APTA HHS Quarterly Report Vol 55, No. 3

The Quarterly Report

SUMMER 2020

Vol. 55 | No. 3

In this
Issue:

1 Medication
Management in
Home Care

2 Did You Hear
Read All About It!

7 When Change Happens: Medication Management in Home Care
Strategies for Leading
Through Change By Aban Singh PT, LL:B

10 Cracking the Code of America is aging fast, and by 2030 it is the first staff member to see the patient upon
ICD-10 in Home Health projected that 20% of Americans will be 65 leaving the discharging facilities.
years old or older.1 Statistics show that 82% of
16 Government Affairs American adults take at least one medication a PTs can make a difference by assisting
Happenings Summer: day, and 29% take five or more.2 As the American patients to understand their medications, and
Waivers from CMS population ages, an inevitable increase in how medications may impact their health status
ailments and comorbid conditions will arise, and recovery process. This article aims to provide
18 Does Nutrition Have a requiring increased medications and the use of an in-depth view of the key aspects of medication
Place in Chronic Disease polypharmacy. Data show that patients taking management and how a physical therapist can
Management? more medications are at higher risk for falls play an active role in facilitating the medication
and prone to reduced functional mobility.3 plan to ensure optimal care is delivered with
21 Recognizing and Medication management has become one of optimal clinical outcomes to the patient.
Reporting Elder Abuse: the most important aspects of home care.
The Role of the PT and PTA Medication management can be considered A good encompassing definition of
a partnership between the patient, his/her medication management is:
24 Here’s a Look at the caregivers, and the homecare staff, which are
Abstracts from the 2019 primarily registered nurse (RN), a physical A multi-faceted process of reconciling,
Poster Presentations therapist (PT), and/or other allied health reviewing, monitoring, and assessing the
professionals. Homecare physical therapists play medications an individual takes to assure
an especially important role in a patient’s home compliance with a specific medication
care routine and recovery, as they are oftentimes regimen, while also ensuring the individual
avoids potentially adverse drug event (ADE)
and other complications.4

Continued on Page 3

Published by the Home Health Section - APTA Did You Hear?
a component of the American Physical Therapy Association
Read All About It!
Editor
Dawn Widmer-Greaves, PT, DPT ACHH Live Course is
Going Virtual for 2020
Managing Editor/Design
Don Knox The 2-day live component is a critical

Publications Committee element of APTA Home Health’s Advanced Competency in Home
Julie Colaw, PT; Zachary Hampshire, PTA; Julie Hardy,
PT, MS; Mary Marchetti, PT, PhD; Olaide Sangoseni, PT, Health Certification program. The live course requires actual
DPT, MSc , PhD; Aban Singh, PT
demonstration of skills being discussed and active participation.
Section Officers:
President......................................Diana Kornetti, PT, MA The 2-day live portion also offers a huge networking opportunity
Vice President............................... Chris Chimenti, MSPT
Secretary........................................... Matt Janes, PT, DPT which is one of the strengths of the program.
Treasurer............................. Philip Goldsmith, PT, DScPT
Executive Director..............................................Don Knox However, due to the current and foreseeable future COVID-19

The Home Health Section Quarterly Report is the restrictions, hosting this in-person course is not possible through
official publication of the Home Health Section of
the American Physical Therapy Association. It is the end of 2020. We are aware that there are participants who are
published four times per calendar year (Winter, Spring,
Summer, Fall). Statements of fact and opinion are the on a time crunch to complete the certification within the 24-month
responsibility of the authors alone and do not imply an
opinion on the part of the officers or the members of the time window and therefore are pleased to offer this virtual option
Home Health Section.
for calendar year 2020.
Article & Content Contributions
Guidelines for contributions are available from the Live content will be delivered in a virtual synchronous format
Home Health Section website. If you have materials you
would like considered for publication, please email them with interactive videos and breakout sessions (using a webinar
via attachment to the Home Health Section Executive
Director: [email protected]. platform such as Zoom) and will be offered in two seminars. Each

Advertising seminar will consist of 4 weekend days of 4-hour sessions numbered
Advertising rates and details are available from the
Section website, www.homehealthsection.org, or by 1 through 4 which must be taken sequentially. Below are the
contacting the Section office at 720-459-5559.
seminars that will be offered through the end of 2020. You may
Electronic subscriptions to the Home Health Section
Quarterly Report are available at a rate of $100/year. choose to attend all 4 sessions in the same seminar or you may for
Order through the Section's online store.
example choose seminar 1 and 2 in September, then seminar 3 and 4
Copyright ©2020 by Home Health Section - APTA
in November, as long as you complete all 4 in the correct order.
Postmaster: Send address changes to Home Health
Section APTA , PO Box 3406 , Englewood, CO 80155. Seminar 1 (Eastern Time Zone):

www.homehealthsection.org • Session One: September 19th, 8:00am–12:00pm ET
PO Box 3406 • Englewood, CO 80155 • 720-459-5559
• Session Two: September 20th, 8:00am–12:00pm ET
Page 2
• Session Three: September 26th, 8:00am–12:00pm ET

• Session Four: September 27th, 8:00am–12:00pm ET

Seminar 2 (Pacific Time Zone):

• Session One: November 14th, 8:00am–12:00pm PT

• Session Two: November 15th, 8:00am–12:00pm PT

• Session Three: November 21st, 8:00am–12:00pm PT

• Session Four: November 22nd, 8:00am–12:00pm PT

Virtual Seminar Details:

• Max 30 registrants per session. Register Early!

• The Five (5) online pre-requisite core courses must be

completed at least 7 days prior to session one of the seminar

you register for.

• Participants would ideally do all 4 sessions within the same

seminar, but will be allowed to, for example, do session 1

and 2 in September and then sessions 3 and 4 in November.

• To qualify as having completed the live component of

the ACHH certification, all 4 sessions will need to be

attended sequentially, and must be attended this year (2020).

Registration Fees:

(Fees include registration JulEy a1r–lyABuirgd. 17 RegAuulagr. 1P8ri–cing
for all 4 sessions)

APTA HHS Member $490.00 $530.00
APTA Member $540.00 $580.00
Non-Member $590.00 $630.00

Continued on Page 26

APTA Home Health Section

Medication management can be broken down into three main When checking medications, the Home Health Agency staff
categories, each of which will be discussed in the article: must verify the name of the medications (generic or brand name),
type (capsules or tablets), frequency (how often the patient needs
1. Medication reconciliation to take the medication), dosage (correct dose in Mmol or mg with
2. Medication education (safety, setting reminders and decimal dot in correct place noted), and indication for use (the
reason the patient is taking the medication and what condition is
helpful aides) being treated). It is also important to check that all medications
3. Medication compliance (education on health literacy and are present at the patient’s home. If something is missing, the
HHA staff should ascertain why and help procure the missing
medication errors) medication. Oftentimes, patients will inform the HHA staff
that they are in the process of getting the medications from the
Each topic will be examined in detail with a discussion to pharmacy or that a family member has them.
ensure all parameters are met for a successful outcome of the
patient’s health. PT will perform a drug review of all the medications present
in the home to ensure there are no harmful drug interactions or
Medication Reconciliation therapeutic duplication (two medications present from the same
Medication reconciliation is a verification and validation chemical family or therapeutic class). The PT must ensure that
lookalike and sound-alike drugs are correctly prescribed (e.g.
process that validates the list of all medications that the patient Avanza/Mirtazapine an antidepressant vs. Avandia/ Rosiglitazone
was receiving in the hospital or care facility before being for Diabetes, Celebrex/Celecoxib an anti-inflammatory vs.
discharged to go home4, This process ensures the patient avoids Cerebryx/Fosphenytoin an anticonvulsant, Celexa/Citalopram an
potentially dangerous drug interactions and other complications. antidepressant).5,6

When a patient is discharged from any facility, be it acute Based on personal experience, the caregiver may sometimes
care, long term care, or a doctor’s office, a requisition is received be reluctant to share the drug information, giving the excuse that
by the main homecare office for homecare services. An RN or PT the nurse already processed this information. Thus, a therapist
is frequently one of the primary staff members that will open this will need to be firm while gently explaining that Medicare requires
patient’s homecare episode and provide medical reconciliation. this, and additional monitoring improves the patient’s safety.
This is called the start of care visit (SOC) or initial evaluation, Furthermore, since the PT is involved with exercises and gait
a comprehensive process in which all aspects of the patient’s training, it is essential for PTs to know what drug(s) the patient is
condition and medications are detailed. The SOC visit involves taking so that the therapy program implemented is comfortable for
completing the OASIS (Outcome and Assessment Information Set), the patient.
a data management guide involving all aspects of the patient’s
care. An Initial Evaluation is less involved, as only a few targeted One of the medications that is often overlooked is oxygen.
OASIS questions are asked. Initial evaluations are done mostly Since oxygen is now a classified as a drug, medication and
by physical therapists, occupational therapists (OT), or speech administration details must be present (e.g., the rate of intake in
therapists (ST), while SOCs are done by RNs or PTs, and very rarely liters per minutes, whether continuous or intermittent flow, the
by STs. Each person on the care team is involved with patient intake method - nasal cannula or a mask, whether administered
care and responsible for favorable outcomes for patients, of which from a home concentrator or tank and whether administered with
medication management is one of the major factors. or without a humidifier).

When calling to make the first appointment for his/her SOC Proper storage of oxygen in the home is paramount to the
visit, the patient or caregiver should have all of the hospital safety of the patient and others living in the same environment as
discharge papers and medication list available, so that the home the patient. Some of the questions that should be asked are:
health agency (HHA) staff can validate it. These medications5
include but are not limited to: • Is there a sign outside the door to ascertain that oxygen
is in use?
• Prescription and non-prescription drugs
• Over the counter drugs (OTC) that the patient may be • Is there any gas in the air at home?
• Is anyone smoking around the patient taking oxygen?
taking, including PRN (pro re nata-as circumstances • Are there working smoke detectors present in the home?
arise) drugs
• Saline/heparin flushes A safe environment for the oxygen administration can be
• Enteral nutrition—including additives created by assessing the patient’s or caregiver’s understanding of
• Creams/ointments the machine and care required.
• Herbals, nutraceuticals (flaxseed, ginseng, antioxidants),
homeopathic preparations, if any If any discrepancy is found (e.g., omissions, duplications,
• Dietary supplements, vitamins differently named medications, different doses, and so forth)
• IV drugs or chemotherapy drugs and their route, including during medication verification, the prescribing physician needs to
the dosage (if known), via PICC (peripherally inserted be informed of the discrepancy and a need for further clarification
central catheter) line or port and frequency is requested. Corrections to the patient’s chart/EMR and
communication with the patient’s physician must be done within 24
The home health care staff will validate the medication list hours of the identification of the discrepancy, and must be recorded
by cross-referencing each item on the list with medication bottle with the appropriate dates. Once the medication verification and
labels and the medications listed in the patient’s electronic medical drug review are completed, medical reconciliation is complete.6
record (EMR).

The Quarterly Report | Summer 2020 Page 3

When a patient is discharged from care, a detailed list of his/ what is needed, in case of an emergency. It is best to carry
her current medication list must be given to the patient. medications in their original container. Additionally, carry
a list of the medications at all times. Teach the patient to be
Medication Education as Part of Patient and Family Education proactive in all their care.8
It is recommended as a best practice to ensure both patient
2. The patient’s functional mobility status: normally done at the SOC
and caregiver are familiar with the medication plan of the patient, or initial evaluation visit will enable the PT to assess a patient’s
including any changes that occur over time.5 For each visit, the ability to access his/her medications. Some factors to consider:
patient should be asked if there was any change in any medication, • Ability to walk the short distance and retrieve their
if any medication was stopped or if the dosage was changed or medications?
substituted. This would include duplications, omissions, drugs • What is the cognitive status of the patient?
ordered but not in the home at the time of the evaluation, different • What are the other comorbidities the patient may have?
doses present on bottle vs. in the chart, and different medications.7 Many arthritic patients have difficulty in opening their
medication bottles. This can be stressful and/or painful
The PT should make a list of all the medications that the for the patient. A potential solution to this issue could be
patient is taking, with active participation from the patient and to call the pharmacy and ensure the patient is given their
caregiver in this process. medications with simple, easy to remove lids.

