APTA HHS Quarterly Report, Vol 54, No. 1

A Publication of the Home Health Section :LQWHU_9RO_1R

The

Quarterly Report

Oxygen Therapy
in the Home Health Setting

by Melissa Bednarek, PT, DPT, PhD

DISCLAIMER: Although most physical therapy Oxygen is often used for patients in the home health
practice acts and board regulations are silent on the setting. It is therefore important to recognize that oxy-
administration of supplemental oxygen, some licensing gen is considered a prescription medication by both the
authorities have provided opinions/statements.1 Thus, it Food and Drug Administration (FDA) and the APTA
is the responsibility of each physical therapist to check Position Statement on Pharmacology in Physical Ther-
with his/her state/jurisdiction licensing authority to apy Practice.1, 2 Like all medications, there are indica-
determine if such an opinion/statement exists. tions for oxygen use, and concerns with a dose that is

Continued on page 3 »

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1 Oxygen Therapy in the Home a component of the American Physical Therapy Association
Health Setting
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5 Letter to the Editor: Preserving
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6 An Interview with the Section 0DQDJLQJ(GLWRU'HVLJQ
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Diana (Dee) Kornetti, PT, MA 5RELQ&KLOGHUV&$(

8 Launch of the PTA Version of the 3XEOLFDWLRQV&RPPLWWHH
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2 - Home Health Section t APTA

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too high or too low. In this article, common indications stimulate the individual
and adverse effects of supplemental oxygen, advantages to breathe. Due to the
and disadvantages of oxygen delivery systems commonly pathology of COPD,
seen in the home health setting, and how to document patients retain carbon
patient use of supplemental oxygen will be discussed. dioxide that no longer
stimulates their drive to
Indications for Supplemental Oxygen breathe. Rather, the pa-
The atmosphere is composed of several gases. In particu- tient with COPD relies
lar, oxygen accounts for approximately 21% of those on low levels of oxy-
gases. This value is known as the fraction of inspired gen in the tissues, i.e.,
tohxeygreesnp,iorartFoirOy t2.reWe tioththinehaallvaetoiolin.,Tohxeygheignhpearspseressdsuorwenof hypoxia, to breathe.
the oxygen in the atmosphere versus the lower pressure Thus, there is concern Melissa Bednarek, PT, DPT, PhD
of oxygen in the bloodstream creates a gradient through for providing too much
which oxygen will diffuse into the bloodstream and supplemental oxygen to
bind to the hemoglobin in the red blood cells. a patient with COPD, especially at rest, and the poten-
tial to decrease his/her drive to breathe.1 Thus, the goal
Supplemental oxygen is frequently used to treat low for a patient with COPD is not a pulse oximeter read-
ing of 100%, as he/she needs to maintain an appropri-
levels of oxygen in the blood, a condition known as ate level of hypoxia to stimulate breathing.

hsuypppolxeemmeinat.3alHoixgyhgeernFciOrea2 tvealaunesinacvraeialasebdleptrhersosuurgehgradi- Commonly Used Devices Seen in Home Health

ent that will drive oxygen into the bloodstream.1 An It is important to mention the oxygen delivery systems

example of a non-pathological reason for hypoxemia is commonly seen in the home health setting. There are

low barometric pressure at high altitudes. Although the three common systems: compressed oxygen gas cylin-
ders, liquid oxygen and concentrator.1, 8
FpirOess2uisrestriellsu2l1ts%inata high altitudes, the lower barometric
decreased pressure gradient between

the atmosphere and the bloodstream. An example of The compressed oxygen gas cylinder is gas under ex-

a pathological reason for hypoxemia is the increased treme pressure and comes in various size cylinders.

diffusion distance between the alveoli in the lungs and The cylinder should remain in an upright position to
prevent explosion.8 Advantages of compressed oxygen
the bloodstream, such as with diffuse interstitial lung
gas cylinders are that tanks are refillable with minimal
disease. The presence of hypoxemia, both at rest and maintenance required.8 Disadvantages include the previ-

with activity, should be monitored with a pulse oxim- ously mentioned safety concerns, as well as the need

eter.3 Oftentimes the physician will establish parameters for storage until such time that a tank can be refilled. A

for resting and exercise pulse ionxipmraecttriyce(SwpaOs 2d)e.sDcreibtaeidls regulator is needed to release the pressure safely from a
on the use of pulse oximetry
compressed oxygen gas cylinder. One commonly used
in the Winter 2018 issue of the Home Health Section
type of a regulator is “continuous,” in which the oxygen
Quarterly Report.4
is released in a continuous fashion at the set liter flow.
Oxygen Toxicity
Another commonly used type of regulator, “pulse dose,”
Like any medication administered in too high of a dose, only releases oxygen upon inhalation.1 With intermit-

adverse effects are possible with high amounts of supple- tent release, the latter device is an oxygen conserving
device.8
mental oxygen. What constitutes a “high amount”
At temperatures below -183°C, oxygen will convert
olofnogxypgeerino?dAs nofFtiiOm2e,grweialtledratmhaange6t0h%e ,luenspgeaciirawllyayfsorand from a gas to a liquid, resulting in liquid oxygen.8 Ad-
alveoli.5,6 To reduce the concern for injury, the medical
vantages of this liquid oxygen is that less space is needed
ntaeneaedmdw.wTitihhlleauncsteeicvteihtsyse.alrToyhwFeeisOgte2FniveOaral2ul terhemcaotammy mveeaetrsnydtbhaeettiwopnaeteiinesnfrote’rsst
a peripheral oxygen saturation between 90-96%.4 This for storage in a reservoir tank versus multiple com-

connects to the concept of oxygen titration, in which pressed gas cylinders. Portable tanks can be refilled from
a larger reservoir tank.1 Disadvantages include cost, as
oxygen levels are altered to maintain a specific target
oxygen saturation value.1,7 well as liquid oxygen will evaporate over time from the
portable tanks.1

The third type of oxygen delivery system is a concen-

A discussion of oxygen therapy in patients with chronic trator that will concentrate the ambient air to oaxFyigOen2
obstructive pulmonary disease (COPD) is warranted. In greater than 21%.1 Advantages of this type of
the healthy individual, elevated levels of carbon dioxide
include: less storage space needed, no refills necessary,

Winter 2019 - 3

and lower cost. Disadvantages include: the need for the physical therapist and others on the medical team in
determining if the current oxygen therapy prescription
electricity to power the device, the device noise and is appropriate to the patient’s needs, both at rest and
the heat given off by the device.1 Oftentimes, pa- with activity.

tients with this type of oxygen will have a compressed Melissa Bednarek, PT, DPT, PhD is a Board-Certified
Clinical Specialist in Cardiovascular and Pulmonary
oxygen gas cylinder as backup in the case of a power Physical Therapy. She is an Associate Professor in the Doc-
tor of Physical Therapy Program at Chatham University in
failure. Pittsburgh, PA. With expertise in pharmacology and car-
diovascular and pulmonary physical therapy, she authored
A nasal cannula is an oxygen delivery device that modules for the Advanced Competency in Home Health
and is a faculty member for the ACHH Live course. She
transmits the oxygen from the oxygen delivery system can be reached at [email protected].

to the patient via a tube that terminates directly inside References

the patient’s nares. As it is commonly seen in patients 1. Hillegass E, Fick A, et al. Supplemental oxygen
utilization during physical therapy interven-
in home health, it is worth mentioning how a nasal tions: Evidence based recommendations from
the Cardiovascular and Pulmonary Section Task
cAannnasuallacwanonrkusl.aAcgoaninne,cttheedFtioOa2ninoxaymgebniesnotuaricreisse2t1a%t . Force on Supplemental Oxygen. Cardiopulm
Phys Ther Jl. 2014:25(2):38-49.
a flow rate of 1 liter per mFoinr ueatech(lpadmd)itpioronvaildlepsma,FtihOe2
of approximately 24%.3 2. APTA Position Statement. (HOD P06-18-34-
390) [Amended: HOD P06-04-14-14; Initial:
FItiOsh2oiunlcdrebaesensobteydapthpartoxliitmeraftleolwy s4%at (see Table 1).3 HOD 06-89-43-89]. https://www.apta.org/up-
or above 4 lpm loadedFiles/APTAorg/About_Us/Policies/HOD/
Practice/Pharmacology.pdf. Accessed November
should be humidified due to the drying effects of 24th, 2018.

oxygen.3 Furthermore, liter flow rates greater than 6 3. Paz JC, West MP. Acute Care Handbook for
Physical Therapists, 4th ed. St. Louis, MO. Else-
are unlikely to provide madadyitbioeninaldFiciaOte2,da.nd another vier Saunders, 2013.
device (e.g., facemask)
4. Singh A, Hampshire Z. Pulse oximetry: Over-
Table 1. Relationship between liter view & use in practice. Home Health Section
ÀRZDQGR[\JHQGHOLYHU\ The Quarterly Report. 2018. 53(1): 11-13, 16.

