schedule the admission visit, he also requests that the patient have all prescribed and over-the-counter medications available for review. Tom expresses gratitude to the patient for collecting the prescribed medicines and over-the-counter products upon arriving at their home. He proceeds to conduct a thorough review of the drug regimen, with each bottle, eye drop, injectable, lotion, inhalant, and supplement placed in a bag on the table. To begin, Tom ascertains the patient’s diagnosis and reason for hospitalization from both the electronic medical record (EMR) and verbal communication with the patient. He then uses his knowledge of pharmacology and a drug reference to determine which medications correspond to which diagnosis. Although the nursing staff is responsible for monitoring reactions, interactions, and the efficacy of therapy during the drug regimen review, Tom remains vigilant in identifying any instances of non-adherence or significant side effects. Despite his awareness that the registered nurse (RN) will review the medications entered in the EMR , he takes it upon himself to note any discrepancies.6 • Tom enters the following into the EMR for the nurse to review: • Medications: (New)Albuterol BID 1.25mg/ 3 ml, COPD • (New) trimethoprim/sulfamethoxazole (Bactrim) BID 160/800mg x 15 days, UTI • (Unchanged) Insulin, Diabetes • (Unchanged) Metoprolol QD in AM 50mg, HTN • (Unchanged) Systane QD 2 drops in each eye, Dry eyes During the Brown Bag review, Tom initiated the medication reconciliation review by posing three crucial questions to the patient: the purpose of each medication, the correct dosage, and when to take them. He started by asking the patient about a small plastic container of albuterol, inquiring about its purpose. The patient informed Tom that it was prescribed for COPD during their hospital stay and that he was to use it twice a day with a nebulizer. However, the patient struggled to remember how to use the nebulizer, resulting in irregular medication adherence. Tom then examined the patient’s other medications, handing them a bottle of Bactrim and posing the same three questions. The patient disclosed that they stopped taking the medication prescribed for their urinary infection after their symptoms subsided. Tom also inquired about the insulin that the patient had been using for years to manage their diabetes, to which the patient admitted that they only took it once a day and did not check their blood glucose levels regularly. The patient also used eye drops for dry eyes and took metoprolol every morning for blood pressure management, although they occasionally skipped the dose due to experiencing dizziness when standing up from the sofa. After a comprehensive medication review, Tom identified several issues that required further attention. To address these concerns, he contacted the agency and used SBAR (Situation, Background, Assessment & Recommendation) techniques to communicate the problems with the patient’s medication management. The agency agreed to obtain an order from the physician for an RN to provide education and medication management during a home visit. Moving forward, Tom was diligent in monitoring the patient’s adherence to all medications. He also reviewed the proper use of the nebulizer with the patient and developed a treatment plan for the patient’s orthostatic hypotension. Overall, Tom took proactive steps to address the patient’s medication issues and ensured that they received the necessary education and support to manage their medications effectively. By collaborating with other healthcare providers, Tom delivered comprehensive care that met the patient’s specific needs. The authors are currently working to finish the fourth edition, and anticipate that it will provide valuable insights for home clinicians. They are excited about the prospect of publishing the new edition later this summer, online and in print. References 1. Racial and Ethnic Diversity in the United States: 2010 Census and 2020 Census. United States Census Bureau. Updated August 12, 2021. Accessed March 11, 2023. https://www.census.gov/library/visualizations/interactive/ racial-and-ethnic-diversity-in-the-united-states-2010-and-2020-census.html 2. Kutner M, E G, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy(NCES 20016- 483). US Dept of Education; 2006. 3. Guide to Physical Therapy Practice 3.0. American Physical Therapy Association. May 16, 2022. Updated 2014. http://guidetoptpractice.apta.org/ 4. 