Some factors that need to be addressed are: 3. Where the medications are kept: they should be kept in a place
1. Patient and caregiver education beginning with the first where the patient can reach the medications easily (i.e., not
too much of a reach or stretch required). If the caregiver is in
day of home care visit: the HHA staff should be informed charge, he/she can always share with the patient where the
of any changes in their drug regime, either with increased/ medications are kept so that if needed, the patient can retrieve
decreased doses, change in medications, discharged drug. All them independently. Additionally, in the case of cognitive issues,
of the changes need to be listed in EMR under drug review/ it is easier to tell the patient to change the medication bottle
management. and place it in a different location after taking it. By seeing the
• Assess the patient and caregiver’s understanding of the medications are now in a different location, the patient can know
that he/she took his medications. For instance: keep medications
medication that the patient is taking at the time of first on top of the bedside table before use and place bottles in the
contact and with any medication changes later on. drawer after use.
• Emphasis should be placed on taking medication at correct
times, especially pain medication. The patient needs to 4. Cognition and forgetfulness: Patients often forget to take their
understand how this could assist him/her to reach improved medications, and then will sometimes panic and take a double
outcomes (i.e., relief of pain and/or improved functional dose, or not take them at all. Patients may have other underlying
mobility). health conditions that increase their forgetfulness, such as
• Disposal of old and expired drugs should be done fluctuating blood pressure, which can make them lethargic and
immediately and appropriately with the agreement of less aware of what they have taken or when they have taken their
the patient and caregiver. Rationale should be stated so medication. It is important to stay up to date with the patient and
the patient/caregiver understands the importance of this be vigilant of his/her behavior and actions. Label medications
action. Any drug that the patient is not taking currently with large lettering for visually impaired patients. This request
can be placed in a location that is separate from the current can be made with the pharmacist who can do this.
medications.
• Educate patients to check all medications every time before 5. Health literacy: Often, older patients have problems
ingesting them. maintaining the drug regime due to poor health literacy. When
• Educate patients on which foods or drinks to avoid when doctors use medical terminology with patients, the patients do
taking certain medications (i.e., not eating various not always understand instructions well. It is important to teach
vegetables with blood thinners). patients that if they do not understand any instructions given
• Educate patients regarding how to take medications, with by their doctor, they should ask for clarification and request it be
water, juice, or intravenously. explained in simpler language.
• Express the importance of not sharing their medication with
anyone else. 6. Non-prescription medications/supplements: Instruct the
• Educate the patient so he/she understands never to use patient/caregiver to check with the doctor and/or the
another person’s medication from that person’s quota since pharmacist before taking any over-the-counter medications
the dosage of the patient’s medications could be different. such as aspirin, other pain relievers, antacids, or cold remedies.
• Make sure the patient brings all his/her medications to Vitamins, minerals, and other supplements should also only
every doctor’s office visit and let the physician review all the be used with the advice of the doctor and/or pharmacist. These
medications so the physician’s office can also help with the may cause side effects when combined with regular medications.
medication reconciliation process.
• Instruct patients to make sure to have an adequate supply
of medications. For short term medications like opioids
post-surgery, ensure there is enough to last the weekend.
• Advise patients to carry all medications that he/she may
need if going out of town and make sure to carry more than

Page 4 APTA Home Health Section

Medication Compliance Besides the above concerns, many other factors result in
Adherence to medical management in-home care is a critical nonadherence, for example: inability to take medications in a
timely period due to lack of caregiver, or due to soreness at an
aspect of medical treatment to allow patients to regain their prior injection site for individuals with diabetes. These factors need to
level of function while at home. The World Health Organization be understood by healthcare providers so that they can enable
notes that the average nonadherence/noncompliance rate is 50% patients to take action to mitigate the barriers that may lead to
among those with chronic illnesses, and cites that as a serious nonadherence.9
issue.9 Various consequences of nonadherence might include
worsening conditions, an increase in comorbid diseases, with The healthcare industry is dealing with a massive problem
subsequent increases in health care costs, readmissions to hospital, of poor or nonadherence. Nonadherence can lead to serious
and in worst-case scenarios, death.9 adverse drug events.12 These events are associated with as
many as 1.3 million emergency department visits per year, and
As a home care provider, you have likely heard many patients 350,000 hospitalizations each year.2 Most of these events may be
provide reasons for why they have decided to not take their preventable with proper patient education and compliance.13
medications. The eight most common reasons for medication
nonadherence are as follows10,11: Home healthcare physical therapists can do a lot to alleviate
and minimize these problems. Once a patient is on a homecare
1. Fear: Patients frequently cite that they are afraid of physical therapist regimen, PTs are frequently the first health care
the medication side effects, without understanding the providers that meet the patients. Furthermore, depending on the
importance of why the drug was prescribed. severity and needs of the patient, PTs may visit a patient anywhere
from three to five times a week. Due to the constancy and frequency
2. Cost of the drug: If high co-pays are present for the drugs, of visits, we, as therapists, can build a relationship of trust with a
patients are more likely to forgo the medications. This is patient. The ability to foster these relationships with patients is
dependent on the patient’s financial status. integral to educating the patients on their medications, as well as
monitoring their medication routine and compliance.14
3. Misunderstanding how to take the drug: Many patients
have poor health literacy and taking the medication, or how A friendly, yet professional, relationship may help the patient
best to take the medication, is not well understood, despite express his/her reasoning for poor medication adherence. Many
label instructions. Especially when a patient takes multiple times, non-adherence is due to a lack of understanding or difficulty
medications, drug interactions, and instructions can be in cognition, visual, functional mobility, or poor health literacy,15
difficult to understand. Physical therapists are educated to evaluate these areas. Once the
cause of noncompliance is known, it is very easy to correct and find
4. Depression: Often, with depression, patients can be forgetful, solutions to these problems. Some non-adherence examples and
causing them to not adhere to their medication plan. solutions are provided below.

5. Mistrust: Patients may be skeptical of their health care For example, a patient may not be able to retrieve or open
provider, especially when discharged from the hospital was his/her medication bottle. In the home, a physical therapist can
completed by an internist. recognize this and take steps to contact the patient’s pharmacists
to explore more accessible bottles or packs for the patient’s use.
6. Lack of symptoms: When a lack of symptoms is present, the Functional mobility deficits can be worked on in numerous ways:
patient may feel it is not necessary to continue with their exercises to improve balance, posture, strengthening, and gait
medications. Often, reasoning may include saving financial training exercises may help enable the patient to remain home
resources and helping medications to last over a more and in his/her environment. Most times, physical concerns can
extended period. be effectively addressed by physical therapists. Finding simple,
safe, and clear solutions will help patients gradually remove any
7. Worry: Sometimes, patients feel that they may get mobility barriers.
dependent on medications.
Another reason for non-adherence is poor cognition.16 Patients
8. Too many medications (or polypharmacy): With the may forget whether or not they took their medications. PTs can
prescription of multiple medications, patients may be help the patients and their caregivers by creating charts or setting
confused about how to manage their drug schedules with up reminders on most used or frequently visited places. Multiple
various timings, days, or frequencies. medication reminder aides are available now and can be introduced
to patients or their caregivers.

Reminder aides can play a big role in assisting patients
in medication compliance. In today’s world, voice-activated
technologies and assistive devices, such as the Amazon Alexa,
Google Home, or Microsoft Cortana, can be set up to play vocal
reminders for patients to take their medications. Smartwatches,
necklaces, fitness trackers, or phone reminders can also be used.
There are even home servers and tracking systems such as the Pill
Drill.17 Color-coded pillboxes/charts serve as reminders. These
things are specifically meant to assist patients in following a
medication regimen.

The Quarterly Report | Summer 2020 Page 5

Finally, financial concerns are often cited as one of the reasons to help ensure appropriate patient care is delivered and optimal
patients may not fill their medications. Healthcare professionals clinical outcomes are obtained.
can help by informing providers of these issues and assist in
finding alternative methods for the patient to procure his/her Additional Resources:
medications or generic versions of them. Various organizations • The Joint Commission: National Patient Safety Goals:
assist patients in these manners, such as medical social workers or https://www.jointcommission.org/en/standards/national-
medical assistance programs. Additionally, encouraging patients patient-safety-goals/
and their caregivers to speak with their pharmacists is a great step. • NeedyMeds: BeMedWise Patient Information and Education
Pharmacists are another resource that can guide patients and their Program: https://www.bemedwise.org/
caregiver on various options.18 • Medication Management for Older Adults: https://www.
bemedwise.org/medication-management-for-older-adults/
Guiding a patient in medication and home care program • First Databank: https://www.fdbhealth.com/
compliance requires trust between the PT and the patient. It is • Medication Reconciliation - Getting Started Kit: https://
of utmost importance, as compliance will enhance outcomes, www.patientsafetyinstitute.ca/en/toolsResources/pages/
and allow patients to remain at home, be independent, and avoid med-rec-resources-getting-started-kit.aspx
readmissions to the hospital. With health care costs reaching nearly
insurmountable limits, all participants need to understand and play About the Author:
a role in ensuring patient health success. A partnership is important Aban Singh, PT, LL:B, has been working as a physical
between the patient and his/her healthcare team. Physical therapists therapist for almost 39 years, in all aspects of Physical
are often the personnel that visit patients to teach them exercises, Therapy from management, teaching, acute care,
manage, and improve their deficits. Thus, good communication quality assurance and chart audits. She is currently
between the patient and the therapist is always very important. involved at clinical level. In the last few years, she has
Assessing a patient’s health literacy and providing individualized focused on Home Health Care. She is a member of the
exercise programs at their level of understanding and ability will help publication editorial committee and often contributes
lead to success in their health outcomes. articles to the Home health section of APTA.

Conclusion Aban has traveled and worked in many different parts of the
Medication management is a partnership between the patient/ world, enabling her to bring a fresh perspective and diverse insight
to the healthcare practice of physical therapy. She can be reached
caregivers and the homecare staff. Communication is of paramount at [email protected].
importance among the prescribing provider, the HHA staff, and
the patient. The patient must feel confident that a care plan is References:
manageable, and solutions will be reached if any question arises. 1. Ewert S. U.S. Population Trends; 2000 to 2050. http://www.ncsl.org/
Collaboration is important amongst homecare staff members,
as each member of the HHA team is responsible for monitoring Portals/1/Documents/nalfo/USDemographics.pdf. Published October 2015.
a patient’s compliance with his/her medication regime. Even a Accessed February 24, 2020.
simple question such as, “Did you take your pills or has there been 2. Centers for Disease Control and Prevention. Medication safety basics.
any change in your medication?” is sufficient to identify what is https://www.cdc.gov/medicationsafety/basics.html. Published September
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take their cues from us and will feel empowered in their decision- 3. Older Adult Falls. Centers for Disease Control and Prevention website.
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medication reconciliations should be an integral part of the practice

Page 6 APTA Home Health Section

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module/2702595#resource. Published June 5, 2015. Accessed March 17, 2020. 20. Janes M, Adamski H, Strunk E, Kornetti D, Langham B, Walsh J. Medication
and Physical Therapy Practice: APTA Home Health Section Quarterly Report.
15. National Institute for Health: Clear Communication: https://www.nih.gov/ Published April 2019. Accessed February 20, 2020.
institutes-nih/nih-office-director/office-communications-public-liaison/clear-
communication. Accessed on 6/24/2020.