Liters per minute Approximate FiO2 5. Malhotra A, Schwartzstein RM. Oxygen
21% Toxicity. UpToDate. Waltham, MA; UpTo-
room air 24% Date; 2018. https://www.uptodate.com/
1 28% contents/oxygen-toxicity?search=oxygen%20
2 32% toxicity&source=search_result&selectedTitle=1~
3 36% 122&usage_type=default&display_rank=1
4 40%
5 44% 6. Mach WJ, Thimmesch AR, Pierce JT, et al.
6 Consequences of hyperoxia and toxicity of
oxygen in the lung. Nurs Res Pract. 2011.
A physical therapy implication of a patient using a 2011:260482. 10.1155/2011/260482. http://
nasal cannula in the home setting is ensuring that an dx.doi.org/10.1155/2011/260482. Accessed
appropriate length of tubing is available for mobility December 2nd, 2018.
throughout the home. Patient education on managing
that tubing (e.g., coiling the tubing when walking) is 7. Frownfelter D, Dean E. Cardiovascular and Pul-
necessary to reduce fall risk. In addition, observation monary Physical Therapy: Evidence to Practice. 5th
of the skin around the ears should be done routinely ed., Elsevier Mosby, St. Louis, 2012.
to note areas of breakdown from the tubing in a pa-
tient using long-term oxygen therapy. 8. Tarpy SP, Celli BR. Long-term oxygen therapy.
N Engl J Med. 1995; 333:710-714.
Documentation of Use of Supplemental Oxygen
Accurate documentation of oxygen therapy is im-
portant. Documentation should include the oxygen
delivery device (e.g., nasal cannula), as well as the liter
eflroewd.1(eF.gu.r,t3helrpmmo)r,ea,sthbeotphuclsaenoaxfifmecetttrhyereFaiOdin2 gdealnivd-
the activity at the time should be included; for exam-
ple, “SpO2 of 96% at rest with 2 lpm of oxygen via
nasal cannula.” Thorough documentation will assist

4 - Home Health Section t APTA

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by Gala Malherbe, PT, MS

These are trying times in health care. Has there ever Electronic Medical Records (EMRs) in health care are
been a time in recent history when that statement did here to stay. As they continue to evolve and improve
not apply? One of our greatest challenges today, not over time, it is our responsibility as health care profes-
only as health care providers but also as health care sionals to not allow the systems to change the way we
recipients, is preserving the space where a health care meet our patients. We should not allow the screens to
provider and patient can interact, face to face, skin to come between us and our patients, or allow the clicking
skin. A space where listening can take place, not only to and scrolling to come between us and excellent patient
words, but also to unspoken messages.   care. This excellence, which starts with paying attention
is strengthened by the connections and trust we build
Often patients are poor advocates for their own health. with those we serve.  
They may lack the insight or communication skills
needed for action. A patient may not report a symptom In my 20-year career as a physical therapist, I have seen
because it seems unrelated, may not realize that subtle many changes in documentation systems. I started my
symptoms present or worsening for years are meaning- career with some computerized documentation but
ful pieces in the puzzle of a bigger picture diagnosis or utilized paper charting the majority of my 18 years
condition that could be treated or made more manage- in home health. In the past five years, I have moved
able through education. During an interview, patients through three different EMRs. Each time, despite frus-
may at times respond inaccurately due to lack of under- trations with learning a new system, I have reminded
standing of the question or subject matter, or even due myself that the system should not dictate how I provide
to being in a stage of denial. To perform a meaningful care. An EMR is for documentation, telling the story.
assessment, a health care provider must reword ques- An EMR does not write the story and does not dictate
tions and clarify when non-verbal cues are inconsistent how the story should go.  
with responses or suggest that the patient is leaving out
details. Without a certain degree of undivided attention I recognize that the time I have with each patient needs
during health care appointments, a deeper understand- to remain client-centered and the flow needs to reflect
ing of the individual as a whole cannot be reached.   each patient’s needs as well as my expertise and experi-
ence as a physical therapist, rather than prompts from
In an age where computerized documentation has a screen. As a home health provider, I have a unique
become the norm, it is increasingly common and even vantage point to listen closely to what is being said
required for visits to encompass “screen time.” We are both verbally and non-verbally to assist with finding
in the relatively early stages of this health care transi- solutions, uncovering undiagnosed health issues, and
tion. Not too long ago, most office visits with a health educating patients and their caregivers in a way that
care professional involved note taking or straight up makes a meaningful impact on their ability to manage
listening followed by a dictation or visit write up. The and improve overall health and function.  
examiner determined the session’s flow based on the
individual needs and subjective reports of the patient.  Computerized documentation has been the biggest
challenge for me personally in my role as a physical
With the advent of computerized documentation, therapist. It takes discipline and persistence to remain
patients may feel frustrated and possibly isolated. They firm in my values as a health care provider when the
sometimes answer questions while looking at a health distractions of processes and requirements are being
care provider’s back as he/she enters responses and may broadcast digitally and sometimes arbitrarily from a
even be asked the same questions by the next provider screen. I believe in the importance of quality documen-
who enters the examination room. More and more, tation reflective of skilled care and patient involvement
patients are separated from health care providers by a each session. But first and foremost, that care needs to
laptop. Rather than making eye contact, patients find be provided. I have found that stepping away from or
themselves looking at the provider’s eyelids as he/she closing my computer allows me the space to most ef-
searches the screen, fills in the prompts, scrolls through fectively and professionally accomplish this. 
the required fields to make the visit “valid.” 

Winter 2019 - 5

It is essential that we, as health care professionals, make Gala Malherbe PT, MS has been a home health physical
time during our sessions to be fully present with our therapist in Marquette, Michigan for 18 years. Previously,
patients and their caregivers, look them in the eye and she provided inpatient rehabilitation as a physical therapist
listen in a way that communicates to the patients that on the Spinal Cord Injury Team at Mary Free Bed Reha-
the time we spend with them matters. How each of us bilitation Center. She graduated from Central Michigan
chooses to do this AND complete the required docu- University and is a member of the Home Health Section
mentation is our choice and our challenge. I believe it is of the APTA. She is completing her Home Health Advance
not only possible, but that striving to do so will foster a Competency. She can be reached at s_g_malherbe@hot-
culture of quality health care and uphold the well-being mail.com.
of us all. 

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Interviewed by Dawn Widmer-Greaves, PT, DPT

What brought you to home health (HH)? lution and devel-
t I opened an agency in Florida. Prior to this, I
owned a company that provided contract therapy opment of our
for several HH agencies. I saw an opportunity
to enter private practice through agency owner- program content
ship. My prior experience had exposed me to the
importance of working with other professions in at CSM has
a collaborative way to deliver interdisciplinary
care as we do in home health. This prior experi- helped to drive
ence made owning an agency a great fit for me to
enter private practice. I was also driven to impact HH members to
the way therapists’ delivered care in the commu-
nity. Owning an agency gave me the freedom to attend. Our re-
empower therapists to practice to the highest level
of their license. search committee

Can you talk about what you see as the top 2 to 3 has grown poster
accomplishments of the Home Health Section in
2018? and platform Dee Kornetti, PT, MA
t The roll out of the Advanced Competency for presentations

Home Health (ACHH) was a huge accomplish- helping to get
ment for the section this year moving from
concept to full implementation as evidenced by the science behind home health physical therapy
graduation of the first class during CSM-2018.
The section has a responsibility to set the stan- out in front of folks. We continue to provide
dards for physical therapists practicing in the HH
setting. This competency program helps us to not physical therapists practicing in our setting with
only set the standard but serves as a vehicle for
clinicians to meet those standards. access to a variety of resources and the expertise to
t We improved the value-add to our membership
over the course of 2018, which is a very important meet the needs of the patients we serve. We always
focus of the section. Excellence in programming is
one avenue for demonstrating that value. The evo- want to invest in giving back to the members and

provide tangible benefits to those contemplating

section membership.

t We have substantially increased our social media

presence toward our strategic goal of engaging and

connecting with current and prospective mem-

bers to grow our membership. In our setting, we

are typically not practicing alongside each other.

Our cars are our offices, and patient homes our

treatment environment. Having a social media

presence allows us to help our members build a

sense of community in a solitary practice setting.

It is a place where our members can engage, share

and collaborate with their peers. The social media

presence has also allowed us to up the profile of

HH as a practice setting by reaching a broader

audience.

6 - Home Health Section t APTA

What do you see as the top 3 initiatives for the HH support that organization in the transition from a
section in 2019? volume to value-based payment model.

t Emphasize membership. The section runs on a These opportunities, and challenges are within
membership of like-minded therapists working to the grasp of the HH Section, and I would like to
promote high standards of clinical care. We need thank our membership for their support, involve-
the engagement of physical therapists in the home ment and offered expertise. We see this through
health setting, so we can bring that value to a volunteerism, committee, task force and work-
wider audience. Get the word out! group activities. With the participation of many,
the work load is light!
t Enhance our bandwidth as a section. We can do
this by providing more opportunities for volun- I would like to invite anyone who is contemplat-
teerism as well as expanding our functionality ing becoming active – or more active – in the pro-
through a partnership with a multi-faceted profes- fessional association, to consider the home health
sional association management group. Partnering section as a great place to start!
expands the depth of the expertise breadth of our
service capability as a section and provides more :HOFRPHWRWKH4XDUWHUO\
opportunity for enhanced operations, (i.e., multi- 5HSRUW¶V1HZ(GLWRU
modal - podcasts, website design, and usability) 'DZQ*UHDYHV37'37
and collaboration.
Dr. Greaves has practiced in various settings since
t Leadership role related to payment model graduating from Indiana University with her BS
reforms for 2020 and beyond. It is the responsi- in PT in 1982. Over the last 18 years, her practice
bility of all of us as PTs and PTAs to advocate for focus has been Home Health. She appreciates the
the profession, our patients and our setting. We opportunity to share her passion for home care
need to demonstrate how our care impacts out- through the support of therapists delivering servic-
comes, and how our skills and abilities advance an es in this functionally focused treatment setting.
agency’s ability to achieve those outcomes.
She completed her transitional DPT at Des Moines
What is the HH Section’s role in preparing the mem- University in 2010. She is a co-author on multiple
bership for implementation of PDGM in 2020? poster presentations related to the provision of reha-
bilitation in the Homecare environment, including
t As a section, we need to provide very clear and di- CSM, AAOS, NAON and APTA National Meet-
rect content, dispel myths, and work with APTA ings. She has also been a session presenter at CSM.
to get the word out – not only to membership but Dr. Greaves is currently VP of Home Services for
industry stakeholders and therapy employers. We Aegis Therapies.
need to provide support, resources, and training,
so therapists understand how to be successful in Dr. Greaves has been appointed by the Home
the new payment model for the betterment of our Health Section Executive Committee as Chair of
patients. the Publications Committee and now serves as Edi-
tor of the Section publication. The Section extends
What is the HH Section’s role in preparing agencies its thanks to Jason Berl for his service as Editor and
for PDGM? his assistance in making for a smooth transition.