2022 National Homecare Patient Safety Goals. Joint Commision. Accessed March 16, 2022. https://www.jointcommission.org/standards/nationalpatient-safety-goals/home-care- national-patient-safety-goals/ 5. Davies LE, Spiers G, Kingston A, Todd A, Adamson J, Hanratty B. Adverse Outcomes of Polypharmacy in Older People: Systematic Review of Reviews. J Am Med Dir Assoc. Feb 2020;21(2):181-187. doi:10.1016/j.jamda.2019.10.022 6. Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies. Federal Register. Updated 01/13/2017. Accessed 3/11/2023, https://www.federalregister.gov/documents/2017/01/13/2017-00283/ medicare-and-medicaid-program-conditions-of-participation-for-homehealth-agencies About the Authors The 4th edition of the publication is coedited by Daniel Huddart and Celeste Cheek. Daniel Huddart is an assistant professor at Touro University in Nevada and has been practicing home physical therapy for over 30 years. He earned his bachelors in PT from the University of Missouri Columbia in 1992, APTA board certification in Geriatrics in 2005, and DPT from the College of St. Scholastica in 2014. Additionally, he holds advanced credentials in home health. Page 18 APTA Home Health

Celeste Cheek, PT, DPT, is currently a home health physical therapist for Mountainview Home Health in Yakima, WA. Celeste graduated with a B.S. in Science from Langston University in 2000 and earned her transitional Doctorate in Physical Therapy (tDPT) from Langston University in 2015. In 2018, she was appointed to the APTA Home Health Section Practice Committee, and served as co-managing editor and contributor to the recently published book Home Health Toolbox II: Tests and Measures for Use in the Home. She also received the Excellence in Home Health Leadership award in 2020 for her contributions to the Home Health Section. Celeste is currently a contributor and co-managing editor to the upcoming revision of Providing Physical Therapy in the Home, Volume 4. In her personal time, Celeste enjoys traveling, writing, and creating art. and IHHC with a webinar and a lunch and learn, reviewing the most current and up-to-date literature and research at the time, on Assessing and Treating Post-Acute Sequelae of SARS-CoV-2 Infection related to fatigue. She is also currently assisting ICAHN with recent educational activities regarding (PASC)-Post Acute Sequelae of SARS-CoV-2 COVID Long Haulers and as an ICAHN Recovery Program Committee member. In 2018, Dr. Ganson began undergoing LAMP certification through HPA-Health Policy and Administration the Catalyst Section of the APTA. She successfully completed the standardized and evidence-based curriculum in Leadership Development. She completed the ACHH-Advanced Competency in Home Health through APTA Home Health on March 6, 2018-March 31, 2023. She recently renewed her ACHH certification by taking the relevant advanced competency education required. She believes this has helped keep her clinical skills current and practicing at the highest level of her PT licensure within the home health setting. Dr. Ganson became an Illinois Homecare & Hospice Council (IHHC) member in 2002 and an IHHC Board Member in 2020, an IHHC Western District Director, and an IHHC Co-Chair of the Rehab. Committee. She was recognized at one of the annual IHHC Conferences as a top responder to advocacy in the state of Illinois for IHHC. Dr. Ganson received her Executive Master’s in Business Administration in Leadership from Bradley University Foster College of Business Administration in 2004. She is a Credential Clinical Instructor through the APTA since 2012. She has attended the National Association of Home Care & Hospice (NAHC) Annual Conference to seek out the most current and up to date information to share with her Rehabilitation Services Department team members in regard to Review Choice Demonstration-RCD, Pre-Claim Review-PCR, Patient Driven Groupings Model-PDGM, and now Value-Based Purchasing-VBP. Suzanne Havrilla, PT, DPT, Board Certified in Geriatric Physical Therapy, is the Acting Interim Director of Home Support (private duty division) and the Assistant Director of Home Health Services (adult home health) for the Johns Hopkins Home-Based services division (Johns Hopkins Home Care Group). She has been with Johns Hopkins for 18 years, 15 of those years in a management role. She has received her Geriatric