When Change Happens:
Strategies for Leading Through Change

By Tonya Y. Miller PT, DPT, PhD

When asked to write an article on managing complex change the murder of George Floyd. With all this change happening at
at the American Physical Therapy Association (APTA) Combined once, the subject matter in this article might seem like a mountain
Sections Meeting in Denver this past February, I was excited to too high for individuals and organizations to climb. I asked myself,
share my experience leading home health teams through many “When faced with so much change, where do we possibly begin?”
different regulatory and industry changes over 20 plus years of
home health leadership. Of course, I had no idea what was right As I reflected on the topic, I began to realize that no matter
around the corner. Little did I know that we would not only face the what the size of the change or the speed of the change, some
significant changes associated with the Patient-Driven Groupings common themes always apply. This article addresses the key
Model (PDGM) but also the changes brought upon our country by strategies that home health leaders can leverage to help their teams
the coronavirus pandemic and the sociopolitical turmoil following through change.

The Quarterly Report | Summer 2020 Page 7

Be in the know So, what exactly does DISC mean? Table 1 lists the four
“People are different, but they are predictably different.”1 This behavioral styles, their common attributes, and biggest fears. What
is interesting to note is that approximately 65% of all individuals
important concept is invaluable in understanding how we deal have the primary style of “S” which stands for steadiness. The
with change. When considering how we move through change, it’s biggest fear of the “S” behavioral style is change. Certain styles are
important to have a framework to understand how people behave often more attracted to different careers and caregiving careers
in different circumstances. A useful tool that provides insight such as healthcare professions tend to attract individuals with
into the different approaches is the DISC assessment of behavioral primary “S” behavioral styles. Therefore, home health teams
tendencies. The DISC behavioral assessment is a valid and reliable may consist of even higher percentages of individuals who have a
assessment that quantifies human behaviors into four quadrants primary “S” behavioral style.1 Ever wonder why change can seem so
titled dominance, influencing, steadiness, and compliance.1,2 difficult for many in your organization? Well for most, it is simply
The theoretical work of William Marston, M.D., as published in built into how they view the world.
Emotions of Normal People (1928) is the foundation for the current
DISC behavioral styles.1 Martson’s original work, which describes The good news is once we understand that most of us fear
four latent dimensions of personality, was used to develop the change and resist making or adapting to change, we can focus on
DISC assessment which is useful for examining ideal job roles and strategies to facilitate turning change from something feared to
team interactions.3 This important tool can help you understand something individuals embrace. Instead of pushing individuals
how individuals react in different circumstances and challenges into adopting or accepting change, leaders need to break down
including how they react to change. the change into manageable components, connect change to what

Table 1 Percentage of the population Attributes Biggest Fear
Style 3-5% Driven by Challenges Being taken advantage of
D-Dominant 10-15% Engages often in social interaction Loss of social recognition
I-Influence 55-65% (up to 85% in the health care workforce) Strives for Security Change
S-Steadiness 10-15% Works towards correctness Being wrong
C-Compliance

motivates the team, integrate change into daily routines, and find through the process will have a greater chance of moving the team
ways to engage everyone in the process. through change than those who present a large challenge requiring
new tools and actions. Leaders need to consider all the ways the
Shrink the Change team already engages in the activities necessary to change and then
At first glance change often seems impossible. This effectively connect those activities to the concept of having a head
start. By making these connections leaders shrink the change.
overwhelming feeling relates to the tendency to look at the end
goal and not the next step. Although understanding the big picture Connecting this back to the primary “S” behavioral styles,
and the vision of where the organization is headed is important, a team comprised of many individuals who have a primary “S”
it is often too much for individuals to envision and connect to behavioral style are less likely to fear a change that is closer to their
where they are currently. Therefore, big goals and grand visions current reality. Shrink the change…reduce the fear.
can often paralyze teams from moving forward. Leaders need to
communicate the vision and at the same time break that vision Connecting Change and Motivation
down into manageable pieces. Understanding ways in which behavioral styles drive our

In their book “Switch” the authors Chip Heath and Dan Heath approach to change is a large part of successfully leading others
discuss the concept of shrink the change. Chip and Dan discuss through change, but leaders also need to understand how emotions
research in which two different groups of customers were given can hijack the process. A driving force behind many of our emotions
loyalty cards for car washes. The first group had to collect 8 car are our values or internal motivators.5 When we understand what
wash stamps to get a free car wash while the other group had to motivates us and what motivates others, we can connect the dots
have 10 car wash stamps to get a free car wash. The catch was that between the activities associated with the change to those things
the group of 10 were given a head start… they receive two free that motivate us. There are many ways to examine motivation,
stamps so that they only needed 8 stamps. Yes, the same number but one way that I found helpful in my career is by utilizing a
as the first group. However, the results were much different standardized assessment tool. An example of one of these tools
between the two groups. The group who had the head start is The Talent Insight Assessment Tool of Driving Forces, which is
collected their stamps faster and at a higher rate. By shrinking the a tool based on the theoretical framework established by Edward
change, the group who had the head start perceived an easier path Spanger in his 1928 work entitled “Types of Men”.5 This framework
to reaching the end goal than the group who felt like they were examines six different categories of motivation. Table 2 outlines
starting with nothing.4 and defines these six different categories. Understanding how
people connect to these different motivators empowers a leader
Consider shrinking the change for home health organizations. to ignite a passion for change by aligning the change to what
When faced with regulatory changes or transition to remote motivates individuals.
working, the leader who can demonstrate how the team is designed
to take on the change and already has the tools necessary to walk

Page 8 APTA Home Health Section

Table 2 Description
The value one derives from gaining knowledge
Driving Force (motivator) The value one perceives in task completion and results of their tasks
Knowledge The value one perceives the objectivity or harmony in their surroundings
Utility The value one perceives in helping others
Surroundings The value one perceives from a certain level of status
Others The value one perceives in new ideas and methods of doing things
Power
Methodologies

Let’s walk through an example. An individual who is highly process, individuals will see the space and time for new projects
motivated by altruism in their interactions with others may have allowing for actions associated with change to slowly move into
heightened emotions anytime they feel that social justice is their locus of control.
threatened or promoted. By aligning organizational change to their
strong motivation for altruism, they become more engaged in the Pull Don’t Push
process and more committed to its success. Simply demonstrating Think about how organizations initiate a change only to find
how a change makes the lives of their patients better or allows
them to keep providing great care to patients connects their that after a large initiative and a bit of time people are either back
motivations to the outcome. Leaders who take time to understand to their old routines or have found a way to work around the desired
the motivations of their teams and are thoughtful in understanding process. Why do we fail so often at creating real change?
how changes either conflict or connect with team members’
motivations are more likely to keep teams engaged through The challenge comes back to the concept of trying to push
challenging activities associated with the change process. individuals through change versus pulling together to move the
individuals through it. Let’s go back to the primary “S” behavioral
Stop Doing style. As we know, individuals who have the primary “S” style
When change occurs, we often react by trying to slow the may fear and resist change. Instead of pushing, leaders need to
understand strategies to gently pull individuals through the change.
speed of the change or stop the change altogether. This process
leads to frustration as well as wasted time and resources. During Leaders who pull teams along by allowing for participation in
times of change, it’s important to take a step back and consider the evaluation of the problem, examining potential solutions, and
our locus of control. Spending time evaluating what aspects are establishing measures of success create a sense of empowerment
in your control and what items are external to your control is a and investment in the change. Pulling teams along takes more
great start to developing a plan to address change. By categorizing time and more focus from the leader as well as an understanding
items into those things within your locus of control, those things that their way may not be the best. Let’s walk through an example.
you can influence, and those things that are a concern but beyond Leader X has decided there needs to be a new process for scheduling
your locus of control, you can start to develop actionable items to visits. Leader X outlines the new process. At the next staff meeting,
address the areas within your control.6 Identifying the items within Leader X describes the new process to the team and explains that
your control and establishing strategies to address them expands the new process starts on Monday. This method of pushing change
your locus of control. onto the team is bound to backfire. Sure enough, weeks later there
is frustration and confusion around the process and most team
Creating a stop doing list is a strategy utilized to identify those members are doing twice the work since they are using the old
items within your locus of control. Let’s look at how to move forward process and then completing the new process to make the boss
with that stop doing list. When faced with a new project or a change happy. Now let’s change this scenario to a pull situation. Leader X
we often start by looking at what we are going to do to accomplish it. determines that there is a problem with scheduling visits. Instead
We have all been there…have a new project…start a new to-do list! of coming up with a solution, Leader X states the problem at the
This brings with it a level of stress and anxiety for most because our next staff meeting and solicits feedback in a variety of ways from
days are already filled with tasks and we have no room for a new list the team. Once the true problem is identified, Leader X gains
of things to accomplish. So how can we fit one more thing into our feedback from team members on possible solutions including
day? That’s where the stop doing list comes into play. By starting activities they already do that will still work in the new process as
with a stop doing list we begin with the concept that we are not well as things they can stop doing to create space. Once the team
going to add new things and more work. Instead, we are going to first finds possible solutions, Leader X determines the most effective
evaluate the things we currently control and move some of them off solution from the list and presents it to the team. Together they
our list. Tackling the stop doing list first gives you a sense of control develop an implementation plan to move to the new scheduling
over the path and allows for space to consider those things that you process. They plan several check-in points and solicit feedback
can control in the next project. I find that spending time on my stop along the way. The team gradually moves to the new scheduling. In
doing list once a month whether faced with a change or not allows this example, Leader X pulled the team along through the change
me to feel more in control of projects and life in general. The stop thus reducing stress and potential for resistance to change.
doing list increases my locus of control and empowers me to take on
new projects and goals. In the second situation Leader X understands the behavioral
styles and motivators of the team, they found a way to shrink the
Leaders need to facilitate open discussions and provide a safe change by incorporating current activities, expanding their locus of
place for individuals to develop stop doing lists. Through this control through the stop doing list, and finally soliciting feedback
from the team along the way. Engaging these strategies Leaders X

The Quarterly Report | Summer 2020 Page 9

facilitates long term change that moves the organization towards passionate about personal growth and developing strong leadership
cores committed to integrity, accountability, and self-awareness.
its best potential. Tonya can be reached at [email protected].