t Arming our therapists with the tools they need to
support agency initiatives. We need to advocate
on behalf of physical therapists, so that section
membership is seen as a value add to the agency.
An agency should trust and believe that a member
of the HH section is a good quality individual
with required tools and resources at their finger-
tips to establish and make sound clinical practice
decisions. Making sure physical therapists can
articulate what is exceptional standards of care
as well as identify and improve substandard care.
The industry needs to have confidence that HH
Section members will make good decisions, based
on best practice as they look at the big picture and

Winter 2019 - 7

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by Christine Childers, PT, BSc (Hons), PhD

The concept of specialization was explored extensively Completion of these core modules is then followed with
by Jensen et al, at the turn of the millennium.1 They a 2-day live program that will be in conjunction with
found that expert practice included improved informa- the PT live course, and will be launched at CSM in
tion synthesis, problem solving, recall of patterns and Washington DC, January 2019. During this live event,
relationships and offered more patient centered care. the PT and PTA participants will spend some time
Later in 2003, Resnik and Jensen added that experts together and some separately, a concept that was thor-
demonstrated improved self-reflection, patient educa- oughly endorsed by both parties, allowing for discussion
tion and based on a strong knowledge base, offered and integration of ideas.
more individualized treatments.2 Home health is a spe-
cialized field of physical therapy and has its own unique Kandy Ortgies has been instrumental in the develop-
challenges and requirements for both the PT and the ment of this program. She will be the lead instructor for
PTA working in this arena. the PTA live program of the Advanced Competency in
Home Health for the Physical Therapist Assistant.  She
In late 2017 the Home Health Section launched the has already completed the program and will be working
Advanced Competency in Home Health (ACHH) for closely with all faculty to develop appropriate content
the Physical Therapist. The program was developed to for the live section of the PTA training. Kandy Ortgies,
follow a sequence of core online modules that are criti- PTA received her Associate of Applied Science Degree
cal to the provision of quality care in the home health from the Physical Therapist Assistant Program at Kirk-
setting. These are followed by a mandatory face to face wood Community College in Cedar Rapids, Iowa in
“live” 2-day program and conclude with elective mod- 1996. For 15 years she worked as a senior PTA in the
ules. After a successful launch and a well-attended live general medical service, inpatient orthopedics, inpatient
pre-conference course at CSM in New Orleans 2018, it and outpatient rehabilitation, and Skilled Nursing Facil-
was determined that a Physical Therapist Assistant ver- ity. During that time, she was instrumental in develop-
sion of the training should be offered. ing an early ambulation protocol for ventilator-depen-
dent patients. She has also worked in rapid recovery in
To determine content for the PTA version of the pro- a nursing home. In 2003 she joined Kirkwood Com-
gram, a focus group of individuals who had graduated munity College as adjunct faculty, teaching and assisting
from the PT version of the ACHH discussed various in the PTA Program. Since 2011 Kandy has worked in
options and provided recommendations to Program the home health setting for UnityPoint at Home Care.
Director Chris Childers, PT, BSc (Hons), PhD. Dr. She is a credentialed clinic instructor, CPR instructor,
Childers presented these to a focus group of PTA and active member of multiple committees, including
clinicians who are active in the Home Health Section. Quality Assurance Performance Improvement (QAPI),
The initial suggestions included core online modules, Patient Family Experience Council, Performance Im-
a one-day live event and possible electives. The over- provement, and assisting in the developing of an orien-
whelming reaction of the PTA group was that the PTA tation road map for new PT/PTA hires. Her interest is
version should not be significantly different to the PT in improving the quality of life through physical therapy
version and should include a 2-day live component. The for her home health patients.
PTA advanced competency program was subsequently
approved by the section board and includes a PTA Learn more about the Advanced Competency in Home
assessment module along with all the other core mod- Health program here:
ules required for the PT version. These modules are all https://www.homehealthsection.org/page/AdvCompe-
currently available through the APTA Learning Center. tencyHH

8 - Home Health Section t APTA

Christine Childers, PT, BSc (Hons), PhD, Board Certi- 2012, working as an assistant professor for the University
fied Clinical Specialist in Geriatric Physical Therapy, of St. Augustine for Health Sciences. Teaching full time, she
Certified Exercise Expert for Aging Adults, Certificate maintains her clinical skills through home health visits. She
in Advanced Competency in Home Health, received her is currently Director for the Home Health Section’s Ad-
Bachelor’s Degree in Physiotherapy from the University of vanced Competency in Home Health program.
East Anglia, England. In 1998 she moved, with her hus-
band then serving in the USAF, to Utah where she became References
licensed to practice in the U.S. During their eight years in 1. Jensen, G.M., et al., Expert Practice in Physical
Salt Lake City, Utah, Chris practiced in the skilled nurs- Therapy. Phys Ther. 2000;80(1):28-43.
ing arena and in 2005 she gained her MS in Gerontology
from the University of Utah, the same year she became a 2. Resnik, L, Jensen, GM. Using Clinical
board-certified Geriatric Clinical Specialist. In 2006 she Outcomes to Explore the Theory of Ex-
moved to California, again working in the skilled nursing pert Practice in Physical Therapy. Phys Ther.
arena until she transitioned into the academic setting in 2003;83(12):1090-1106.

The Home Health Section would like to recognize all the graduates of the Advanced
Competency in Home Health Program to date. The program has been very well received
and has exceeded the initial expectations. If you are interested in in completing the pro-
gram, learn more here: https://www.homehealthsection.org/page/AdvCompetencyHH.

Congratulations, graduates!

Teresa Ingram Aagaard, PT (Tallahassee, FL) Christine Kamph, PT, DPT (Ewing, NJ)
Melynda Kaye Affentranger, PT (Oklahoma City, OK) Anna B. Kazmierczak, PT, DPT (Upper Saddle River, NJ)

Krissi Alave, PT (Chicago, IL) Lori Kirchner, PT,DPT (Waterford, WI)
Jo-Anne Arcilla, PT (Antioch, CA) Marguerite Laver, PT (Eugene, OR)
Judith A. Badenoch, PT, MPT (Mount Shasta, CA) Christine Burney Madden, PT (Massapequa Park, NY)
Christopher Joseph Biland, PT (Gilbert, AZ) Ray Malaluan, PT (CARROLLTON, TX)
Erin Solberg Bjork, PT (Sacramento, CA) Kristen Lynn Marsden, PT, DPT (Oviedo, FL)
Rachel Hannah Botkin, PT (New Albany, OH) Jeffrey M Mauk, PT (San Francisco, CA)
Sarah Elizabeth Brockman, PT, DPT (Spokane, WA) Martin McKeon, ,MPT (Lancaster, PA)
Nicholas Donald Buchholz, PT (Inwood, WV) Tambarlee Marie Mercer, PT, DPT (Lolo, MT)
Danielle Buckwalter, PT (Schwenksville, PA) Jeffery G. Meyer, PT, MS (Circle Pines, MN)
Kacie M. Burns-Blaszczyk, PT, DPT (Myrtle Beach, SC)
Christine Mary Childers, PT, MS (Winchester, CA) Molly A. Miller, PT (Tampa, FL)
Chris Chimenti, PT (Ontario, NY) Ubaldo Mora, PT, DPT (Mason, TX)
Julie Christine Colaw, PT (Fishersville, VA) Deborah Morgenstern, PT, DPT (Radnor, PA)
Mary Ann Davidson, PT (San Diego, CA) Amy L. O'Leary, PT (Bristow, VA)
Jane F. DeLoach, PT, DPT (Raleigh, NC) Dom F Clarence Papa, PT (Vallejo, CA)
Wilfred Jesus Diaz, PT, DPT (Lakewood, CA) Gina C. Petraglia, PT, DPT (Fort Myers, FL)
Skyler Jay Dixon, PT, DPT (Mesa, AZ) Jocelyn Anetta Reeder, PT, DPT (Charlottesville, VA)
Luanne Elizabeth Dourney, PT (Melbourne, FL) Nicole Rodriguez, PT, DPT (Oceanside, CA)
Johnny Suikai Fan, PT (Lafayette, CA) Ken Rosenfeld, PT (San Jose, CA)
Eric Keith Fontenot, PT (Washington, LA)
Sarah Trueman Fuehne, PT, MPT (Saint Louis, MO) Cheryl Ryder, PT (La Mesa, CA)
Marcie Ganson, PT, DPT, MBA (Havana, IL) Sigrun Schaudies, PT (Mercer Island, WA)
Sean Daniel Greene, PT (Auburn, CA) Paul R. Schleich, PT, DPT, MS (Bloomsburg, PA)
Lucas Femino Hastings, PT, MPT (Albuquerque, NM) Leanne Murphy Segura, MSPT, DPT (Henderson, NV)
Luzelle Havenga, PT (Pawleys Island, SC) Donald Keith Shaw, PT, PhD, D.Min. (Goodyear, AZ)
Francine J. Hepler, PT (Pilesgrove, NJ) Elmar Montero Sibayan, PT (Manteca, CA)
Mindy Galperin Hillerman, PT, MPT (Langhorne, PA)
Joseph Jackson, PT (Dadeville, AL) Salma Sulaiman, PT, DPT (Hays, KS)
Kimberly Michelle James, PT, DPT (Humble, TX) Eleazar Somintac Tayag, PT (Victorville, CA)
Cynthia Jarrett, PT, DPT (Leland, MS) Brittney Michelle Timm, PT, DPT (Saint Marys, PA)
Ashley Dawn Glover Jarrett, PT, DPT (Lynchburg, VA)
Cristine F. Jimenez, PT (Monroe, NC) Jan S Viet, PT (Lufkin, TX)
Shannon Marie Jones, PT (Cascade, VA) Leah Gasgonia Villanueva, PT, DPT (Walnut Creek, CA)
Terriann Jui, PT (Pleasant Hill, CA)
Richard Anthony Villemarette, PT (Jena, LA)
Rebecca Walsh, PT (Albuquerque, NM)

William Walsh, PT, MA, MBA (Albuquerque, NM)
Aimee Elizabeth Warren, PT (Hurricane, WV)

Rebecca Sue Williams, PT (Rapid City, MI)

Winter 2019 - 9

*RYHUQPHQW$ႇDLUV+DSSHQLQJV

&<+RPH+HDOWK3URVSHFWLYH3D\PHQW6\VWHPDQG
&<&DVH0L[$GMXVWPHQW0HWKRGRORJ\5H¿QHPHQWV

by Carol Zehnacker, PT, DPT, CEEAA

The Final Rule for CY 2019 Home Health Prospective grouping. The figure at left from the final rule demon-
Payment System Rate Update and CY 2020 Case-Mix strates how each 30-day period of care would be placed
Adjustment Methodology Refinements was filed on into one of the 432 Home Health Resource Groups
October 31, 2018 with some changes from the pro- (HHRGs) under PDGM for CY 2020.
posed rule. These changes were a result of public com-
ments made including those by APTA and the Home Admission Source and Timing
Heath Section, in addition to those from a Technical There was minimal change between the proposed rule
Expert Panel (TEP) held in February 2018. The content and the final rule specific to episode timing. Early tim-
of this article is largely specific to the Patient Driven ing is within the first 30 -day episode and is weighted
Groupings Model (PDGM) components of the final higher than late. The admission source is classified as
rule. institutional if the patient has an acute facility or post
A significant change to (PDGM) was that the case mix -acute facility stay within 14 days of the episode and is
combinations were increased from 216 to 432 with weighted higher than community. CMS, however, did
additions of 7 subgroups under the Medication, Man- add Inpatient Psychiatric Facility to the list of qualifying
agement, Teaching and Assessment (MMTA) clinical institutional settings.