Clinical Specialist certificate from the American Board of Physical Therapy Specialists and has over 25 years of experience treating geriatric patients in home care and managing a multi-disciplinary home health team. She also received her OASIS Certification in 2012, 2015. She manages 2 research into practice programs- CAPABLE and a Memory Care Program modeled after the MIND at Home model. A member of the APTA since 1981, Suzanne believes in the important role physical therapy plays in the lives of the elderly in the community. She stays active on the APTA Home Health s listserv, is involved in a rehab managers group across Johns Hopkins Medicine (JHM) and keeps home health rehab represented at all levels across JHM. For the past 6 years, Suzanne has served on the Board for the PTA program at Howard County Community College (HCCC). She was instrumental in starting student programs between Johns Hopkins Home Care and HCCC as well as, PT students from University of Maryland, OTA students from CCBC and OT students from Towson University. Dr. Andrew Morgan, PT, DPT, MBA, COS-C, is a physical therapist with over 20 years of clinical experience. He received his Bachelor of Science of Education from Baylor University in 1999 and his Masters and Doctorate degrees in Physical Therapy from UT Health San Antonio in 2002 and 2013 respectively. Andrew also holds a Master of Business Administration from UT San Antonio. Andrew works for Homecare Dimensions under the WellMed and United Health Group corporate umbrellas as the alternate administrator over Texas and the director of therapy services over Texas and Florida. He is a regular contributor to WellMed radio and presents at WellMed senior centers in Texas, discussing such topics as fall risk reduction in the elderly population and the importance of geriatric strength training. Andrew is a dynamic instructor who teaches multiple continuing education courses for Summit professional education. In 2022, he ran a successful fundraising campaign, becoming the Leukemia and Lymphoma Society South Texas Man of the Year. Kandy Ortgies, PTA, received her AAS from the physical therapist assistant program at Kirkwood Community College in Cedar Rapids, Iowa in 1996. She worked for St Luke’s Hospital in Cedar Rapids, Iowa for 15 years in acute care and inpatient and outpatient rehab. From 2011 to 2019 she was a PTA for UnityPoint at Home - Home Care. She has been an instructor for the PTA program at Kirkwood Community College in Cedar Rapids, Iowa 2003 to 2019 teaching Intro to PTA, Rehab for Medical Conditions and Fundamentals for PTA. Kandy earned her Certificate of Advanced Competency in Home Health in September of 2018. She served as faculty for the Certificate of Advanced Competency in Home Health for the PTA from 2018 to 2021. Since May of 2019, she has been the Home Care Consultant for St Luke’s Hospital. Seeing the worry melt from her acute care patient’s faces as she tells them she will arrange home care services to enable them to stay in their homes as long as possible, is a bright spot in her day. Continued from Page 2 The Quarterly Report | SPRING 2023 Page 19

The Impact of Assistive Technology on Quality of Life of HomeDwelling Individuals with Parkinson’s: A Scoping Review Authors: Alexa Cardella, SPT, Tracey L. Collins PT, PhD, MBA, BoardCertified Specialist in Geriatric Physical Therapy, Sarah Gordon, SPT Abstract Text: Purpose/Hypothesis: To analyze the impact of assistive technology on quality of life (QoL) of home-dwelling individuals with Parkinson’s Disease (PD). Methods: A literature search of ProQuest, Cochrane, PubMed, and EBSCO was conducted using search terms: (“Assistive technology” OR “assistive technologies” OR “assistive device” OR “assistive devices” OR “technology” OR “technologies” OR “smart home” OR “smart homes” OR “home automation” OR “domotics” OR “smart technology”) AND (home OR “home environment” OR “home-based” OR “home health”) AND (Parkinsons OR “Parkinson’s Disease” OR “Parkinson Disease” OR “parkinsonism”) AND “quality of life”. Search limits: published 2012-2022; peer-reviewed (ProQuest, EBSCO); “anywhere except full text” (ProQuest); “title abstract keyword” (Cochrane). Selection criteria included: home-dwelling people with Parkinson’s (PwP); assistive technology that can be used at home daily; QoL outcomes (physical/ cognitive); qualitative or quantitative studies. Each study was