We are facing significant changes in our world, country, and References:
1. Bonnestetter B, Suiter, J. The universal language: DISC reference manual.
the health care industry. Now more than ever, leaders need to
Phoenix AZ. Target Training International:2016. ISBN: 978-0-9707531-4-4.
understand how individuals react to change and learn ways to 2. Gehrig E. Styles insight reliability study. TTI Success Insight website. https://

facilitate teams to move through change. This article gives leaders research.ttisi.com/project/style-insights-2017-reliability-study/. Published
May 2017. Accessed June 5, 2020.
a foundation to develop strategies necessary to guide teams 3. Bell R, Fann SA, Morrison JE, Lisk JR. Determining personal talents and
behavioral styles of applicants to surgical training: A new look at an old
through these ever-changing times. Remember…know your team, problem, Part 1. Journ. Surg Ed. 2011; doi: 10.1016/j.surg.2011.05.016.
4. Heath C, Heath, D. Switch. How to change things when things are hard.
make the motivation connection, shrink the change, stop doing, London, England Random House Business Group: 2010.
5. Talent Insight Assessment. Target Training International website. https://
and pull don’t push! blog.ttisi.com/12-driving-forces-what-you-need-to-know. Updated June 25th,
2020. Accessed June 30th, 2020.
About the Author 6. Brimm L. How to embrace complex change. The Harvard Business Review
Tonya Y. Miller is an Assistant Professor in the website. https://hbr.org/2015/09/how-to-embrace-complex-change.
Graduate School of Physical Therapy at Lebanon Published September 1, 2015. Accessed May 15, 2019.
Valley College. In addition to her role as a faculty
member, Tonya Miller is a national speaker and
founder of TYM Coaching. With over 25 years of
executive leadership skills and a Ph.D. in Leadership
Studies, Tonya combines real-world experience with

academic expertise. From coaching front-line healthcare providers
to board room negotiations, Tonya uniquely tailors her leadership
coaching programs to fit any individual or organization. She’s

Cracking the Code of ICD-10 in Home Health

By Jaclyn Warshauer, PT, CRC, and Shannon Liem, MS, CCC-SLP; COS-C

The principal diagnosis per 30-day payment period, as noted role along with the other members of the IDT in identifying and
on the claim, is one of the main drivers of home health (HH) communicating conditions and concerns observed. According to
reimbursement under PDGM (Patient-Driven Groupings Model), the International Classification of Diseases, 10th Revision, Clinical
as it determines the clinical grouping. This means that accurate Modification (ICD-10-CM) Official Guidelines for Coding and
recording of the diagnoses and documentation supporting the Reporting, “A joint effort between the healthcare provider and the
relevance of those chosen becomes paramount to ensure accurate coder is essential to achieve complete and accurate documentation,
reimbursement. Selection of diagnosis codes to represent the code assignment, and reporting of diagnoses and procedures.”1
patient’s clinical characteristics and conditions should be an
interdisciplinary team (IDT) effort. Therapists play an important The ICD-10-CM is used for classifying diagnoses and reasons
for visits in all health care settings in the United States. There

Page 10 APTA Home Health Section

are two primary resources used to ensure appropriate coding: the §409.44(c)(1)(ii) states that “the patient’s clinical record must
2020 ICD-10-CM Code Tables (Code Tables) and the ICD-10-CM include documentation describing how the course of therapy
Official Guidelines for Coding and Reporting (Official Guidelines). treatment for the patient’s illness or injury is in accordance
The Official Guideline is a companion document to the Code with accepted professional standards of clinical practice.” If
Tables. These guidelines are provided by the Centers for Medicare there is not an identified cause of muscle weakness, then it
and Medicaid Services (CMS) and the National Center for Health would be questionable as to whether the course of therapy
Statistics (NCHS). Adherence to the Official Guidelines when treatment would be in accordance with accepted professional
assigning ICD-10-CM diagnosis codes is required under the standards of clinical practice.
Health Insurance Portability and Accountability Act (HIPAA). It is SECONDARY DIAGNOSES (OASIS M1023) include coexisting
expected that home health agency (HHA) clinicians and coders will conditions actively addressed in the patient’s Plan of Care, and any
ensure that diagnoses and ICD-10-CM codes reported in the OASIS comorbid conditions having the potential to affect the patient’s
data set meet these guidelines.2 The Code Tables and Official responsiveness to treatment and rehabilitative prognosis, even
Guidelines are updated annually on October 1. ICD-10-CM will be if the condition is not the focus of any HH treatment itself. The
referred to going forward as ICD-10. secondary diagnoses may or may not be related to a patient’s recent
hospital stay but must have the potential to impact the skilled
Diagnosis Instruction from the OASIS-D Guidance Manual services provided by the HHA according to the OASIS-D Guidance
In HH, a comprehensive assessment is completed to understand Manual.2 Diagnoses are to be listed in the order that best reflects
the seriousness of each condition and supports the disciplines and
the patient’s overall medical condition and care needs before services provided. Secondary diagnoses are ordered by the degree
selecting and assigning diagnoses on the OASIS. Many agencies that they impact the patient’s health and need for HH care, rather
utilize a coder or coding company to make recommendations than the degree of symptom control. For example, if a patient
based on the documentation provided to assist with accurately is receiving HH care for Type 2 diabetes that is “controlled with
applying the ICD-10 guidance. However, the final determination difficulty,” this diagnosis would be listed above a diagnosis of a
of the patient’s primary and secondary home health diagnoses fungal infection of a toenail that is receiving treatment, even if the
must be made by the assessing clinician based on the findings of fungal infection is “poorly controlled.”2
the assessment, information in the medical record, and input and On the OASIS, up to five secondary diagnoses may be added.
documentation from the referring practitioner.2 Utilizing a coder However, the claim allows up to 24 secondary diagnoses. CMS has
does not relieve the responsibility of the IDT to understand the noted that any additional diagnoses listed on the claim should
basic coding conventions and ensure that there is a connection follow the definitions found in the OASIS Guidance Manual.4 The
between the documentation and code selection. CY2019 HH Final Rule states, “Because ICD–10 coding guidelines
require reporting of all secondary diagnoses that affect the plan
The diseases and conditions reported on the OASIS must of care, we would expect that more secondary diagnoses would be
have been documented by the referring practitioner at the time of reported on the home health claim given the increased number of
assessment. If a patient assessment suggests certain conditions secondary diagnosis fields on the home health claim compared to
may be present, but are not documented by the practitioner, or the the OASIS item set.”5
documentation lacks specificity, the practitioner should be queried Diagnoses should be excluded if they are resolved or do not
for clarification, with the possibility of adding the diagnosis before have the potential to impact the skilled services provided by the
the assessment is finalized. HHA. An example of a resolved condition is cholecystitis following
a cholecystectomy. It is also important to note that diagnoses
PRIMARY DIAGNOSIS (OASIS M1021) is the chief reason may change during the HH stay due to a change in the patient’s
the patient is receiving home care and the one most related to health status or a change in the focus of HH care. At each required
the current HH Plan of Care. According to the OASIS-D Guidance OASIS time point, the clinician must assess the clinical status and
Manual,2 “The primary diagnosis may or may not relate to the determine the primary and secondary diagnoses based on patient
patient’s most recent hospital stay but must relate to the skilled status and treatment plan.2 When diagnosis codes change between
services (skilled nursing, physical therapy, occupational therapy, one 30-day claim and the next, there is no requirement for the
and speech-language pathology) rendered by the HHA.” Note that HHA to complete an RFA 5 “Other Follow-up” assessment. With the
on the claim, the chief reason for the home care is referred to as the current rule, this assessment is optional to change the diagnosis on
principal diagnosis. Generally, these diagnoses should match. the claim.3 Anecdotally, it appears many agencies are completing
the RFA 5 so the diagnoses match on the claim and the OASIS.
It is also important to note that not every ICD-10 code The CoP 484.55(d) does require an RFA 5 when there has been a
available will correspond to a clinical grouping in PDGM. Of the major improvement or decline in a patient’s condition that was not
over 72,000 ICD-10 codes available, approximately 43,000 are envisioned in the original Plan of Care.6 CMS expects agencies to
considered “groupable.” When an ungroupable code is entered have and follow agency policies that determine the criteria for when
on the claim as a principal diagnosis, it will not create a clinical the “Other Follow-up” assessment is to be completed.4
grouping. This results in a Questionable Encounter (QEC) and will
not return a HH Resource Grouper (HHRG) for reimbursement. Applying the Guidance and Selecting an ICD Code1
CMS has indicated that QECs are too vague to support a home care The Official Guidelines assist both the healthcare provider
episode and provided an example in the CY2020 HH Final Rule.
According to CMS3: and the coder in identifying diagnoses that should be reported.
The importance of consistent, complete documentation in the
As we stated in the CY 2019 HH PPS final rule with comment medical record cannot be overemphasized. Without it, accurate
period (83 FR 56474), M62.81, “Muscle weakness, generalized”
is a vague code that does not clearly support a rationale for
skilled services. Further, the lack of specificity for this code
does not support a comprehensive plan of care. We noted that

The Quarterly Report | Summer 2020 Page 11

coding cannot be achieved. The entire record should be reviewed Coding Terminology1
to determine the specific reason for the encounter and the Coding terminology is not intuitive. The following ICD-10
conditions treated.
coding terms, listed in like-categories, are provided so that when
The Coding Tables have two parts: The Alphabetic Index and terms are referenced in the coding guidelines or included in an
the Tabular List. ICD-10 code name, there is conceptual meaning behind the term.

ALPHABETIC INDEX: Lists thousands of “main terms” NEC: NOT ELSEWHERE CLASSIFIABLE, OTHER, or OTHER
alphabetically. Under each of those main terms, there is often a SPECIFIED: These terms are used when the ICD system does not
sublist of more-detailed terms. The Alphabetic Index is used to have a code specific for the patient’s condition to accurately report it.
determine the section/code to refer to in the Tabular List and does
not always provide the full code. NOS: NOT OTHERWISE SPECIFIED or UNSPECIFIED: These
terms are used when there is inadequate condition information
TABULAR LIST: Lists ICD-10 codes alphanumerically from (e.g., in the medical record) to select a more specific code.
A00.0 to Z99.89. It is divided into chapters based on body systems
or conditions. This list provides the ICD-10 codes plus their EXCLUDES1: Means “NOT CODED HERE!” The code excluded
descriptors and coding instructions, as applicable. should never be used at the same time as the code above the
Excludes1 note in the Tabular List. It is used when two conditions
To select a code that corresponds to a diagnosis cannot occur together, such as a congenital form versus an acquired
documented in the medical record, first locate the term in the form of the same condition. (Figure 1)
Alphabetic Index, and then verify the code in the Tabular List.
Read and be guided by the instructional notations that appear Figure 1: Excludes1 Example The ICD-10 code, R26.2 Difficulty
on both tables. The Alphabetic Index does not always provide the in walking, not elsewhere classified, includes multiple
full code. Addressing laterality and any applicable 7th character can Excludes1 conditions that are not to be coded when R26.2 is used.
only be done in the Tabular List. Excludes1:

The 2020 Code Tables and Official Guidelines can be accessed • Falling (R29.6)
from the CMS website at www.cms.gov/Medicare/Coding/ • Unsteadiness on feet (R26.81)
ICD10/2020-ICD-10-CM. • Ataxia (R27.0)
• Hereditary ataxia (G11.-)
Level of Detail in Coding1 • Locomotor (syphilitic) ataxia (A52.11)
ICD codes should accurately reflect the clinical documentation • Immobility syndrome (paraplegic) (M62.3)

in as much specificity as possible. Do not code conditions that were EXCLUDES2: Means “Not included here.” An excludes2 note
previously treated and no longer exist. However, “history” codes indicates that the condition excluded is not part of the condition
may be used as secondary codes if the historical condition has an represented by the code, but a patient may have both conditions
impact on current care or influences treatment. at the same time. When this appears under a code, it is acceptable
to use both the code and the excluded code together, when
The condition may be considered current, affecting patient appropriate. For example, code R10.11, Right upper quadrant pain,
care, if any of the following occur: has an Excludes2 of Dorsalgia (M54.-). This means that the right
upper quadrant pain code does not include dorsalgia. If the patient
• Assessment/Evaluation has dorsalgia in addition to the right upper quadrant pain, it would
• Monitoring be appropriate to code both R10.11 and M54.- together.
• Treatment
IN DISEASES CLASSIFIED ELSEWHERE: This is a manifestation
Codes are to be used and reported at their highest number of code and must be used in conjunction with the underlying condition/
characters available. They are composed of codes with 3, 4, 5, 6 or etiology code that is causing the manifestation. Such codes are never
7 characters. Codes with three characters are included in ICD-10 as permitted to be used as first listed or principal diagnosis codes.
the heading of a category of codes that may be further subdivided An example is dementia in Parkinson’s disease. In the Alphabetic
using fourth and/or fifth characters and/or sixth characters, which Index, code G20 is listed first, followed by code F02.80 or F02.81
provide greater detail. A three-character code is to be used only if it in brackets (see Figure 2). Code G20 represents the underlying
is not further subdivided. A code is invalid if it has not been coded etiology, Parkinson’s disease, and must be sequenced first, whereas
to the full number of characters required for that code, including codes F02.80 and F02.81 represent the manifestation of dementia in
the 7th character, if applicable. diseases classified elsewhere, with or without behavioral disturbance.