$GPLVVLRQ6RXUFHDQG7LPLQJ)URP&ODLPV Clinical Groupings

&RPPXQLW\ &RPPXQLW\ ,QVWLWXWLRQDO ,QVWLWXWLRQDO The clinical groupings were updated in the final rule
(DUO\ /DWH (DUO\ /DWH
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007$ ,QWHUYHQWLRQV 007$ t MMTA: Surgical Aftercare Assessment, valuation,
6XUJLFDO *,*8 teaching, and medication management for surgi-
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&LUFXODWRU\ 'LVHDVH t MMTA: Cardiac/Circulatory - Assessment, evalu-

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/RZ 0HGLXP +LJK cardiac or other circulatory related conditions:
t MMTA: Endocrine - Assessment, evaluation,
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t MMTA: GI/GU Assessment, evaluation, teaching,
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and medication management for gastrointestinal
+RPH+HDOWK5HVRXUFH*URXS
or genitourinary related conditions
t MMTA: Infectious Disease/Neoplasms/Blood-

forming Diseases - Assessment, evaluation, teach-

ing, and medication management for conditions

related to infectious diseases, neoplasms, and

blood-forming diseases
t MMTA: Respiratory - Assessment, evaluation,

teaching, and medication management for respira-

tory related conditions

10 - Home Health Section t APTA

t MMTA: Other - Assessment, evaluation, teach- Visit the CMS HHA Center web page for more infor-
ing, and medication management for a variety of mation.
medical and surgical conditions not classified in https://www.cms.gov/center/provider-Type/home-
one of the previously listed groups Health-Agency-HHA-Center.html APTA & Home

Functional Impairment Levels and Corresponding OA- Health Section resources and webinars on PDGM:
SIS Items t General Information: http://www.apta.org/Pay-
The functional levels remained the same as in the pro- ment/Medicare/CodingBilling/HH/
posed rule with – “low impairment”, “medium impair- t Q&A Session 1: Focuses on what led to the
ment”, of “high impairment” determined by CMS PDGM proposal, how case-mix weight will be
relying on Outcome and Assessment Information Sets calculated, questionable encounter codes, and best
(OASIS) codes to designate a patient’s level of function. practice behaviors the industry can and should be
The following OASIS items were finalized as determin- model at this time, etc. https://adobe.ly/2DPHwzt
ing the functional impairment level adjustment under t Q&A Session 2: Focuses on PDGM grouper tool,
the PDGM: how the PDGM may impact therapy utilization
in the future, talked about unified post-acute care
y M1800: Grooming. payment system, and the importance of demon-
y M1810: Current Ability to Dress Upper Body. strating value. https://adobe.ly/2IzFthF
y M1820: Current Ability to Dress Lower Body. t Webinar on CMS Final Rule for Home Health &
y M1830: Bathing. More: http://www.apta.org/InsiderIntel/2018/11/
y M1840: Toilet Transferring.
y M1850: Transferring. Please take the time to avail yourself of these excellent
y M1860: Ambulation/Locomotion. resources. The Home Health Section will continue to
y M1033: Risk of Hospitalization (at least four provide education this year on PDGM and how to sur-
vive and thrive with this new payment system.
responses checked)
Of Additional Note
With the inclusions of the additional clinical groupings, CMS is promoting innovation and modernization of
CMS recalculated the functional points and the thresh- home health care by allowing the cost of remote patient
olds for the functional impairment levels. This resulted monitoring to be reported by home health agencies as
in a few minor changes to the functional thresholds allowable costs on the Medicare cost report form. Also
compared to the thresholds in the CY 2019 HH PPS included in the final rule, and as a result of the APTA’s
proposed rule. There is also the potential future inclu- efforts, CMS clarified that physical therapists, occu-
sion of the IMPACT Act, Section GG, Functional pational therapists, and speech language pathologists
Items, which will be collected on the OASIS starting acting within their scope of practice may utilize remote
January 1, 2019. A detailed analysis of the development monitoring during a home health episode.
of the functional points and the functional impairment
level thresholds by clinical group can be found in the Legislation on PDGM and Home Health Services
technical report posted on the HHA Center webpage. As of the time of publication of this Quarterly Report,
S.3458 was introduced by Senators John Kennedy
Comorbidity Adjustment (R-LA) and John Cassidy (R-LA) and H.R. 6932
Comorbidity adjustments for PDGM remained as introduced by Representative Ralph Abraham (R-LA)
“no adjustment,” “low,” or “high” in the final rule. A Garrett Graves (R-LA), Scott Desjarlais (R-TN), Vern
single secondary diagnosis that falls within a list of 11 Buchanan (R-FL), and Terri Sewell (D-AL) would re-
comorbidity subgroups could qualify the patient for a quire Medicare to implement adjustments to reimburse-
low comorbidity adjustment. Two or more secondary ment rates only after behavioral changes by home health
diagnoses that result in comorbidity subgroups could agencies that affect Medicare spending actually occur,
result in an adjustment for high comorbidity. instead of assuming changes might happen. The bills
further ensure budget neutrality while requiring all nec-
Available Tools and Resources for PDGM essary increases or decreases in payment rates be phased
To support HHAs in evaluating the effects of the in at a ceiling of no more than two percent per year to
proposed PDGM, CMS is providing, upon request, a mitigate the risk of service interruptions to Medicare
Home Health Claims-OASIS Limited Data Set (LDS). beneficiaries in need of home health.
Additionally, CMS has posted an interactive PDGM
Grouper Tool on the HHA Center webpage that will
allow HHAs to enter characteristics of a sample patient.
The tool then calculates the PDGM 30-day case mix or
resulting LUPA.

Winter 2019 - 11

S. 3545 (Home Health Payment Innovation Act of
2018) introduced by Senators Susan Collins (R-ME),
Debbie Strabenow (D-MI), and Bill Nelson (D-FL)
would likewise ensure payment changes for home health
services be based on observable data and payment
reductions are capped at two percent. It would also al-
low for greater flexibility for Medicare beneficiaries in
Medicare Advantage plans. “Notwithstanding any other
provision of law, any MA organization shall be permit-
ted to waive the ‘confined to his home’ requirement in
the home health services benefit when the organization
determines it is in the best interest of the enrollee.”
Members were encouraged to support these bills by con-
tacting their appropriate legislators and were instructed
in the use of PTaction on the APTA website.

Administrative Burden
CMS Regulatory Provisions to Promote Program Ef-
ficiency, Transparency, and Burden Reduction
The Centers for Medicare and Medicaid Services (CMS)
have issued a proposed rule reforming Medicare regu-
lations that are identified as unnecessary, obsolete, or
excessively burdensome on health care providers and
suppliers. With the proposals in the rule, CMS seeks to
reduce burdens for health care providers and patients,
improve the quality of care, decrease costs, and ensure
that patients, their providers and physicians are making
the best health care choices.
 
Several members of the HH Section submitted com-
ments to CMS using the template at the APTA website
and APTA published a blog to encourage members to
voice their concerns and frustrations regarding excessive
regulations and documentation impeding patient care.

Volunteers Needed
The Government Affairs Committee continues to seek
input from the members of the Home Health Section
and also seeks volunteers for the committee and the li-
aison program. Help us to help you by getting involved
and serving your profession.

Carol Hamilton Zehnacker PT, DPT, CEEAA is the owner
of Physical Therapy Consults. LLC and contracts with
Bayada Home Health. She is the Chair of the Govern-
ment Affairs Committee and may be reached at doctorz@
comcast.net.