independently evaluated for methodological quality by 2 blinded reviewers using the Mixed Methods Appraisal Tool. Results: A total of 156 articles were screened for eligibility. Six met selection criteria, including mixed methods (n=1), quantitative (n=4), and qualitative (n=1) studies. Levels of evidence were scored as a percentage of quality criteria met, from 60% to 100%. Sample sizes ranged from 13 to 290 subjects (n=452). Interventions spanned between 1 sitting and 1 year, incorporating home monitoring devices (n=3) or home assistive devices (n=3) via focus groups, patient monitoring, simulated training, and a survey. The primary outcome measure was QoL. Using home assistive devices resulted in statistically significant increases in QoL (p<0.001; z=-3.92). Though speech was a reported issue, participants in a study noted success with voice assisted technologies (VAT); 63.5% of participants in another study used the speech-to-text functions to cope with symptoms, like tremors. Using home monitoring devices was associated with a statistically significant improvement of walking (p=0.02) and 79.9% of participants in a study either strongly agreed or agreed that it helped improve mobility, especially during freezing of gait. Conclusions: Evidence supports the use of assistive technology including VAT, home automation and home monitoring devices in the home setting, promoting QoL for PwP. Limitations include the use of simulations and variability in treatment parameters. Further research is needed to measure the impacts home-based assistive technology has on PwP’s QoL and on PD-related symptoms, as well as to identify which devices are ideal. Clinical Relevance: Assistive technology is an option of support for PwP struggling at home due to their PD-related symptoms impacting QoL. Physical therapists, particularly those in the home health setting, should be knowledgeable of these supportive devices, as they can be involved in introducing and educating their patients on these options. References: 1. Duffy O, Synnott J, McNaney R, Brito Zambrano P, Kernohan WG. Attitudes towards the use of voice-assisted technologies among people with Parkinson Disease: findings from a web-based survey. JMIR Rehabil Assist Technol. 2021; 8(1): e2306. doi: 10.2196/23006 2. Latella D, Grazia Maggio M, Maresca G, Andaloro A, Anchesi S, Pajno V, De Luca R, Di Lorenzo G, Manuli A, Calabro RS. Effects of domotics on cognitive, social and personal functioning in patients with Parkinson’s disease: a pilot study. Assist Technol. 2021. doi: 10.1080/10400435.2020.1846095 3. Amini A, Banitsas K, Young WR. Kinect4FOG: monitoring and improving mobility in people with Parkinson’s using a novel system incorporating the Microsoft Kinect v2. Disabil Rehabil Assist Technol. 2018; 14(6): 566-573. doi: 10.1080/17483107.2018.1467975 4. Motolese F, Magliozzi A, Puttini F, Rossi M, Capone F, Karlinski K, Stark-Inbar A, Yekutieli Z, Di Lazzaro V, Marano M. Parkinson’s Disease remote patient monitoring during the COVID-19 lockdown. Front Neurol. 2020; 11(567413). doi: 10.3389/fneur.2020.567413 Home Health Academy Platforms CSM 2023 Page 20 APTA Home Health

5. Cubo E, Mariscal N, Solano B, Becerra V, Armesto D, Calvo S, Arribas J, Seco J, Martinez A, Zorrilla L, Heldman D. Prospective study on cost-effectiveness of home-based motor assessment in Parkinson’s Disease. J Telemed Telecare. 2017; 23(2): 328-338. doi: 10.1177/1357633X16638971 6. McNaney R, Tsekleves E, Synnott J. Future opportunities for IoT to support people with Parkinson’s. CHI. 2020. doi: 10.1145/3313831/3376871. Rehabilitation Outcomes Among Frail Older Adults in the United States Authors: Joanna Zhao Ye, SPT, Odessa Rene Addison, PT, DPT, PhD, Elizabeth Parker, PhD, RD, Brock Beamer, Jason Raymond Falvey, PT, DPT, PhD Abstract Text: Purpose/Hypothesis: Current rehabilitation care paradigms are not well aligned with the needs of frail older adults, who are at elevated risk of adverse health outcomes and disability. The purpose of this study was to understand how frailty impacts rehabilitation outcomes during an episode of care. We hypothesized frail older adults would be more likely to report poor rehabilitation outcomes and have a greater likelihood of exhausting insurance benefits during episodes of care. Number of Subjects: This study used data from Round 5 of the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries aged 65 years and