Many ICD codes, especially in the musculoskeletal section, HISTORY (OF): Personal history codes explain a patient’s past
have site and laterality designations: medical condition that no longer exists and is not receiving any
treatment, but that has the potential for recurrence, and therefore
SITE: The site represents the bone, joint, or the muscle involved. may require continued monitoring. A history of an illness, even if
For some conditions where more than one bone, joint, or muscle is no longer present, is important information that may alter the type
commonly involved, such as osteoarthritis, there is a “multiple sites” of treatment ordered.
code available. For categories where no multiple site code is provided
and more than one bone, joint or muscle is involved, multiple codes
should be used to indicate the different sites involved.

LATERALITY: Specifies whether the condition occurs on the left,
right, or is bilateral. If no bilateral code is provided and the condition
is bilateral, assign separate codes for both the left and right side.

Page 12 APTA Home Health Section

Figure 2: Manifestation Codes Dementia (degenerative THE 7TH CHARACTER: Not all conditions have a 7th character. It
(primary) (old age) (persisting) F03.90 with is used to explain the point in the episode of care from the patient’s
injury/condition perspective. The 7th character has different
• aggressive behavior F03.91 meanings depending on the section of the ICD-10 manual where it
• behavioral disturbance F03.91 falls (e.g., type of fracture, type of injury). The notes in the Tabular
• combative behavior F03.91 List will instruct if a 7th character is required. There are three
• Lewy bodies G31.83 [F02.80] categories of 7th character codes as noted in Table 1.
• with behavioral disturbance G31.83 [F02.81]
• Parkinsonism G31.83 [F02.80] Initial Encounter: 7th Characters A-C
• with behavioral disturbance G31.83 [F02.81]
• Parkinson’s disease G20 [F02.80] • Active treatment for the condition such as surgical treatment, ER
• with behavioral disturbance G20 [F02.81] encounter, diagnostic testing, initial casting, physician visit.
• violent behavior F03.91
• Rarely used outside the acute setting.
AFTERCARE: Aftercare visit codes cover situations when the
initial treatment of a disease has been performed and the patient Subsequent Encounter: 7th Characters D-R
requires continued care during the healing or recovery phase, or
for the long-term consequences of the disease. Typically, aftercare • Routine care for the condition during the healing/recovery phase.
codes are represented by ICD-10 codes starting with the letter Z, or • Includes encounters for rehabilitation and aftercare of injuries.
by using the subsequent encounter 7th digit on the injury, fracture, • Subsequent encounter is most common in post-acute care.
or poisoning ICD-10 code.
Sequela (Late effects): 7th Character S
Aftercare Z code category examples:
• Z47.- Orthopedic aftercare • Care for the residiual effect (condition produced) after the acute phase of
• Z48.- Encounter for other postprocedural aftercare an illness or injury has terminated.

• No time limit on when a sequela code can be used.
• Examples: Scar after a burn, contracture after a healed fracture.

Table 1: 7th Character Categories

Such codes should not be used if treatment is directed at a Putting it All Together—Coding Process Example
current, acute disease. The diagnosis code is to be used in these A patient is referred to HH with a diagnosis of “COPD.” No
cases. The aftercare Z codes should also not be used for aftercare
for injuries, fractures, or poisoning; instead, assign the acute injury other information is known about the type of COPD, if this is an
code with the appropriate 7th character (for subsequent encounter). exacerbation, or any related pulmonary conditions.

PLACEHOLDER “X”: The ICD-10 utilizes a placeholder character First, locate the diagnosis in the Alphabetic Index (Figure 4). It’s a
“X”. The “X” is used as a placeholder in certain codes to allow for bit trial and error in selecting a word to begin your search. For example:
future expansion, and to fill out empty characters when an ICD
code has less than six characters and a 7th character is required. • Look up Chronic – it says “see Condition”
Where a placeholder exists, the X must be used for the code to be • Look up Pulmonary – it says “see Condition”
considered valid. The full code, to the 7th character, including • Look up Condition – it says “see Disease”
any possible X placeholders, will not typically be shown in the • Look up Disease—find Pulmonary
Alphabetic Index or Tabular List. An example is noted in Figure 3. • Find COPD under Disease > Pulmonary
The code instructions indicate that the appropriate 7th character is
to be added, but the code options only include four characters. As Figure 4: Coding Process Example (Alphabetic Index)
such, the placeholder character X must be inserted for the fifth and Disease, diseased—see also Syndrome
sixth characters to complete the code S47.1XXD, Crushing injury of pulmonary—see also Disease, lung
right shoulder and upper arm, subsequent encounter.
• artery I28.9
Figure 3: Code Requiring Placeholder X • chronic obstructive J44.9
S47 Crushing injury of shoulder and upper arm with
Use additional code for all associated injuries • acute bronchitis J44.0
Excludes2: crushing injury of elbow (S57.0-) • exacerbation (acute) J44.1
The appropriate 7th character is to be added to each code from • lower respiratory infection (acute) J44.0
category S47 • decompensated J44.1
with
• A - initial encounter • exacerbation (acute) J44.1
• D - subsequent encounter • heart I27.9
• S - sequela • specified NEC I27.89
S47.1 Crushing injury of right shoulder and upper arm • hypertensive (vascular)—see also Hypertension,
S47.2 Crushing injury of left shoulder and upper arm
S47.9 Crushing injury of shoulder and upper arm, pulmonary I27.20
unspecified arm • primary (idiopathic) I27.0
• valve I37.9
• rheumatic I09.89

Next, look up the related code (J44.9) in the Tabular List and
review the instructional notations starting with those under the
J44 category heading. (Figure 5)

The Quarterly Report | Summer 2020 Page 13

Figure 5: Coding Process Example (Tabular List) “Includes” provides further definition or gives examples of
the content of the category.
J44 Other chronic obstructive pulmonary disease “Code also” instructs that two codes may be required to fully
describe a condition. The sequencing of the codes depends on
Includes: the circumstances of the encounter and any direction given in
asthma with chronic obstructive pulmonary disease the Official Guidelines.
chronic asthmatic (obstructive) bronchitis “Use additional” is typically required when a condition has both an
chronic bronchitis with airways obstruction underlying etiology and multiple body system manifestations. Coding
chronic bronchitis with emphysema convention would require that the underlying condition be sequenced first,
chronic emphysematous bronchitis following by the manifestation.
chronic obstructive asthma
chronic obstructive bronchitis Excludes1 means “NOT CODED HERE!”
chronic obstructive tracheobronchitis Do not also code this condition.

Code also type of asthma, if applicable (J45.-) Excludes2 means “Not included here.”

Use additional code to identify:
exposure to environmental tobacco smoke (Z77.22)
history of tobacco dependence (Z87.891)
occupational exposure to environmental tobacco smoke (Z57.31)
tobacco dependence (F17.-)
tobacco use (Z72.0)

Excludes1:
bronchiectasis (J47.-)
chronic bronchitis NOS (J42)
chronic simple and mucopurulent bronchitis (J41.-)
chronic tracheitis (J42)
chronic tracheobronchitis (J42)
emphysema without chronic bronchitis (J43.-)

J44.0 Chronic obstructive pulmonary disease with
(acute) lower respiratory infection

Code also to identify the infection

J44.1 Chronic obstructive pulmonary disease with
(acute) exacerbation
Decompensated COPD
Decompensated COPD with (acute) exacerbation

Excludes2: chronic obstructive pulmonary disease [COPD] with
acute bronchitis (J44.0)
lung diseases due to external agents (J60-J70)

J44.9 Chronic obstructive pulmonary disease, unspecified
Chronic obstructive airway disease NOS
Chronic obstructive lung disease NOS

Excludes2:
lung diseases due to external agents (J60-J70)

Based on the information known from the documentation, and part in unraveling the diagnostic story to help the team properly
after reviewing the instructional guidance, the correct ICD coding code a patient’s primary reason for home care and contributing
for this patient’s condition is J44.9: Chronic obstructive pulmonary comorbidities. When everyone understands their cooperative
disease, unspecified. efforts go a long way to accurately and thoroughly describe a
patient’s condition through ICD-10 codes, cracking the code may
Proper ICD-10 coding can seem overwhelming and confusing. not be as hard as it seems.
Focusing on the collaborative efforts may help to make some
sense out of a process that can seem formidable. Therapists play a

Page 14 APTA Home Health Section

About the Authors References:
1. Centers for Medicare and Medicaid Services. ICD-10-CM Official Guidelines
Jaclyn Warshauer, PT, CRC, is the National Director
of Medical Review and Quality Services at Aegis for Coding and Reporting FY 2020 (October 1, 2019–September 30, 2020).
Therapies and is a certified coder. At Aegis Therapies, https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2020-Coding-
she monitors and trains on regulatory affairs, trains Guidelines.pdf. Accessed 6/10/2020.
therapists on conducting documentation auditing, and 2. Centers for Medicare and Medicaid Services. Outcome and Assessment
is a resource regarding Medicare coverage, coding, and Information Set OASIS-D Guidance Manual Effective January 1, 2019.
documentation requirements. Before employment with https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Aegis therapies, Jaclyn was a Medicare Medical Reviewer for 9 years with Instruments/HomeHealthQualityInits/Downloads/OASIS-D-Guidance-
National Government Services, a Medicare MAC. Jaclyn has served as a Manual-final.pdf. Accessed 6/10/2020.
resource to CMS on subjects related to coverage and documentation of 3. Centers for Medicare and Medicaid Services. Medicare and Medicaid
therapy services. [email protected]. Programs; CY 2020 Home Health Prospective Payment System Rate Update;
Home Health Value-Based Purchasing Model; Home Health Quality Reporting
Shannon Liem graduated from Florida State University Requirements; and Home Infusion Therapy Requirements; Final Rule. Federal
with a Master’s Degree in Communications Disorders. Register: November 18, 2019. https://www.govinfo.gov/content/pkg/FR-2019-
She is a licensed speech-language pathologist in the 11-08/pdf/2019-24026.pdf. Accessed 6/15/2020.
state of Florida and been in practice for more than 29 4. Centers for Medicare and Medicaid Services. October 2019 CMS Quarterly
years with experience in acute care, skilled nursing OASIS Q&As. https://qtso.cms.gov/system/files/qtso/CMS_OAI_3rd%20
facilities, outpatient, and home health. She has been Qtr_2019_QAs_OCT_2019_Final_508.pdf. Accessed 6/10/2020.
employed by Aegis Therapies for the last 25 years 5. Centers for Medicare and Medicaid Services. Medicare and Medicaid
and currently serves as a National Clinical Director for Home Health Programs; CY 2019 Home Health Prospective Payment System Rate
providing support for clinical programming, compliance, and regulatory Update and CY 2020 Case-Mix Adjustment Methodology Refinements; Home
updates within the home health environment. She is COS-C certified Health Value-Based Purchasing Model; Home Health Quality Reporting
since 2015. Requirements; Home Infusion Therapy Requirements; and Training
Requirements for Surveyors of National Accrediting Organizations; Final
Rule. Federal Register. https://www.govinfo.gov/content/pkg/FR-2018-11-13/
html/2018-24145.htm. Accessed 6/24/2020.
6. Centers for Medicare and Medicaid Services. State Operations Manual.
Appendix B – Guidance to Surveyors: Home Health Agencies. https://
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/
som107ap_b_hha.pdf. Accessed 6/24/2020.