12 - Home Health Section t APTA

Research Corner

+LJK,QWHQVLW\,QWHUYDO7UDLQLQJDQG0DQXDO7KHUDS\3URFHGXUHVLQWKH
0DQDJHPHQWRID3DWLHQWZLWK)LEURP\DOJLDDQG'HUPDWRSRO\P\RVLWLV

LQWKH+RPH+HDOWK6HWWLQJ$&DVH5HSRUW

by Kristina Koroyan, PT, DPT; Adeel H. Rizvi, PT, DPT

Background/Purpose In addition, it has also been demonstrated that elderly
Fibromyalgia (FM) is a chronic pain condition of patients can benefit from manual therapy (MT) proce-
unknown etiology whose global mean prevalence in the dures directed toward the spine and lower extremities.
general population is 2.7% with a female-to-male ratio Recent literature suggests that manual therapy proce-
of 3:1.1,2 The American College of Rheumatology has dures can decrease pain and disability scores, as well as
recommended guidelines and diagnostic criteria for FM. increase function and ambulatory speed in the elderly
For individuals diagnosed with FM, therapeutic exercise population.14-19 It has been shown that economy of
(TE) has been shown to be effective; however, no con- movement has a direct relationship to functional capac-
sensus has been made on the type, frequency, duration, ity.20 It has also been hypothesized that decreased joint
and intensity of physical activity.3 TE may include aero- mobility of the spine and lower extremities can increase
bic training, coordination and balance training, posture energy expenditure with ambulation thereby decreasing
stabilization, body mechanics, flexibility exercises, gait functional capacity.21,22 Perry et al.21 demonstrated that
training, relaxation techniques, and muscle strengthen- mobility deficits of the spine and lower extremities can
ing exercises. The primary focus of any chosen TE is directly affect lumbopelvic rhythm and energy economy.
to decrease pain and disability and improve the overall Although the literature is clear regarding the use of
quality of life. HIIT and MT as effective treatments, there is limited
evidence to support that both MT and functional HIIT
Functional high-intensity interval training (HIIT) is a combined in the home setting is more effective than
form of TE that is superior to low-level aerobic training non-combined treatments for functional capacity. More
when prescribed to increase functional capacity, as it has research is needed to demonstrate the effects of a com-
been shown to increase both power and VO2 max in bined protocol of functional HIIT and MT in patients
the elderly patient population.4 It has been demonstrat- who are homebound.
ed that older patients in a home health (HH) setting
who display a decline in functional capacity second- In regard to dermatopolymyositis, a recent systematic
ary to a decrease in aerobic capacity can benefit from review by de Oliveira et al.23 reported physical train-
HIIT.4-6 ing as an important intervention for increasing muscle
strength and aerobic capacity in patients with systemic
It should be noted that the use of a metabolic cart is autoimmune myopathies. The study recommended
considered to be the gold standard for assessing peak physical exercise for the improvement of function and
oxygen uptake in an elderly population with aerobic quality of life in patients newly diagnosed with derma-
impairments.7 While standardized cardiopulmonary tomyositis, polymyositis and inclusion body myositis.
exercise tests (e.g. Bruce protocol test, Ellestad protocol The purpose of this case study is to examine the com-
test, Balke treadmill test) have been developed for use in bined use of functional HIIT and MT as an effective
clinical settings, they may not be conducive for cardio- management protocol for a patient with decreased func-
pulmonary assessment in the home.8,9 These procedures tional capacity in the HH setting secondary to fibromy-
are complex and exhibit costly and time-consuming algia and dermatopolymyositis.
drawbacks;8 however, there are other indirect methods
to measure peak oxygen consumption in the home such Patient Profile
as the six-minute walk test (6MWT).10-12 The 6MWT The patient is a 65-year-old Hispanic female with medi-
has been demonstrated to be both reliable and valid for cal diagnoses of fibromyalgia and dermatopolymyositis.
measuring functional capacity in the older adult popula- Her past medical history includes hypertension and
tion and may be less invasive and more conducive to a hypercholesterolemia which were being managed non-
home environment.13 pharmacologically. No other co-morbidities were noted.
Her rheumatologist prescribed the patient Norco, Imu-

13 - Home Health Section t APTA Winter 2019 - 13

ran and prednisone with a subsequent referral for home high expectation for improvement, negative depression
care services; medication details can be found in Ap- screening and family support. She was appropriate for
pendix A. The rheumatologist referral included nursing, further physical testing for lower extremity strength,
physical and occupational therapy, and social work dis- aerobic capacity, mobility, and balance.
ciplines. The primary intent of this referral was for pain
management and a return to prior level of function per The patient was taken through a series of standardized
the rheumatologist. The patient was not receiving any performance-based outcome measures used during the
other professional services during home care services. initial physical therapy visit. These outcome measures
included the 30-Second Chair Stand test, 6MWT, Berg
At the initial evaluation by the physical therapist, the Balance Scale, and Timed Up and Go Test (TUG). Oth-
patient displayed progressive worsening of ambulatory er subject-report outcome measures were utilized, in-
quality and quantity with accompanied fatigue and cluding the Numeric Pain Score (NPS) and the Patient
pain. Her pain predominated in the spine and lower Specific Functional Scale (PSFS); see Table 2 for initial
extremities. Cutaneous manifestations of dermatopoly- and discharge outcomes. She demonstrated substan-
myositis were visible on the patient’s chest, shoulders dard scores on all initial performance-based outcome
and forearms and tender to the touch. The patient was measures which placed her at risk for further decline in
unable to perform household and work duties as a small overall functional capacity. She verbalized understand-
business owner due to pain, fatigue, and disability. She ing of her physical examination scores and importance
lived in a one-story home with her spouse and three of therapeutic exercise in the treatment of functional
children. The patient’s primary goal was to return to capacity impairments.
her known level of functional status prior to the ex-
acerbation of this condition. She desired to become Absolute contraindications for manual therapy were
independent again with driving, ambulating without a ruled out prior to utilization. Manual therapy pro-
front-wheel walker, preparing meals, and managing her cedures were performed based upon joint play and
own business. The family’s goals were for the patient to range of motion assessment of the spine and lower
become as independent as possible, particularly with extremities. The patient was treated for patient-specific
ambulatory tasks. functional and mobility limitations of the spine (e.g.
lumbar and thoracic), as well as in the lower extremity
Physical Therapy Assessment  (e.g. decreased extension and internal rotation of the
After consenting to physical therapy services, a systems hip, extension of the knee, and deficits at the ankle/foot
review was conducted as part of the initial visit. She complex).
was negative for constitutional signs of fever, night
sweats, malaise, weight loss and gain. She denied chest Based upon examination findings, a physical therapy
pain, palpitations, lower extremity swelling, shortness diagnosis was established for decreased functional capac-
of breath, wheezing, cough and sputum. Her vital signs ity secondary to decreased aerobic power and endurance
(blood pressure, heart rate, respiratory rate, temperature, with a secondary diagnosis of mobility deficits of the
oxygen saturation) were within reportable measures. She spine and lower extremities.
had positive integumentary signs for diffuse-flat, purple-
red skin erythema on anterior chest (“shawl sign”), Physical Therapy Intervention
shoulders and forearms. She was experiencing lumbar, Manual therapy treatment procedures included thrust
hip, knee and ankle joint pain and stiffness as well as and non-thrust interventions; high velocity, low ampli-
generalized weakness. She denied dizziness, paresthesia, tude (HVLAT) procedures were limited to the fol-
sensory changes, loss of consciousness and headaches. lowing: lumbar HVLAT (L2-L5) lateral recumbent,
She had no complaints of otalgia, rhinorrhoea, and ody- mid-thoracic posterior-anterior (PA) extension HVLAT
nophagia. Changes in bowel frequencies had resolved in prone, long axis hip distraction manipulation, and
with fiber supplementation, otherwise negative for talocrural distraction manipulation. Non-thrust mo-
nausea, vomiting, indigestion, irritable bowel syndrome, bilizations included internal rotation hip mobilization
blood/mucus in the stool. She also denied urological in prone, anterior-posterior (AP) knee mobilization in
symptoms for dysuria, hematuria and incontinence supine. Non-thrust mobilizations were performed for
(urgent, stress and mixed). 30-seconds for 3 sets each.

Her low fear avoidance and pain catastrophizing scores Treatment sessions consisted of 8 one-hour physical
were positive prognostic factors for physical therapy therapy sessions at 3x/week with MT procedures per-
treatment. Other prognostic factors that suggested ap- formed to specific mobility impairments that preceded
propriateness for physical therapy included the patient’s one bout of functional HIIT. The patient was prescribed

14 - Home Health Section t APTA

Research Corner

HIIT for decreased functional capacity as evidence by By the last week of physical therapy, the patient was not
substandard scores on the 6MWT,24 Timed Up and Go utilizing her front wheel walker in the home or outside
Test,25 Second Sit-to-Stand Test,26 and Berg Balance the home. She was experiencing decreased overall pain
Scale.27 The patient was dosed functional HIIT at 1:1 and beginning to work from home to maintain her
small business. She required decreased assistance from
ratio (time of effort/active recovery) for a maximum family members with all self-care tasks and returned to
preparing meals for her family. Altogether, the patient
duration of 12 minutes at 80-90% VO2 peak or 85- demonstrated improvement and progression toward
95% HR max.28 The patient was given active recovery at goals of returning to prior level of function.

60-70% HR max prior to subsequent bouts of func-
tional HIIT.28,29 (See Table 1 for a detailed description of

interventions performed)

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Outcome The patient was encouraged to continue with a home
exercise program which was provided in writing and
All outcome measures were assessed during the initial picture format. Patient verbalized and demonstrated
home exercise program with no further required educa-
(visit 1) and discharge (visit 9) as seen in Table 2. The tion and instruction at discharge. The physical therapist
made recommendations for continued care through
patient demonstrated overall improvement by the last outpatient physical therapy in which the patient fol-
lowed.
visit as evidenced by meeting the minimal detectable
change (MDC) on the PSFS30 and minimal clinical Winter 2019 - 15
important difference (MCID) on the NPRS31.