older in the United States. Our sample consisted of 1003 community-dwelling older adults who completed an episode of rehabilitation care during the survey year, including home care, outpatient care, and inpatient care. Materials and Methods: We used a validated 5-item NHATS Fried Frailty scale to categorize patients as frail (≥3/5) or non-frail (<2/5). We then evaluated the association between frailty status and 3 key outcomes: 1) Patient-reported achievement of rehabilitation goals, 2) Patient-reported functional improvement during rehabilitation episode, and 3) Exhausting rehabilitation insurance benefit during the last episode of care. Last, we estimated adjusted relationships between frailty and rehabilitation outcomes using multivariable, survey-weighted logistic regression models. Results: Nearly 1 in 3 older adults who received rehabilitation care in the past year were frail. Compared to non-frail participants, the frail participants in our sample were generally older, had more comorbidities and higher rates of dementia, and lastly used more home care rehabilitation. In models adjusted for age, sex, comorbidities, and Medicaid eligibility, the odds of a frail older adults failing to meet their rehabilitation goals were 92% higher (OR=1.92, 95% CI 1.35 to 2.70) than non-frail older adults. In addition, frailty was significantly associated with lower probability of functional recovery and a higher likelihood of exhausting insurance benefits during rehabilitation episodes. A sensitivity analysis restricting to patients who used home and community-based rehabilitation yielded comparable results. Conclusions: Frail older adults have poorer outcomes when receiving rehabilitation care, partly driven by exhaustion of insurance benefits that may leave recovery needs unmet. Reforms in clinical practice and payment policies are needed to better serve the needs of frail older adults. Clinical Relevance: Physical therapy plays a powerful role in mitigating the effects of frailty to prevent transitions towards declining function and independence. Since frail older adults are more likely to receive rehabilitation services in a home health setting compared to non-frail rehabilitation users, home health clinicians have the potential to help reduce frailty-related disparities in rehabilitation outcomes. References: 1. Ferrante LE, Pisani MA, Murphy TE, Gahbauer EA, Leo-Summers LS, Gill TM. The Association of Frailty With Post-ICU Disability, Nursing Home Admission, and Mortality: A Longitudinal Study. Chest. 2018;153(6):1378-1386. doi:10.1016/J.CHEST.2018.03.007 2. Freedman VA, Kasper JD. Cohort Profile: The National Health and Aging Trends Study (NHATS). International Journal of Epidemiology. 2019;48(4):1044. doi:10.1093/IJE/DYZ109 3. Hartley P, Adamson J, Cunningham C, Embleton G, Romero-Ortuno R. Clinical frailty and functional trajectories in hospitalized older adults: A retrospective observational study. Geriatr Gerontol Int. 2017;17(7):1063-1068. doi:10.1111/ GGI.12827 4. Heyward J, Jones CM, Compton WM, et al. Coverage of Nonpharmacologic Treatments for Low Back Pain Among US Public and Private Insurers. JAMA Network Open. 2018;1(6):e183044-e183044. doi:10.1001/ JAMANETWORKOPEN.2018.3044 5. Kojima G. Frailty as a Predictor of Nursing Home Placement among Community-Dwelling Older Adults: A Systematic Review and Meta-analysis. Journal of Geriatric Physical Therapy. 2018;41(1):42-48. doi:10.1519/ JPT.0000000000000097 6. Merchant RA, Morley JE, Izquierdo M. Exercise, Aging and Frailty: Guidelines for Increasing Function. Journal of Nutrition, Health and Aging. 2021;25(4):405-409. doi:10.1007/S12603-021-1590-X/FIGURES/3 7. Xu W, Li YX, Hu Y, Wu C. Association of Frailty with recovery from disability among community-dwelling Chinese older adults: China health and retirement longitudinal study. BMC Geriatrics. 2020;20(1):1-7. doi:10.1186/ S12877-020-01519-6/TABLES/5. Clinician Perceptions on the Keys to Implementing Effective Telehealth Authors: Leigh-Ann Alexandra Bramble, PT, DPT, Jay Tadashi Mizuta, PT, Scott Kinkead Siverling, PT, DPT, Karen Ann Juliano, PT Abstract Text: Purpose/Hypothesis: This research study aimed to better understand physical therapist perceptions on telehealth (TH) physical therapy: benefits, challenges, and needs. Number of Subjects: 48 rehabilitation clinicians with a range of experience with TH at Hospital for Special Surgery (HSS). Materials and Methods: An electronic survey regarding clinician perceptions of TH was sent to the rehabilitation staff at HSS (N=234). This survey contained fixed and open-ended questions. Completion was voluntary and anonymous. Thematic analysis was used to explore the open-ended survey The Quarterly Report | SPRING 2023 Page 21