Provide Home Programs
Using Your Phone!

Merging HomeHealth with Mobile Technology

Printed handouts
PDF for email
Video exercise links
Free phone app for patients

Free 2 Week Trial - Free Training
Introduction Discounts

www.ExerciseProLive.com
[email protected] 800-750-2756

The Quarterly Report | Summer 2020 Page 15

Government Affairs Happenings Summer:
Waivers from CMS By Carol Zehnacker PT, DPT, CEEAA

COVID 19 has provided some opportunities for which home the impact on acute care and long-term care facilities.
health agencies have been advocating for many years. COVID-19 Also, it allows for maximizing coverage by already scarce
has elevated home-based care’s impact on the national stage, with physicians, and advanced practice clinicians, and allow
skilled nursing facilities (SNFs) and hospitals leaning on providers those clinicians to focus on caring for patients with the
to care for more medically complex patients. The Centers for greatest acuity.
Medicare & Medicaid Services (CMS) has also demonstrated its • Waive Onsite Visits for HHA Aide Supervision. CMS
appreciation for in-home care, granting providers long-overdue is waiving the requirements at 42 CFR §484.80(h), which
operational flexibility.  requires a nurse to conduct an onsite visit every two weeks.
This would include waiving the requirements for a nurse
CMS is empowered to take proactive steps through 1135 or other professional to conduct an onsite visit every two
waivers as well as, where applicable, the authority granted under weeks to evaluate if aides are providing care consistent
section 1812(f) of the Social Security Act (the Act) to rapidly expand with the care plan, as this may not be physically possible
the Administration’s aggressive efforts against COVID-19. As a for a while. This waiver is also temporarily suspending the
result, the following blanket waivers are in effect, with a retroactive 2-week aide supervision by a registered nurse for home
effective date of March 1, 2020, through the end of the emergency health agencies requirement at §484.80(h)(1), but virtual
declaration. These waivers DO NOT require a request to be sent to supervision is encouraged during the period of the waiver.
the [email protected] mailbox or that notification be made • Allow Occupational Therapists (OTs), Physical
to any of CMS’s regional offices. Therapists (PTs), and Speech-Language Pathologists
(SLPs) to Perform Initial and Comprehensive
Home Health Agencies (HHAs) Assessment for all Patients. CMS is waiving the
• Providers able to order home health services now requirements in 42 CFR § 484.55(a)(2) and § 484.55(b)
include PAs, NPs, and CNSs, potentially reducing delays (3) that rehabilitation skilled professionals may only
in care: Until now, only physicians were able to certify perform the initial and comprehensive assessment when
the need for home health services. The legislation allows only therapy services are ordered. This temporary blanket
physician assistants, nurse practitioners, and clinical nurse modification allows any rehabilitation professional (OT,
specialists to order home health services for beneficiaries, PT, or SLP) to perform the initial and comprehensive
reducing delays and increasing beneficiary access to care in assessment for all patients receiving therapy services as
the safety of their homes. part of the plan of care, to the extent permitted under state
• Requests for Anticipated Payment (RAPs). CMS is law, regardless of whether or not the service establishes
allowing Medicare Administrative Contractors (MACs) eligibility for the patient to be receiving home care.
to extend the auto-cancellation date of Requests for The existing regulations at § 484.55(a) and (b)(2) would
Anticipated Payment (RAPs) during emergencies. continue to apply; rehabilitation skilled professionals would
• Reporting. CMS is providing relief to HHAs on the not be permitted to perform assessments in nursing-only
timeframes related to OASIS transmission through the cases. CMS continues to expect HHAs to match the
following actions below: appropriate discipline that assesses the needs of the patient
- Extending the 5-day completion requirement for the to the greatest extent possible. Therapists must act within
comprehensive assessment to 30 days. their state scope of practice laws when performing initial
- Waiving the 30-day OASIS submission requirement. and comprehensive assessments, and access a registered
Delayed submission is permitted during the PHE. nurse or other professional to complete sections of the
• Initial Assessments. CMS is waiving the requirements assessment that are beyond their scope of practice.
at 42 CFR §484.55(a) to allow HHAs to perform Medicare- Expanding the category of therapists who may perform
covered initial assessments and determine patients’ initial and comprehensive assessments provides HHAs with
homebound status remotely or by record review. This will additional flexibility that may decrease patient wait times
allow patients to be cared for in the best environment for for the initiation of home health services.
them while supporting infection control and reducing

Page 16 APTA Home Health Section

• 12-hour Annual In-service Training Requirement for on aspects of care delivery most closely associated with
Home Health Aides. CMS is modifying the requirement at COVID-19, and tracking adverse events during the PHE. The
42 CFR §484.80(d) that home health agencies must assure requirement that HHAs and hospices maintain an effective,
that each home health aide receives 12 hours of in-service ongoing, agency-wide, data-driven quality assessment and
training in 12 months. Following section 1135(b)(5) of the performance improvement program will remain.
Act, they are postponing the deadline for completing this
requirement throughout the COVID-19 PHE until the end Flexibility for Medicare Telehealth Services Medicare B
of the first full quarter after the declaration of the PHE • Eligible Practitioners. Under authority granted under
concludes. This will allow aides and the registered nurses the Coronavirus Aid, Relief, and Economic Security Act
(RNs) who teach in-service training to spend more time (CARES Act) that broadens the waiver authority under
delivering direct patient care and provide additional time section 1135 of the Social Security Act, the Secretary
for staff to complete this requirement. has authorized additional telehealth waivers. CMS is
waiving the requirements of section 1834(m)(4)(E) of the
• Detailed Information Sharing for Discharge Planning for Act and 42 CFR § 410.78 (b)(2) which specify the types of
Home Health Agencies. CMS is waiving the requirements of practitioners that may bill for their services when furnished
42 CFR §484.58(a) to provide detailed information regarding as Medicare telehealth services from the distant site. The
discharge planning, to patients and their caregivers, or waiver of these requirements expands the types of health
the patient’s representative in selecting a post-acute care care professionals that can furnish distant site telehealth
provider by using and sharing data that includes, but is not services to include all those that are eligible to bill Medicare
limited to, (another) home health agency (HHA), skilled for their professional services. This allows health care
nursing facility (SNF), inpatient rehabilitation facility (IRF), professionals who were previously ineligible to furnish and
and long-term care hospital (LTCH) quality measures and bill for Medicare telehealth services, including physical
resource use measures. This temporary waiver provides therapists, occupational therapists, speech-language
facilities the ability to expedite discharge and movement of pathologists, and others, to receive payment for Medicare
residents among care settings. CMS is maintaining all other telehealth services.
discharge planning requirements.
Sequestration and Medicare Advantage:
• Clinical Records. Following section 1135(b)(5) of the Numerous commercial payers, United Healthcare, Aetna, and
Act, CMS is extending the deadline for completion of the
requirement at 42 CFR §484.110(e), which requires HHAs to Anthem have suspended 2% sequestration in alignment with the
provide a patient a copy of their medical record at no cost CARES Act for the remainder of 2020. As it relates to commercial
during the next visit or within four business days (when payers, providers should be aware of the following:
requested by the patient). Specifically, CMS will allow HHAs
ten business days to provide a patient’s clinical record, • Providers that have contracts with Medicare Advantage
instead of four. plans tied to the amount the providers would be paid under
various Medicare payment systems, and/or tied to a portion
Home Health Agencies (HHAs) and Hospice of the plan’s capitation payments, generally should receive a
• Training and Assessment of Aides. CMS is waiving the 2% increase from the plans.
requirement at 42 CFR §418.76(h)(2) for Hospice and 42
CFR §484.80(h)(1)(iii) for HHAs, which require a registered • Providers that are not contracted with a Medicare
nurse, or in the case of an HHA a registered nurse or Advantage plan also should receive at least a 2% increase
other appropriate skilled professional (physical therapist/ because they are supposed to be paid at least what the
occupational therapist, speech-language pathologist) to provider would have received under original Medicare.
make an annual onsite supervisory visit (direct observation)
for each aide that provides services on behalf of the • Some commercial contracts use Medicare-based rates. If the
agency. Following section 1135(b)(5) of the Act, CMS is commercial plans using Medicare-based rates are applying
postponing completion of these visits. All postponed onsite sequestration on commercial claims, they may ‘forget’ to
assessments must be completed by these professionals no turn off these edits. You’ll want to be alert to any applicable
later than 60 days after the expiration of the PHE. contractual appeal deadlines.
• Quality Assurance and Performance Improvement
(QAPI). CMS is modifying the requirement at 42 CFR MLN Matters Number: SE20011 Revised Article Release Date:
§418.58 for Hospice and §484.65 for HHAs, which requires June 1, 2020.
these providers to develop, implement, evaluate, and
maintain an effective, ongoing, hospice/HHA-wide, Telehealth and Medicare Part A
data-driven QAPI program. Specifically, CMS is modifying The move toward telehealth was a long-term trend that home
the requirements at §418.58(a)–(d) and §484.65(a)–(d) to
narrow the scope of the QAPI program to concentrate on health providers were cognizant of before COVID-19. But because
infection control issues, while retaining the requirement the virus has demanded social distancing, telehealth has forced
that remaining activities should continue to focus on adverse its way into health care in a manner that would have been almost
events. This modification decreases burden associated unimaginable in 2019.
with the development and maintenance of a broad-based
QAPI program, allowing the providers to focus efforts “I think the genie’s out of the bottle on this one,” CMS
Administrator Seema Verma said in April. “I think it’s fair to say
that the advent of telehealth has been just completely accelerated,
that it’s taken this crisis to push us to a new frontier, but there’s
absolutely no going back.” The telehealth boom could mean
improved patient outcomes and new lines of business for home

The Quarterly Report | Summer 2020 Page 17

health providers. Waiver Resources
For telehealth to be effective for home health providers, • COVID-19 Emergency Declaration Blanket Waivers &
Flexibilities for Health Care Providers (PDF) UPDATED
Congress and CMS would need to pave the way for direct (6/25/20) https://www.cms.gov/files/document/summary-
reimbursement. Currently, a home health provider cannot get covid-19-emergency-declaration-waivers.pdf
paid for delivering virtual visits in fee-for-service (FFS) Medicare. • Blanket waivers of Section 1877(g) of the Social Security Act
Sen. Susan Collins, R-Maine. has hinted at introducing legislation (3/30/20) https://www.cms.gov/files/document/covid-19-
that would allow for direct telehealth reimbursement in the blanket-waivers-section-1877g.pdf
home health arena. However, no bill is present at the time of the • https://www.cms.gov/Medicare/Fraud-and-Abuse/
publication of this article. While home health providers can’t PhysicianSelfReferral/Spotlight
directly bill for in-home telehealth visits, hospitals and certain • https://www.cms.gov/About-CMS/Agency-Information/
health care practitioners can. That regulatory imbalance could Emergency/EPRO/Current- Emergencies/Current-
lead to home health providers being used less frequently. William Emergencies-page
Dombi, president of the National Association of Homecare and • https://www.cms.gov/Medicare/Provider-Enrollment-and-
Hospice (NAHC) has stated that reimbursement for telehealth was Certification/ SurveyCertEmergPrep/1135-Waivers
a priority: “Our goal is to get telehealth recognized as the payment
equivalent to face-to-face visits. Hopefully there will be some About the Author
resolution and home health providers will be able to provide and Dr. Zehnacker is the owner of Physical Therapy
be reimbursed for telehealth services for the safety of both patients Consults, LLC, and contracts with Bayada Home
and therapists.” Health. She is the Chair of APTA Home Health’s
Government Affairs Committee and may be reached at
[email protected].