Table 2. 2XWFRPH0HDVXUHV ,QLWLDO9LVLW 'LVFKDUJH9LVLW

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6XEMHFW5HSRUW2XWFRPH0HDVXUHV %HVW

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Discussion continued HIIT regimen may have led to further physi-
The patient demonstrated improvement in perfor- cal improvements. Further research could include larger
mance-based outcome scores for the 30-Second Chair sample sizes and long-term benefits of combined func-
Stand test, 6MWT, BERG, and TUG. The patient tional HIIT and MT in the home health setting.
required the use of upper extremities during the initial
attempt on visit one for the 30-Second Chair Stand test Kristina Koroyan is a licensed physical therapist and cur-
(ICC=1.0);32 however, the discharge score may have rent fellow-in-training with the American Academy of
demonstrated improvement in lower extremity strength Manipulative Therapy (AAMT). She is in pursuit of inves-
as she completed the test without the use of arms. She tigating her current case series in regard to high intensity
improved upon aerobic capacity/endurance as evidenced interval training and manual therapy procedures in the
by meeting the MDC (190.98 feet) for the 6MWT.33 home care setting. She may be reached at [email protected]
Although she did not have a prior history of falls, her
initial score on the BERG indicated a greater risk for Adeel Rizvi is a licensed physical therapist and founding
falling, however she met the MDC of 6.3 points on program director of a developing physical therapist assistant
the BERG to indicate a true change (CI=95%).34 The program in Clovis, CA. His research interests include try-
patient achieved an improved score by discharge of less ing to understand pathological and physiological basis and
than the cut off threshold of 12 seconds indicating im- implications of impairments and disease. Currently, he is
proved mobility and decreased risk for falls.35 pursuing his Ph.D. in Health Sciences with a concentra-
tion in Global Health Education and Research. He may be
There were limitations to this study as only pre and reached at [email protected]
post testings were completed. The home care services
were limited in number of visits and additional visits of

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16 - Home Health Section t APTA

Research Corner

References 12. Bohannon RW. Six Minute Walk Test: A
1. Sosa-Reina, M., Nunez-Nagy, S., Gallego-Iz- Meta-Analysis of Data from Apparently
quierdo, T., Pecos-Martín, D., Monserrat, J. and Healthy Elders. Topics in Geriatric Rehabil.
Álvarez-Mon, M. Effectiveness of Therapeutic 2007;23(2):155-160
Exercise in Fibromyalgia Syndrome: A Systema-
tic Review and Meta-Analysis of Randomized 13. Sperandio ER, Arantes RL, Matheus AC, Silva
Clinical Trials. Biomed Res Int. 2017:2356346. RP, et al. Intensity and physiological responses
to the 6-minute walk test in middle aged and
2. Queiroz LP. Worldwide epidemiology of older adults: a comparison with cardiopul-
fibromyalgia. Curr Pain Headache Rep. monary exercise testing. Braz J Med Biol Res.
2013;17(8):356. 2015;48(4):349–353.

3. Arnold B, Ha ࡇuser W, Arnold M, et al. Multi- 14. Cibulka MT., et al. Hip Pain and Mobility
component therapy of fibromyalgia syndrome. Deficits-Hip Osteoarthritis: Revision 2017. J
Systematic review, meta- analysis and guideline. Orthop Sports Phys Ther. 2017;47(6):A1-A37.
Schmerz. 2012;26(3):287–290.
15. Hoeksma HL., et al. Manual Therapy in
4. Weston KS, Wisløff U, Coombes JS High-in- osteoarthritis of the hip: outcome in sub-
tensity interval training in patients with lifes- groups of patients. Rheumatology (Oxford).
tyle-induced cardiometabolic disease: a systema- 2005;44(4):461-4.
tic review and meta-analysis Br J Sports Med.
2014;48:1227-1234. 16. MacDonald CW., et al. Clinical Outcomes Fol-
lowing Manual Physical Therapy and Exercise
5. Nemoto K, Gen-no H, Masuki S, Okazaki K, for Hip Osteoarthritis. A Case Series. J Orthop
Nose H. Effects of HIWT on Physical Fitness Sports Phys Ther. 2006;36(8):588-599.
and blood pressure in Middle-aged and older
people. May Clin Proc. 2007;82:803-811. 17. Deyle GD., et al. Effectiveness of manual phy-
sical therapy and exercise in osteoarthritis of the
6. Karlsen T, Aamot I, Haykowsky M, Rognmo knee. A randomized controlled trial. Ann Intern
O. High Intensity Interval Training for Maxi- Med. 2000;132(3):173-81.
mizing Health Outcomes. Prog Cardiovasc Dis.
2017;67-77. 18. Courtney CA, Steffen AD, Fernandez-de-las-
Penas C, Kim J, Chmell SJ. Joint Mobilization
7. Forman DE., et al. Prioritizing Functional Enhances Mechanisms of Conditioned Pain
Capacity as a Principal End Point for Therapies Modulation in Individuals with Osteoarthri-
Oriented to Older Adults with Cardiovascular tis of the Knee. J Orthop Sports Phys Ther.
Disease. Circulation. 2017;135:e894–e918. 2016;46(3):168-76.

8. Fletcher GF, et al. Exercise Standards for Tes- 19. Whitman JM., et al. A Comparison Between
ting and Training: A Scientific Statement from Two Physical Therapy Treatment Programs
the American Heart Association. Circulation. for Patients with Lumbar Spinal Steno-
2013;128:873–934. sis. A Randomized Clinical Trial. Spine.
2006:15;31(22):2541-9.
9. Beltz, N., Gibson, A., Janot, J., Kravitz, L.,
Mermier, C. and Dalleck, L. Graded Exercise 20. Kraus WE, SJ Keteyian, editors. Cardiac Reha-
Testing Protocols for the Determination of bilitation. Humana Press;2007.
VO2max: Historical Perspectives, Progress, and
Future Considerations. J of Sports Med. 2016, 21. Perry J, Burnfield JM. Gait Analysis: Normal
pp.1-12. and Pathological Function. Slack Incorporated;
2ed., 2010.
10. Bohannon RW, Bubela DJ, Wang Y-C, Magasi
SS, Gershon RC. Six-minute Walk Test versus 22. Richardson C, Hodges PW, Hides J. Thera-
Three-minute Step Test for Measuring Func- peutic Exercise for Lumbopelvic Stabilization:
tional Endurance (Alternative Measures of A Motor Control Approach for the Treatment
Functional Endurance). J Strength Cond Res. and Prevention of Low Back Pain. Churchill
2015;29(11):3240-3244. Livingston. 2ed., 2004.

11. Ross RM, Murthy JN, Wollak ID, Jackson AS. 23. de Oliveira, Misse RG, Lima FR, Shinjo SK.
The six minute walk test accurately estimates Physical exercise among patients with systemic
mean peak oxygen uptake. BMC Pulm Med. autoimmune myopathies. Advances in Rheuma-
2010;10:31. tology. 2018;58:5.

Winter 2019 - 17

24. Bohannon RW, Crouch R. Minimal clinically and Application as a Clinical Outcome Measure.
important difference for change in 6-minute J Orthop Sports Phys Ther. 2012;42(1):30-40.
walk distance of adults with pathology: a syste-
matic review. J Eval Clin Pract. 2016;1-5. 31. Salaffi F, Stancati A, Silvestri CA, Ciapetti A,
Grassi W. Minimal clinically important changes
25. Barry E, Galvin R, Keogh C, Horgan F, Fahey in chronic musculoskeletal pain intensity mea-
T. Is the Timed Up and Go test a useful predic- sured on a numerical rating scale. Eur J Pain.
tor of risk of falls in community dwelling older 2004;8(4):283-91.
adults: a systematic review and meta-analysis.
BMC Geriatr. 2014;14:14. 32. Telenius EW, Engedal K, Bergland A. Inter-rater
reliability of the Berg Balance Scale, 30 s chair
26. Rikli RE, Jones, JC. Development and Vali- stand test and 6 m walking test, and construct
dation of a Functional Test for Communi- validity of the Berg Balance Scale in nursing
ty-Residing Older Adults. J Aging Phys Act. home residents with mild-to-moderate demen-
1999;7(2):129-161. tia. BMJ Open. 2015;5.

27. Downs S. The Berg Balance Scale. Commentary. 33. Perera S, Mody SH, Woodman RC, Studenski
J of Physiother. 2015;61:46. SA. Meaningful change and responsiveness in
common physical performance measures in
28. Hannan AL., et al. High intensity interval trai- older adults. J Am Geriatr Soc. 2006;54(5):743-
ning versus moderate intensity continuous trai- 9.
ning within cardiac rehabilitation: a systematic
review and meta-analysis. J Sports Med. 2018;9. 34. Donoghue D. How much change is true
change? The minimum detectable change of the
29. Coetsee C, Terblanche E. The effect of three dif- Berg Balance Scale in elderly people. J Rehabil
ferent exercise training modalities on cognitive Med. 2009;41(5):343-6.
and physical function in healthy older popula-
tion. Eur Rev Aging Phys Act. 2017;14(13). 35. Lusardi MM., et al. Determining Risk of Falls
in Community Dwelling Older Adults: A Syste-
30. Horn KK, Jennings S, Richardson G, Van Vliet matic Review and Meta-analysis Using Posttest
D, Hefford C, Abbott JH. The Patient-Specific Probability. J Geriatr Phys Ther. 2017;40(1):1-
Functional Scale: Psychometrics, Clinimetrics, 36.

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18 - Home Health Section t APTA

Research Corner

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by Alexis Reile, PT, DPT; Christina Kemp, PT; Lisa Inglis, PT, DPT