responses. Researchers independently coded responses to each question then developed consensus, refined and operationally defined each code. This was done in an iterative fashion until all data were coded and no new codes emerged. Data was recoded with final codes. Throughout this consensus driven process, discrepancies, alternative explanations, and negative cases were explored. Codes, categories and themes were continually revised as data were explored. Peer reviewers enhanced trustworthiness by: independently exploring the data, reviewing the coded data, checking for accuracies, biases and missing data and reviewing themes as they emerged. To optimize trustworthiness and minimize researcher bias we used: prolonged engagement with the data; triangulation of researchers; peer reviewers; ongoing analysis, interpretation, and consensus development until saturation was achieved. Results: Four themes were identified: 1) TH Benefits the patient, the clinician, and the organization; 2) clinical, technological, environmental, and regulatory challenges must be addressed to implement TH effectively; 3) TH clinicians require specific personal, clinical, and technological knowledge, skills, and attributes; 4) Effective TH sessions consider patient characteristics and needs, session type, and home environment. Conclusions: Providing care via TH has a unique set of benefits for patients, clinicians, and organizations; however, it is not as easy as turning on a camera. This mode of service delivery presents its own unique set of challenges. Sample strategies to overcome these challenges include: identifying patient needs and resources to determine appropriate patients and modes of service delivery (virtual, hybrid) for the highest quality care; providing educational opportunities for clinicians to learn how to perform efficient examinations and movement assessments in a virtual environment; using high level education and communication strategies; providing staff training on the use of and troubleshooting technological challenges for both patients and providers. Clinical Relevance: TH saw widespread use during the Covid-19 pandemic and is likely to continue as a mode of care delivery. This study explicates physical therapist perspectives of TH physical therapy to enable best practices for safe, proficient, and high-quality clinical care for the patient and further guidance to leverage the TH setting for therapeutic advantage and clinical excellence. References: 1. Phimphasone-Brady, P., et al. “Clinician and staff perspectives on potential disparities introduced by the rapid implementation of telehealth services during COVID-19: a mixed-methods analysis.” Translational behavioral medicine 11.7 (2021): 1339-1347. 2. Davies, Luke, et al. “An international core capability framework for physiotherapists to deliver quality care via videoconferencing: a Delphi study.” Journal of Physiotherapy 67.4 (2021): 291-297. 3. Fritz, Julie M., et al. “Outcomes of Telehealth Physical Therapy Provided Using Real-Time, Videoconferencing for Patients with Chronic Low Back Pain: A Longitudinal Observational Study.” Archives of Physical Medicine and Rehabilitation (2022). 4. Grundstein, M. Jake, et al. “The Role of virtual physical therapy in a post– pandemic world: Pearls, pitfalls, challenges, and adaptations.” Physical Therapy 101.9 (2021): pzab145. 5. Scott Kruse, Clemens, et al. “Evaluating barriers to adopting telemedicine worldwide: a systematic review.” Journal of telemedicine and telecare 24.1 (2018): 4-12. 