Does Nutrition Have
a Place in Chronic
Disease Management?

By Dr. Michele Carr, RDN, DPM, NWCC, FAPWCA

For decades, traditional medical practice has largely majority of older Americans.
emphasized using good nutrition to prevent disease. But what According to the National Council on Aging (NCOA), in 2017
about patients who already have an ongoing illness? Can
adequate nutrition significantly lessen the effects of chronic 80% of older adults in the US had at least one chronic disease and
disease? Although there is still much to be discovered, nutritional 68% had two.1 This is a tremendous burden on the individual,
intervention is emerging as a key strategy to improve outcomes for the healthcare system, and even the government. In fact, it is
patients dealing with chronic disease. This encompasses the vast estimated that 75% of national healthcare costs can be attributed
to the treatment and management of chronic diseases.¹ The top

Page 18 APTA Home Health Section

ten most common chronic conditions include, in descending These discoveries may come as no surprise. It may seem
order, hypertension, high cholesterol, arthritis, ischemic obvious that improved intake in the body leads to a better output of
heart disease, diabetes, chronic kidney disease, heart failure, energy and health. Just think of a car engine. Everyone knows that
depression, Alzheimer’s disease or dementia, and chronic bad gasoline leads to poor car performance. But how can clinicians
obstructive pulmonary disease (COPD).2 incorporate nutrition education into their already busy clinical
practice? That might seem like a daunting task, but it doesn’t have
A lengthy article could be written to expound on the benefits of to be. Here are a few ideas:
nutrition for each of these ten illnesses. For the sake of brevity, the
following are a few recent discoveries which illustrate how nutrition 1. Get Informed
interventions and malnutrition affect outcomes in ongoing illness. Most clinicians received very little education in nutrition.11

• A 2015 retrospective research study summarized the In addition, there is a constant stream of new information and
findings of 10 years of literature on heart failure and evidence-based nutrition recommendations. Educate yourself. Put
nutrition. Scientists concluded that there was a clear nutrition topics on your educational radar. Make a goal to read a
benefit when patients with chronic heart failure received nutrition article or listen to a nutrition podcast each month. Or
educational and prescriptive nutrition interventions. perhaps subscribe to a reputable nutrition newsletter. The Academy
Improved outcomes included decreased hospital of Nutrition and Dietetics (www.eatright.org) or the American
readmission rates, decreased patient deterioration scores, Heart Association (www.heart.org) are two helpful websites with
and decreased inflammatory markers.3 dependable information and resources. When attending medical
conferences, select a course that includes diet or nutrition.
• The correlation between hypertension and dietary
changes is significant. The most effective nutritional 2. Screen for Malnutrition
interventions include weight loss, reduced sodium intake, There are several validated and reliable nutrition screening
increased potassium intake, moderation of alcohol intake,
and Dietary Approaches to Stop Hypertension (DASH)- tools that are free to use and easy to include in an initial
style and vegetarian dietary patterns.4 According to the assessment. It is important to ensure that the selected screening
Mayo Clinic, diet alone can lower one’s systolic blood tool is ideal for your particular patient population. The Mini
pressure by 11 mm Hg.5 Nutrition Assessment-Short Form (MNA-SF), Malnutrition
Universal Screening Tool (MUST), Nutrition Risk Screening
• Although a healthy diet is only part of the prescription, a (NRS-2002), Nutrition Screening Initiative, and Seniors in the
2019 study showed that consuming a diet rich in vegetables, Community: Risk Evaluation for Eating and Nutrition (SCREEN)
fruits, fish, and lean meat is associated with a reduced are just a few. The National Council on Aging published a
risk of depression. In fact, when a group of “moderately- comparison guide of several nutrition screening tools.12 With a
depressed” young adults followed a Mediterranean style of few simple questions, these tools can help identify patients who
eating for three weeks, their depression score fell from the are more likely malnourished and need further assessment by a
“moderate” down to the “normal” range in comparison to registered dietitian.
the control group. On two different depression scales, the
study group with the nutrition intervention reported less 3. Phone a Friend
depressive symptoms and these results were maintained When a patient has a nutritional issue, refer them to the
three months after the study concluded.6
appropriate provider. Clinical collaboration is critical. Contact
• Patients with dementia are at heightened risk for their physician. Express your findings and concerns. Encourage a
malnutrition. A 2014 study in the Clinical Interventions consultation with a registered dietitian, if necessary.
in Aging showed a powerful correlation between
malnourished cognitively impaired patients and increased 4. Watch out for food insecurity
morbidity and mortality.7 Food insecurity is defined as not having a reliable nor

• Those who live with COPD often have weight loss, adequate access to affordable or nutritious food.13 In 2017, almost
sarcopenia (protein wasting), and pulmonary cachexia. One 8% of homes in the US with an adult 65 years or older experienced
study from 2013, showed that if intubated patients with food insecurity.14 Just last year, a study published in The Journal
COPD had BMI’s of less than 21, they required more days of the American Geriatric Society found that if a senior citizen
on the ventilator, and were more likely to be rehospitalized, participated in both Medicaid and Medicare, the rate increased to
placed back on the ventilator, and/or die.8 Many studies over 25%.15 Patients cannot heal wounds, maintain lean muscle
are showing that these problems can be mitigated through mass, recover from injury and fight infection if they cannot get
nutritional intervention and supplementation.9 enough or the right foods to eat.1

• During the 2020 Virtual Endocrinology Conference, 5. Start the conversation
a report was shared on a 3 ½ year study of remote Helping patients improve their intake does not have to be a
counselling in patients with type 2 diabetes. Results from
the intervention showed meaningful improvements in formalized process. It can be as simple as starting a conversation
hemoglobin A1c, body weight and while the patient is resting between exercise sets or while taking
several cholesterol markers.10 their vitals at the bedside. Here are a few easy prompts:

The above is just a brief glimpse of a growing collection “Wow! You seem to have a lot of energy today. What did you
of evidence that indicates nutritional support, education, and have for breakfast?”
intervention can improve a patients’ overall health status, even
when living with an enduring disease.

The Quarterly Report | Summer 2020 Page 19

“What did your doctor recommend for your diet? How is References
that going?” 1. Chronic Disease. National Council on Aging.org. https://www.ncoa.org/

“Since your surgery, how are you managing with getting your healthy-aging/chronic-disease. Accessed on June 10,2020.
groceries and preparing your meals?” 2. 10 Common chronic conditions for adults 65+. National Council on Aging.org

6. Stick to the facts https://www.ncoa.org/blog/10-common-chronic-diseases-prevention-tips/.
Resist the urge to spread anecdotal accounts or sensational Accessed June 10, 2020.
3. Abshire, M et al. Nutritional interventions in heart failure: a systematic
misinformation. Just like politics and religion, it seems that review of the literature. J Card Fail. 2015;1,12:989-99. doi:10.1016/j.
everyone has differing opinions on diet and nutrition. Don’t make cardfail.2015.10.004.
the conversation a battlefield. Simply use evidence-based nutrition 4. Appel, L J. The effects of dietary factors on blood pressure.” Cardiol Clin.
principles when you share information. 2017;35,2: 197-212. doi:10.1016/j.ccl.2016.12.002.
5. Eating a Diet that is You. MayoClinic.org. https://www.mayoclinic.org/
7. Model Good Behavior diseases-conditions/high-blood-pressure/in-depth/high-blood-pressure/art-
Perhaps the most powerful influence a clinician exerts is their 20046974. Accessed on June 6, 2020.
6. Francis HM, Stevenson RJ, Chambers JR, Gupta D, Newey B, Lim CK. A
own example. Patients will remember both what a clinician says brief diet intervention can reduce symptoms of depression in young adults
and especially what they do. Model good behavior in your patient – A randomized controlled trial. PLoS ONE 14(10): e0222768. https://doi.
interactions. A physical therapist might state, “It has been 15 org/10.1371/journal.pone.0222768. Accessed on June 8, 2020.
minutes since you started this activity. Let’s hydrate with some 7. Malara A, Sgrò G, Caruso C, et al. Relationship between cognitive
water before our next exercise. I should probably drink some water, impairment and nutritional assessment on functional status in Calabrian
too.” A nurse may comment, “Your blood sugar is low right now long-term-care. Clin Interv Aging. 2014; 9:105‐110. doi:10.2147/CIA.S54611.
which can be dangerous. What are some good options for you to eat Accessed June 8, 2020.
or drink when your blood sugar is low? Why don’t you eat that now, 8. Li-dong S, Chang-sheng G, Zi-yu Z. Explore the influence of BMI in the
and we can recheck your blood sugar in 15 minutes and make sure optimal time of weaning from sequential mechanical ventilation for severity
you are out of danger?” chronic obstructive pulmonary disease. BMC Emerg Med 2013;13 Suppl 1:S1.
10.1186/1471-227X-13-S1-S1.
8. Don’t be afraid 9. COPD Foundation. Nutrition for Someone with COPD. https://www.
It is never too late to take positive action. Healthcare clinicians copdfoundation.org/Learn-More/I-am-a-Person-with-COPD/Nutrition-for-
Someone-with-COPD.aspx. Accessed June 15, 2020.
employ numerous and creative modalities to help their patients 10. Long-Term Continuous Remote Care Intervention With Carbohydrate
achieve optimal outcomes. Why not add the modality of nutrition? Restriction Reduces Need for Medication in T2D. Edocrinologyadviser.com.
https://www.endocrinologyadvisor.com/home/conference-highlights/endo-
Through thoughtful and educated interviewing and practices, 2020/long-term-continuous-remote-care-intervention-with-carbohydrate-
clinicians can encourage and promote healthy food choices which restriction-reduces-need-for-medication-in-t2d/. Accessed on June 6, 2020.
will help all patients, even those suffering with chronic diseases. 11. Adams K, Butsch WS, Kohlmeier M. The state of nutrition education at
Eat well, be well! US medical schools. J Biomed Ed. 2015; Article ID 357627. https://doi.
org/10.1155/2015/357627. Accessed June 28, 2020.
About the Author 12. Malnutrition screening and assessment tools. National Council on Aging.
Dr. Michele Carr is both a registered dietitian and a org. https://www.ncoa.org/assesssments- tools/malnutrition-screening-
podiatrist. In addition, she is Nutrition Wound Care assessment- tools/#. Accessed June 8, 2020.
Certified (NWCC) and certified in OASIS (COS-C). 13. 13. About Food Insecurity. Foodbankofiowa.org. https://www.foodbankiowa.
These skills have been useful in her position as a org/about-food-insecurity. Accessed June 8th, 2020.
clinical educator for Encompass Health. For over two 14. 14. Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. Household Food
decades, Dr. Carr has enjoyed teaching thousands of Security in the United States in 2017 [Economic Research Report No. 256].
clinicians across the nation, consulting privately for Washington, DC: US Department of Agriculture; 2018. Accessed June 5, 2020.
15. 15. Pooler JA, Hartline-Grafton H, DeBor M, Sudore R, Seligman H. Food
the wound care industry, and speaking professionally at state and insecurity: a key social determinant of health for older adults. JAGS;
national medical conferences. 2018;67,3:421-424. Accessed June 5, 2020.