Background/Purpose patient's illness or injury or to the restoration or main-
Parkinson’s Disease (PD) is defined as a progressive tenance of function affected by the patient's illness or
neurodegenerative disorder predominantly affecting the injury. It is necessary to determine whether individual
dopaminergic neurons of the substantia nigra within therapy services are skilled and whether, in view of the
the basal ganglia of the brain.1 The typical presentation patient's overall condition, skilled management of the
of a patient with PD includes four main characteris- services provided is needed.”7 Coverage is based on
tics: bradykinesia, rigidity, resting tremor, and pos- individualized assessment of the patient and the neces-
tural instability.1,2 Patients with PD also present with a sity of skilled maintenance physical therapy.7 Table 1
stooped posture, asymmetrically reduce or absent arm lists the three criteria under which eligibility and cover-
swing, asymmetrical step size, and difficulty turning in age requirements for skilled therapy are determined.
standing or recumbent positions.2 Disabling functional The case highlighted in this report falls under criteria #3
limitations resulting from PD include impaired bed (the skills of a qualified therapist are needed to perform
mobility, transfers, and gait.2 maintenance therapy). Due to the progressive nature of
the disease, many patients with PD require ongoing care
PD is among the most common neurologic diseases, for management of symptoms. Maintenance physical
with a prevalence of 40.5 per 100,000 individuals therapy is often indicated in patients with PD to ensure
between the ages of 40-49, 106.7 per 100,000 indi- safety in the home, maintain level of function, avoid
viduals ages 50-59, 428.5 per 100,000 individuals ages falls, prevent rehospitalization, and slow the progression
60-69, 1086.5 per 100,000 individuals ages 70-79, and of the disease.
1903 per 100,000 individuals over the age of 80.3 The
incidence rate of PD is 37.55 per 100,000 females over Physical therapy aims to maximize movement quality
the age of 40 years and 61.21 per 100,000 males over and functional independence while preventing second-
the age of 40 years.4 The estimated economic burden of ary complications.2 Three important elements of physi-
PD in the United States alone is at least $14.4 billion cal therapy for patients with PD are movement and
per year.5 Due to the lack of curative treatment for PD, postural strategy training, management of comorbidi-
a combination of drug therapy, surgical therapy, and ties affecting the musculoskeletal and cardiorespiratory
physical therapy is recognized as the standard treatment systems that result from deconditioning, and promot-
for patients with PD.6 ing physical activities that assist in lifelong changes in
exercise habits and preventing falls.8 Once a patient has
Maintenance physical therapy is justified when the been restored to baseline level of function or the high-
goal of therapy is to maintain a patient’s current condi- est attainable level of function, maintenance physical
tion or to prevent/slow decline in function.7 As stated therapy becomes important to prevent decline and slow
in the Medicare Benefit Policy Manual under Chapter the progression of the disease, while preventing hospi-
7, Section 40.2.1, “The service of a physical therapist, talizations and need for higher level of care. According
speech-language pathologist, or occupational therapist to the Centers for Medicare and Medicaid Services,
is a skilled therapy service if the inherent complexity of maintenance physical therapy services are covered when
the service is such that it can be performed safely and/ an individualized assessment of the patient’s clinical
or effectively only by or under the general supervision condition demonstrates that the specialized judgement,
of a skilled therapist.”7 The manual elaborates: “To be knowledge, and skills of a qualified therapist are neces-
covered, assuming all other eligibility and coverage sary in order to maintain the patient’s condition or to
criteria have been met, the skilled services must also prevent or slow further deterioration.9 The purpose of
be reasonable and necessary to the treatment of the this case report is to describe the effectiveness of home

Winter 2019 - 19

Table 1

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care maintenance physical therapy at preventing rehos- vodopa, cholecalciferol, entacapone, gabapentin, ibu-
pitalization, maintaining functional mobility, and slow- profen, metaxalone, metformin, nystatin, omeprazole,
ing progression of the disease in a patient with PD. and Wellbutrin. The patient’s goal for physical therapy
and home care services was to transfer and walk with
Patient Profile the least amount of assistance needed by his spouse or
The patient was a 76-year-old Caucasian male referred aide.
for home care services due to falls and weakness in May
2015. The primary payer for home health care services Physical Therapy Assessment
was Medicare A. A physical therapy assessment was performed in the
patient’s home on May 22, 2015. The patient’s primary
The patient’s past medical history was significant for caregiver, his wife, was present for the examination.
PD, Chronic Obstructive Pulmonary Disease (COPD),
major depressive disorder, type II Diabetes, low back Prior to the onset of PD, the patient worked as a high
pain, generalized muscle weakness, primary hyperten- school music teacher and was an active member in his
sion, abnormalities of gait and mobility, history of church choir. Upon the initial physical therapy evalu-
falling, aphonia, artificial openings of urinary tract, and ation, the patient required contact guard assistance
a history of malignant neoplasm of the bladder. Medica- with most transfers, moderate assistance for bed mo-
tions included atorvastatin, Calmoseptine, carbidopa-le- bility, contact guard assistance for ambulation with a

20 - Home Health Section t APTA

Research Corner

4-wheeled-walker (4WW), minimal assist with ambula- Standing tolerance of the patient was assessed by deter-
tory car transfers, and assistance with toileting, hygiene, mining the number of seconds the patient could remain
and other activities of daily living (ADLs). The patient in an upright standing position using his 4WW before
was living in a 2-story home with first floor accommo- needing to sit and take a rest. This helped to assess the
dations. The home had 5 steps to enter, and the patient patient’s endurance and tolerance to the upright static
used bilateral upper extremities on one handrail to ne- standing position.
gotiate, along with moderate assistance from caregivers.
The patient was considered homebound due to short-
The Function in Sitting Test (FIST), the 30 second sit- ness of breath, difficulty transferring, ambulation
to-stand test, and gait speed were the standard outcome difficulties, inability to leave the home without as-
measures (SOM) used to assess the functional mobility sistance, and significant and taxing effort required to
of this patient. Standing tolerance was also assessed. leave the home. The patient presented with various
gait deviations both at the initial evaluation and at the
The FIST is a standardized outcome measure consist- most recent assessment: narrow base of support, lean-
ing of 14 everyday functional tasks involving sitting ing forward, decreased knee extension bilaterally, poor/
postural control.10 Each task is scored on a scale of 0-4, inconsistent foot clearance, no heel strike, head down
with the highest attainable score of 56.10 The FIST posture, flexed trunk posture, festinating gait, and
quantifies the individual’s sitting balance and describes left side leaning posture. The patient’s standing toler-
sitting balance at the activity level of the International ance was 2 seconds upon initial evaluation, and he was
Classification of Function and Disability (ICF).10 The unable to complete the 30 second sit-to-stand test.
FIST has been determined to have excellent test-retest The gait speed was not assessed until November 2015
reliability, intrarater reliability, and interrater reliability when he scored 0.36 m/s, and the FIST was assessed
in individuals with a diagnosis of a central nervous sys- in October 2016 when he scored 40. The patient and
tem neurological condition.10 The intraclass correlation therapist agreed upon several objective measure goals
coefficients (ICC) of the test-retest reliability, intrarater including 39 for the FIST, 6 for the 30 second sit-to-
reliability, and interrater reliability were 0.97, 0.99, and stand, 0.35m/s for gait speed, and 150 seconds for
0.99, respectively.10 The FIST also demonstrates good- standing tolerance. Goals were established based upon
excellent concurrent validity with the Berg Balance Scale his reported prior level of function, his level of function
(BBS) and the Functional Independence Measure (FIM) at the time of the initial evaluation, and his prognosis to
(Spearman ȡ=0.71-0.85) in a population-based sample have improved strength and mobility, decreased fall risk,
of adults with sitting balance impairments.11 improved balance, and increased endurance. The FIST
proved to be a valuable and sensitive measure for this
The 30 second sit-to-stand test assesses the number of patient, with a goal of 39 serving as a reliable threshold
repetitions of sit to stand transfers an individual can indicator to predict pending regression in function.
complete within 30 seconds. Review of the literature The 30 second sit-to-stand goal was established at 6 to
reveals reliability and validity of the 30 second sit-to- maintain adequate strength and endurance for routine
stand test in community dwelling older adults,12 but not activities of daily living such as grooming and dressing.
specifically in Parkinsonian patients. The 30 second sit- The goal of .35m/s for gait speed aligned with being a
to-stand test has been shown to have a moderately high household ambulator and ensured adequate mobility to
test-retest reliability with an ICC of 0.89,12 and moder- attend medical appointments and visit family for brief,
ate concurrent validity with weight-adjusted leg-press infrequent outings.
performance (r=0.77).12
Due to the patient’s history of advanced PD, chronic
Gait speed analyzes how quickly an individual ambu- back pain, weakness, cognitive limitations, history of
lates in meters/second (m/s). Gait speed has been shown falls, recurrent pressure ulcers, and recurrent urinary
to have intrarater reliability, interrater reliability, and tract infections, his condition was easily variable from
test-retest reliability (ICC=0.9-0.96, r=0.89-1.00) in one visit to the next, as well as by time of day. The
community-dwelling elderly individuals13; a thorough patient began receiving physical therapy at a restorative
review of the literature failed to exhibit reliability and level twice per week with the goal of a return to his
validity of gait speed specifically in patients with PD. baseline level of function. Goals were initially set for
Gait speed has been shown to have construct valid- 4 weeks, and then physical therapy care was extended.
ity with measurements taken during weight-shifting Within approximately 2 months, the patient returned
tasks on the Balance Master (r=-0.49 to -0.72), the to baseline function and restorative physical therapy
BBS (r=0.81), and the Timed Up and Go test (TUG) ended. Maintenance physical therapy was initiated to
(r=0.75).13

Winter 2019 - 21

maintain the patient’s level of function and quality of patient in particular, educating home health aides was

life, as well as to prevent hospitalizations and falls. imperative. The patient had multiple home health aides

over the course of therapy, covered by private pay, play-

Physical Therapy Intervention ing a vital role in his functional status. He reported a

Physical therapy services were implemented initially as significant decrease in function if an aide was not pres-

restorative treatment. Interventions included a variety of ent to properly stretch him, assist him in standing in an

techniques: education in fall prevention, balance train- upright position, and assist him in walking safely and

ing to reduce fall risk, monitoring of pain status, thera- regularly within his home. Physical therapy routinely

peutic exercises, a home exercise program to decrease provided aides with instruction on modifications to

rigidity and improve functional strength, energy con- the aide care plan in response to wide variations in the

servation techniques to maximize productivity, manage- patient’s status over time.

ment of diabetic foot care, pressure relief prevention,

skilled teaching for managing and minimizing identified The patient remained under restorative physical therapy

risks for hospitalization, evaluation of gait, gait training for eight weeks. Due to the complex nature of his con-

with appropriate assistive devices, managing depres- dition, including a decline in cognitive status, decline

sion, transfer training, bed mobility training, and spine in physical status of his caregiver, recurrent skin break-

safety/body mechanics education. Interventions varied down, recurrent urinary tract infections, frequent falls,

each visit to address the most prominent impairments. rigidity, bradykinesia, and weakness in bilateral extremi-

Table 2 details specifics of these interventions. For this ties and trunk, this patient qualified for skilled mainte-

nance physical therapy once he reached his baseline level

of function. The care of a skilled physical therapist was

warranted due to the patient’s variation in presentation

Table 2 from visit to visit and/or within a

day as a result of these complexi-

Examples of Interventions ties combined with his previous-
mentioned comorbidities. Daily/
Type Details
weekly variations included fluctua-