6. Malliaras, P., et al. “‘It’s not hands-on therapy, so it’s very limited’: telehealth use and views among allied health clinicians during the coronavirus pandemic.” Musculoskeletal Science and Practice 52 (2021): 102340. The Cost of Home Health Care: Should PT’s be More of a Team Player? Authors: Denise Gobert, PT, PhD, Keri Michelle Jackson, PT, Shannon Williams, PT, DPT, Med, Debra Rone McDowell, PT, PhD, Abstract Text: Purpose/Hypothesis: Hospital readmissions for patients with Diabetes Mellitus (DM) presents continued healthcare challenges in terms of patient recovery and medical expenses. Limited evidence has addressed rehospitalization trends as related to home health rehabilitation services for patients with DM. Admissions to home health care in Texas is most often performed by nursing professionals which possibly limits rehabilitation home health (RHH) services utilization. The purposes of this study were 1) to explore the Outcomes and Assessment Information Set (OASIS-C2) database sponsored by the Centers for Medicare and Medicaid Services (CMS) to characterize hospital readmissions as related to diabetic diagnosis and 2) to determine if the medical professional assessor at home health services (HHS) is related to RHH services utilization. Number of Subjects: The sample size was 117,044,355 medical cost ratio (MCR) episodes of care for 61% females with an average age of 77yrs (SD = 11.94), and 37.56% with DM. Materials and Methods: This was a retrospective cohort-comparison research design for T2DM Medicare beneficiaries who receive rehabilitation home healthcare during the first 60 days after discharge from hospital inpatient care. A database request was made and approved for a randomized sample data set of 5 million CMS beneficiaries including the OASIS-C2, Base Claims and Revenue Center databases for 2017. Data analysis utilized SAS Analytics Software (vs.9.4) and JMP Pro Statistical Software (vs. 15.0) for descriptive statistics. MANOVA was computed to explore group differences while predictive forest regression modeling was calculated to describe and model predictive trends in the data. Variables of interest included beneficiary demographics, T2DM diagnosis, start of care (SOC), clinical assessor at Home Health Services (HHS) admission, number of RHH visits, length of care, emergent conditions, rehabilitation services vs. no rehabilitation services, and hospital readmissions as discharge (DC) disposition (hospitalization vs. no hospitalization). Results: SOC assessments were primarily performed by registered nurses (75%) with physical therapists second most often at 23%. The average number of therapy visits were 16.0 (SD = 11.94), and there were 75,280 hospital readmissions (32% due to emergent conditions, 5% due to falls). Rehabilitation number of visits and age were significant predictors of DC disposition explaining 25% of variance (p < .0001) while T2DM was a significant covariant to explain an additional 12% (p < .0001). Conclusions: Results demonstrated that patients with a diagnosis of T2DM had significantly more hospital readmissions from HHS. Page 22 APTA Home Health

Additionally, patient admissions to HHS were primarily performed by a nurse rather than a RHH professional. This was directly related to RHH services utilization and DC disposition. Clinical Relevance: Project results suggest that early inclusion of rehab services is significantly related to type of disposition factors predisposing hospital readmissions with patients diagnosed with T2DM. References: 1. U.S. Department of Health and Human Services Centers for Disease Control (CDC). National diabetes Statistics Report 2020: Estimates of Diabetes and Its Burden in the United States. Accessed 3/24/2022 at https://www.cdc.gov/ diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf 2. Falvey JR, Murphy TE, Gill TM, Stevens-Lapsley JE, Ferrante LE. Home Health Rehabilitation Utilization Among Medicare Beneficiaries Following Critical Illness. J Basic Clin Physiol Pharmacol. 2020; 68(7):1512-1519. doi: 10.111/jgs.16412 3. Palermi S, Iacono O, Sirico F, Modestino M et al. The complex relationship between physical activity and diabetes: an overview. J Basic Clin Physiol Pharmacol. 2021 Sep 29. doi: 10.1515/jbcpp-2021-0279. Epub ahead of print. PMID: 34592073 4. Collins T, Yong K, Marchetti M, et al. The value of home health physical therapy. home HEALTHCARE Now. 2019; 37(3):145-151. Doi:10.1097/ nhh.0000000000000760 5. Bick I, Dowding, D. Hospitalization risk factors of older cohorts of home health care patients: A systematic review. Home Health Care Services Quarterly. 