Management of depression Notify MD if patient reports a change in sense tions in strength, cognition, balance,
of well being or mood level of alertness, ability to follow
Instruct patient in pharmacological single or multi-step commands,
and/or non-pharmacological pain Instructed patient in rest and positioning tech- and level of assistance needed to
control methods niques and administration of pain medications ambulate and transfer safely within
prior to therapy the home. Maintenance therapy

Gait training provided with assistive Patient ambulated 40 feet x4 indoors on carpet included similar interventions as

device surface with 4WW and CGx1 restorative therapy, as outlined in

Instruct patient in techniques to con- Instructed in frequent periods of rest and Table 2. Maintenance therapy began
serve energy maintaining appropriate posture on a frequency of alternating once
per week and twice per week, every
Seated exercises Repeated sit to stands x4 from edge of bed, other week in attempt to provide
and HS, calf, and hip abd/add stretches for 30 the lowest frequency of physical
seconds therapy visits necessary to maintain

Instructed patient to stand up tall, look the patient’s level of function. After

Standing posture exercises straight forward, put equal weight through sustaining two falls in one month,
both lower extremities, and to straighten arms physical therapy services were

and knees x5 minutes increased in frequency to twice per

Instruct patient in safe sit to stand Instructed patient to scoot forward, forward week. The frequency was eventually
transfer technique weight shift, push with upper extremities, and decreased to one physical therapy
bring nose over toes visit per week; the patient was also
Instruct patient in safe gait pattern us- receiving occupational therapy ser-
ing verbal/tactile cues Verbal cues for proper step length, step clear- vices once per week at this time, and
ance, posture, and gait speed it was determined that the patient

Static sitting, static standing, postural aware- was able to maintain his level of

Instruct patient in balance training ness in sitting and standing, dynamic sitting: function with two total therapy vis-
activities to reduce fall risk weight shifting in sitting, multidirectional its per week. Throughout the course
reaching activity in sitting, and perturbations of services, the majority of physical

in sitting x10 minutes therapy care for this patient existed

22 - Home Health Section t APTA

Research Corner

as maintenance physical therapy, preventing and slow- due to decline in function. At three years follow-up,
ing inevitable decline in functional mobility due to his the patient received occupational therapy services on a
progressive, degenerative disorder. The unique and so- maintenance level, once per week.
phisticated skills of a therapist were required to mitigate
fall risk and prevent hospitalization due to the patient’s Two months after the initial evaluation, a physical
daily fluctuation in presentation and complexity of therapy recertification was performed. The patient had
multiple comorbid health conditions. Just a few of the progressed to become independent in sit-to-stand trans-
skilled therapy responses to variations in the patient’s fers, stand by assist for ambulation with a 4WW, and
status over time are highlighted in Table 3. minimal-contact guard assistance for stair negotiation.
At this point, the patient had demonstrated a plateau of
Outcome progress and was deemed a candidate for maintenance
Over the period of several years, skilled physical therapy physical therapy to prevent the loss of function and
services fluctuated between restorative and maintenance mobility, and prevent falls and hospitalizations. The
based on the patient’s health and condition. The patient frequency of physical therapy visits was adjusted to best
also received home health occupational therapy services suit his needs.
to assist with functional maintenance of ADLs. An oc-
cupational therapist evaluated and treated the patient at Table 4 shows the dates of physical therapy recertifica-
the start of care and eventually discharged the patient tions for this patient, along with the notes pertaining to
once he reached his functional baseline with ADLs. whether the recertification was being done as restorative
Occupational therapy services later resumed as needed, or maintenance physical therapy. If the patient experi-

Table 3

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Winter 2019 - 23

Table 4

Date Type 5HFHUWL¿FDWLRQV
-XO\ 0DLQWHQDQFH Notes
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enced a significant change in condition due to a fall or intermittent setbacks, over a period of three years with a
illness, services switched over to restorative care. Once progressive, degenerative condition.
the patient returned to his baseline, he returned to
maintenance physical therapy once again. Table 6 displays records of reported falls by the patient
and the patient’s caregiver to the physical therapist,
The FIST, 30 Second Sit-to-Stand test, Gait Speed, and along with notes as to when the patient was hospital-
standing tolerance tests were primarily used to evaluate ized due to the falls. Throughout the course of care, the
the patient’s current level of function. Table 5 lists an patient was sent to the emergency room on only two
overview of the dates these tests were performed and the occasions; he was able to return home without admis-
results of the tests quarterly over the three years of ser- sion to the hospital. The SOM scores in Table 5 reveal
vice. The fluctuation in scores is due to the progressive a correlation with the falls. After a fall and a resultant
and fluctuating nature of the disease and the patient’s setback, SOM scores declined and frequently resulted in
health status. Physical therapy services were determined a switch to restorative physical therapy services to allow
based on the patient’s status and the frequency that best the patient to return to baseline.
suited his needs to allow him the best functional out-
comes. Graph 1 outlines the reduction in falls since home care
services began for this patient. In the first year, the pa-
Table 5 exhibits that upon the patient’s two most recent tient had 8 reported falls. This number was reduced to
recertifications, he scored a 41 and 40 on the FIST, a 6 7 reported falls in the second year of services, and in the
and 4 on the 30 second sit-to-stand test, 0.40 m/s and third year the patient only reported 2 falls.
0/35 m/s on the gait speed, and 205 and 150 seconds
on the standing tolerance test. The scores reveal that the Discussion
patient initially progressed to his baseline with restor- Ongoing physical therapy assessment and intervention
ative care and then remained at his baseline, despite allowed for detection of changes in the patient’s condi-

24 - Home Health Section t APTA

Research Corner

Table 5 Table 6

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Date FIST
6676
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within the home. These fluctuations in the
patient’s condition required a skilled therapist

to continually reassess the patient and adjust

treatment for each specific session based on his
tolerance for that particular visit. Furthermore,
the progressive nature of PD and the patient’s

history of falls warranted ongoing maintenance

),67 )XQFWLRQLQ6LWWLQJ7HVW6676 VHFRQGVLWWRVWDQGWHVW physical therapy to prevent/slow deterioration

and maintain function. Home health mainte-

nance physical therapy has allowed this patient

tion, collaboration with the physician upon medical to remain in the comfort and security of his own home.

He has maintained his level of function despite having
status changes, provision of teaching to caregivers, and a progressive, degenerative disorder, requiring contact
implementation of home modifications to improve
guard assistance of one for transfers and ambulation
safety of the patient and caregiver. In addition to reduc- with a 4WW, with use of a power wheelchair for longer
ing fall risk, skilled physical therapy has also helped to distance ambulation or when symptoms are exacer-
detect skin breakdown issues and urinary tract infec-
bated. Maintenance physical therapy has mitigated the
tions, allowing nursing services to become involved to incidence of hospitalization with this patient, reduced
prevent hospitalizations from these causes.
fall rate, and allowed him to remain living in his home

At the time of manuscript preparation, the patient environment with his wife and assist from a caregiver.

required ongoing skilled physical therapy services at a For this patient in particular and many others with PD,

home care maintenance physical therapy can help to
maintenance level due to daily fluctuation of strength, eliminate unnecessary health care costs and the need for
cognition, balance, level of alertness, ability to follow
a higher level of care and institutionalization.
direction, and level of assistance needed to move safely

Winter 2019 - 25

Graph 1

It should be noted that providing maintenance therapy Although it cannot be determined with any degree of
across multiple concurrent episodes as described in certainty, the authors believe this patient would likely
this case would be considered an exception to the rule. have declined to the point of requiring long-term place-
Most maintenance therapy episodes are likely to involve ment without the advanced clinical oversight provided.
a much shorter duration of time. With that said, the The sophisticated assessment, skilled clinical decision-
Center for Medicare Advocacy addresses time limits in making, and dynamic interventions provided to the
the “Frequently Asked Questions (FAQs) Regarding the patient afforded him the ability to remain in his home
Jimmo v. Sebelius Improvement Standard Settlement”.14 for a greater time than would otherwise have been
The excerpt reads as follows: expected.

“Question: Are there time limits for the coverage of
skilled nursing and skilled therapy services?
Answer: The Jimmo Settlement does not include
any time limits for Medicare coverage. The rules for
the health care settings covered by Jimmo vary.
For home health, as long as the skilled nursing or
skilled therapy services are necessary to maintain
the patient’s functioning or to prevent or slow the
patient’s decline or deterioration, there are no time
limits to home health care. Medicare beneficiaries
are entitled to ongoing coverage, which may last
years, as long as all coverage criteria are met.”

26 - Home Health Section t APTA

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doi:10.1152/physrev.00022.2010. Evidence-based physical therapy for gait
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M, Keus SH, Bloem BR, de Vries NM. Physical
therapy and occupational therapy in Parkinson's 9. Centers for Medicare and Medicaid Services.
disease. Int J Neurosci. 2017; 127(10):930-943. Frequently Asked Questions (FAQs) Regarding
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23, 2017. https://www.cms.gov/Center/Special-
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sheim T. The incidence of Parkinson's Dis-
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doi:10.1159/000445751 validity, responsiveness, and minimal clinically
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Jain A. The current and projected economic 2311. doi:10.1016/j.apmr.2014.07.415.
burden of Parkinson's Disease in the United
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community-residing older adults. Res Q Exerc
6. Nakae H, Tsushima H. Effects of home exercise Sport. 1999; 70(2):113-119. doi:10.1080/02701
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jpts.26.1701. gender-related test performance in community-
dwelling elderly people: Six-Minute Walk Test,
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Medicare Benefit Policy Manual: Chapter 7 gait speeds. Phys Ther. 2002; 82(2):128-137.
Section 40.2.1- Home Health Services. Rev. PMID:11856064
208, issued: 04-22-15, effective: 01-01-15,
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Manuals/Internet-Only-Manuals-IOMs-Items/ Settlement. MedicareAdvocacy website. http://
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2018. the-improvement-standard-case-faqs/. Accessed
on 9/28/18.

Winter 2019 - 27

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