2019;38(3):111 152. DOI:10.1080/01621424.2019.1616026. The Impact of COVID-19 Pandemic on Trends in Home Health Physical Therapy Authors: Sarah Gordon, SPT, Tracey Collins, PT, PhD, MBA, GCS Background: In March of 2020, the World Health Organization declared COVID-19 a pandemic and hospital admissions began to decline due to cancelation of elective procedures and patient deferral of health services.1,2 For patients in acute-care settings, an emphasis was placed on home care discharge due to the rise in COVID-19 related illnesses/deaths that were being reported in post-acute care (PAC) facilities and overall health care limitations due to shortages of personal protective equipment and staffing.1,3,4 The implications of the pandemic on the disruption of all health care services and quality of patient rehabilitation has yet to be determined.2,5 Purpose/Hypothesis: The purpose of this literature review is to identify the impact of the COVID-19 pandemic on trends in home health physical therapy in adults. Materials and Methods: A literature search was conducted in CINAHL, PubMed, ProQuest, and Wiley using the following search terms: (COVID OR “COVID-19 Pandemic”) AND (“physical therapy” OR PT) AND (“home health” OR “home-based” OR “home-based rehabilitation”) AND (treatment OR intervention OR utilization) AND trend. Search limits: peer-reviewed articles, English, human subjects, and publication between 2019-2022. Selection criteria: adults (18+) and trends in home health during the COVID-19 pandemic. Results: Two articles met the selection criteria. The first article examined national multi-payer claims data sets for Jan. 2019 to Oct. 2020 for trends in post-hospital discharge locations and spending for adults (65+). In 2020, the percentage of patients discharged home with home health increased from 20% (2019) to 21% in Oct. 2020, however not significant. By Oct. 2020, the use of home health increased to 72% of the pre-pandemic rate. Total monthly spending for home health declined 41% from $28 million/month in 2019 to $16.5 million/month in Oct. 2020. However, as a percentage of all post-acute care spending, home health increased from an average of 26% in 2019 to 27% in Oct. 2020. The second article compared data of publicly funded home care in Ontario, Canada from March 2020-Sept. 2020 with data from March 2019-Feb. 2020 for adults (18+). At the start of the pandemic, admissions into home care decreased by 10.2% in March and 37.8% in April. During the pandemic, physical therapy services declined by 11.9% in March and 40.2% in April. For patients with potential rehab needs, those receiving therapy services decreased from 21.1% pre-pandemic average to 15.4% in April 2020. Average amount of therapy also decreased from 1.8 hours/month to 1 hour/month in April 2020. For patients with high rehab needs, those receiving therapy services decreased from 64.9% pre-pandemic average to 60.4% in April 2020. Average amount of therapy also decreased from 2.6 hours/month to 2.3 hours/month in April 2020. Conclusions: There is limited research available relevant to the impact of the COVID-19 pandemic on trends in home health physical therapy in adults. The lack of evidence found in this literature review indicates the need for further research. Clinical Relevance: The shifts in physical therapy home health services during the COVID-19 pandemic may have lasting effects on the recipients. Dependent on severity and presentation, some patients may not have received sufficient care, resulting in worse outcomes and increased caregiver burden. References: 1. Sinn C-LJ, Sultan H, Turcotte LA, McArthur C, Hirdes JP. Patterns of home care assessment and service provision before and during the COVID-19 pandemic in Ontario, Canada. PLOS ONE. 2022;17(3). doi:10.1371/journal. pone.0266160 2. Werner RM, Bressman E. Trends in post-acute care utilization during the COVID-19 pandemic. J of the Amer Med Dir Assoc. 2021;22(12):2496-2499. doi:10.1016/j.jamda.2021.09.001 3. O’Neil JC, Geisler BP, Rusinak D, et al. Case management in a COVID-19 surge: A single-institution study of disposition and access to post-acute care. J of the Amer Ger Soc. 2021;70(2):372-375. doi:10.1111/jgs.17595 4. Sterling MR, Tseng E, Poon A, et al. Experiences of home health care workers in New York City during the coronavirus disease 2019 pandemic. JAMA Inter Med. 2020;180(11):1453-1459. doi:10.1001/jamainternmed.2020.3930 5. Gutenbrunner C, Stokes EK, Dreinhöfer K, et al. Why Rehabilitation must have priority during and after the COVID-19-pandemic: A position statement of the Global Rehabilitation Alliance. J Rehabil Med. 2020;52(7):jrm00081. Published 2020 Jul 30. doi:10.2340/16501977-2713 The Quarterly Report | SPRING 2023 Page 23

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