Page 20 APTA Home Health Section

Recognizing and
Reporting
Elder Abuse:
The Role of the
PT and PTA

By Mary T. Marchetti, PT, Ph.D.,

Board Certified Geriatric Clinical Specialist

Abuse of older adults (OAs) can take a variety of forms, short run, and provide for better identification and programs for care
including physical, sexual, emotional, fiscal/financial, and in the long run.
psychological abuse.1 Passive neglect and willful confinement by
caregivers are other ways in which OAs may be victimized.1 Home Elder Abuse is Costly
health physical therapists (PTs) and physical therapist assistants It is estimated that a minimum of $36.5 billion is lost annually
(PTAs) are in a unique position to recognize and respond to the
various types of elder abuse. While the problem is complex and by OAs due to financial abuse and scams.3 Direct costs are costs
deserves an in-depth study, the purpose of this current article is that arise as a direct result of the abuse, such as medical care for
simply to help PTs and PTAs recognize the signs and symptoms of injuries.2 These amount to at least $5.3 billion of healthcare costs
abuse. Also, this article will provide information regarding what annually.2 This amount does not include indirect costs of abuse
actions to take in instances of suspected abuse. incurred, such as exacerbations of chronic conditions as a result of
the stressful living situation.
Due to a variety of reasons, elder abuse is somewhat difficult
to study.2 Elder abuse is a vastly under-reported crime, with an An OA who is abused is three times more likely to be
estimated only 1 out of 14 cases being reported,1,2 however, the New admitted to the hospital compared to those who are not subjected
York State Elder Abuse Prevalence Study estimated that for every to mistreatment.2 Also, those who are victims have a 300%
known case, 24 cases are unknown.2 With such a small percentage increased risk of premature death compared to their non-abused
of incidents reported, it is difficult to determine with any precision counterparts.1
prevalence, type of abuse, and the demographics of the victim
and the abuser, among other specifics. Furthermore, operational The Centers for Disease Control and Prevention (CDC) define
definitions of “elders,” as well as the different types of abuse are elder abuse as “…intentional act or failure to act by a caregiver or
inconsistent among various studies,2 thus making it difficult to another person in a relationship involving an expectation of trust
determine a comprehensive picture of the issue. Approximately 10% that causes or creates a serious risk of harm to an older adult…”4
of OAs in the United States over the age of 60 have experienced some Definitions, however, vary based on the purpose of study or
form of abuse.1 Currently, estimates are as high as 5 million OAs are program, the focus of study/program, state/government agencies,
abused annually in the United States,1 thus it is a significant health and other reasons that may depend on the circumstances (for
care issue. There does seem to be an increasing trend of reporting instance, the legal definition of assault, murder and so forth).
incidents.1 Hopefully, this will enable more OAs to obtain help in the The victims of elder abuse are both men and women, and those
with dementia or physical disabilities are at greater risk.1,2 The
perpetrators of abuse are generally close family and family

The Quarterly Report | Summer 2020 Page 21

caregivers; however, friends, paid caregivers and others may be For instance, in the state of Pennsylvania, healthcare providers
perpetrators, as well.1 who work in a domiciliary setting are required to report suspected
cases of elder abuse.9 That would include home health providers and
Clinicians must recognize the signs and symptoms of potential exclude outpatient settings and acute care. Resources to identify
abuse. Verbal and emotional abuse can be subtle. Physical therapists individual state mandates and ways to report are listed at the end
and PTAs should look and listen to the interactions between the OA of this article. Furthermore, the APTA has an excellent publication,
and the caregiver(s). Language and tone of voice that are belittling Guidelines for Recognizing and Providing Care for Victims of
to the OA would be of concern, as would attempts of the caregiver Elder Abuse, that includes information for each state.10 Legitimate
to exert power over the OA.1 The caregiver may attempt to edit reporters of suspected abuse are generally protected from legal
the responses of the OA with looks, glares or interruptions as the retribution from all potential sources of retaliation.8
OA answers questions. Changes in social engagement, withdrawal
or depression, and frequent arguing are other signs of potential It is important to know your state’s regulations in advance. In
emotional abuse.1 Physical abuse may be evident by unexplained mandatory situations, it may be necessary to advise the patient that
or poorly explained injuries (i.e., the explanation does not fit you are required by law to report any suspected abuse, including
the physical presentation), bruises, lacerations, and fractures.1 anything he/she may tell you. In non-mandatory situations, it may
Multiple injuries in various stages of healing may indicate ongoing be necessary to have the patient’s permission to include information
physical incidents. Signs of neglect include poor hygiene, unmet from the examination before reporting your suspicions to the
or poorly met nutritional needs, lack of appropriate medical care, authorities.
and pressure injuries, among others.1 When performing medication
reconciliation, therapists should take note and follow up if it The APTA10 recommends screening all patients for potential
appears that prescriptions are not being filled or administered abuse. This enables clinicians to become comfortable with asking
properly. Financial abuse, which includes withholding or misuse of certain questions as routine, and it enables the clinician to reassure
the OA’s funds,1 may be less apparent. Practitioners should be aware the patient that these are standard questions asked of all your
of any indications of a change in the OA’s financial status.1 patients, i.e., that you have not singled that person out. When
possible, try and see the patient alone, thus providing him/her the
The American Physical Therapy Association (APTA) Code of opportunity to speak more freely. Indirect questions such as, “Do
Ethics for the PT addresses the roles of the PT in suspected cases you feel safe in your home?” may be a good way to approach the
of abuse: issue. As you examine that patient, if you find concerning injuries
or signs, ask the patient about each. If the explanation does not
4E. Physical therapists shall discourage misconduct by physical fit what you are seeing; for instance, if the patient has multiple
therapists, physical therapist assistants, and other health care injuries on various surfaces of the body but indicates that the
professionals and, when appropriate, report illegal or unethical acts, injuries occurred during a single fall, probe deeper. More direct
including verbal, physical, emotional, or sexual harassment, to an questions, such as “That bruise looks similar to what I’ve seen when
appropriate authority with jurisdiction over the conduct. a person has been hit. Does that ever happen to you?” may elicit
more detailed and honest responses. Ask the patient where he/she
4F. Physical therapists shall report suspected cases of abuse has received care for the injuries. Going to multiple places for care
involving children or vulnerable adults to the appropriate authority, may indicate an attempt to hide a pattern of abuse. Also, carefully
subject to the law.5 observe interactions between the patient and the caregiver for any
signs of control on the part of the caregiver.
For the PTA, the APTA states:
4E. Physical therapist assistants shall discourage misconduct by Documentation must be very thorough and legible.10 Your
notes may become evidence. Write down specifically how the
physical therapists, physical therapist assistants, and other health patient responds to questions. His/Her words may become
care professionals and, when appropriate, report illegal or unethical very important in the investigation and potential prosecution
acts, including verbal, physical, emotional, or sexual harassment, to of abuse. Use a body map to note the locations and types of
an appropriate authority with jurisdiction over the conduct. injuries observed. If neglect is suspected, carefully document
the appearance, attire, and demeanor of the patient, as well as
4F. Physical therapist assistants shall report suspected cases your observations of the home (cleanliness, food availability,
of abuse involving children or vulnerable adults to the appropriate medications properly refilled, and so forth).
authority, subject to law.6
If possible, and with the permission of the patient, take photos
Federal and state laws further dictate the responsibility of of injuries, and possibly of the living situation (photography may be
healthcare providers, including PTs and PTAs, in recognizing and dependent on the home health agency’s policies; remember, using
reporting suspected cases of elder abuse. The Elder Justice Act, your phone is not secure). When photographing injuries, note the
which took effect in 2010, established funding for services and date and time of the photograph, and repeat photos on subsequent
research directed at reducing elder abuse.7 This act also established visits. Position the camera the same distance from the subject each
that all employees of long-term care facilities must report any cases time for consistency, and when possible, use a ruler/tape measure
of suspected abuse.7 Other federal laws established definitions of or an object (paper clip, penny…) to provide some size perspective.
abuse and funding for research, services, and training of local and Document the names and contact information of anyone who is
state prosecutors to reporting and prosecution of elder abuse.7 with the patient at the time of your visit, and if it is necessary to call
the authorities, document the names and identifying information
State laws refine reporting requirements, as well as legal of all respondents. Keep track of any canceled or rescheduled visits.
definitions for prosecution.7 For healthcare providers, reporting These may occur in an attempt to hide new injuries, or the caregiver
may be mandatory, non-mandatory for certain providers, or
mandatory under certain circumstances.8

Page 22 APTA Home Health Section

may be attempting to isolate the patient. Note any changes in the do make identifying abuse more challenging. Be vigilant, but be
patient on the next visit. cautious as well.

If you suspect abuse, evaluate the immediate situation.10 If the Finally, when interacting with any suspected victim of abuse,
patient is in immediate danger, call 911 or the equivalent in your there are some things that should always be kept in mind.9 One
area. If your safety is not compromised, remain with the patient until is to never blame the victim. There may be many reasons why a
the authorities arrive, and you can provide your information. If the victim is reluctant to report abuse, including fear of retaliation,
danger is not immediate, then report to the appropriate office in your shame, embarrassment and for older adults, fear of nursing home
state. Most states require that suspected abuse be reported within a placement. Also, never blame the perpetrator. Most commonly, the
short time, often within 24 hours.8 perpetrator is a family member and, despite the abuse, most victims
still love the perpetrator. Sometimes the best thing we can do for
It is important to keep in mind a variety of issues when the patient: provide him/her an opportunity to speak and feel safe
working with older adults. Oftentimes, there may be reasonable with us, and a supportive, non-judgmental ear.
explanations for things that seem to be pointing towards abuse, so
it is imperative to consider the complete picture rather than isolated About the Author
signs of potential abuse. The fragility of skin and bone may result in Mary T. Marchetti is Assistant Professor at the Rangos
unexplained or poorly explained injuries. School of Health Sciences Department of Physical
Therapy at Duquesne University in Pittsburgh, PA. She
Sensory and cognitive deficits may impact communication, is a Geriatric Certified Specialist and has expertise in
requiring the caregiver to intervene. Dietary and hydration geriatrics, balance, falls, examination, psychosocial
deficiencies are common among older adults. Even pre-morbid issues, and older adults.
familial relationships and habits vary—what you observe may
simply be how the family has always interacted. All of these issues

Resources

Area Association on Aging (AAA) SeniorLAWCenter
Number varies from locale to locale, but every county or region has http://seniorlawcenter.org/contact-us/
an AAA. Often, this is the office to which non-emergent suspicions Helpline: 1-877-PA SR LAW
of abuse should be reported. Organization can provide information on all areas of senior law

National Adult Protective Servicers National Center for Elder Abuse (NCEA)
http://www.napsa-now.org/get-help/help-in-your-area/ https://ncea.acl.gov/Resources/Reframing.aspx
Can assist with reporting in your area
Talking Elder Abuse
Eldercare Online Locator http://www.frameworksinstitute.org/toolkits/elderabuse/
https://eldercare.acl.gov/Public/Index.aspx Provides a toolkit that may be helpful for agencies to access
or call: 1-800-677-1116
Will assist with local reporting information National Council on Aging (NCOA)
https://www.ncoa.org/public-policy-action/elder-justice/
APTA
Guidelines for Recognizing and Providing Care for: Victims of Elder Center for Excellence in Elder Law - Stetson University
Abuse $13.95 member price https://www.stetson.edu/law/academics/elder/home/
Information about each state’s reporting laws available here

References 6. APTA Standards of Ethical Care for the Physical Therapist Assistant. www.
1. Elder abuse facts. National Council on Aging. Available at: https://www.ncoa. apta.org/ethics. 2019.

org/public-policy-action/elder-justice/elder-abuse-facts/. Accessed 1/12/20. 7. Basics. Center for Elders and the Courts. Available at: http://www.
2. Statistics and data. National Center for Elder Abuse. Available at: https:// eldersandcourts.org/elder-abuse/elder-abuse-material-for-right-rail-menu-
for-elder-abuse/basics/elder-abuse-laws.aspx. Accessed 3/16/20.
ncea.acl.gov/What-We-Do/Research/Statistics-and-Data.aspx#prevalence.
Accessed 1/12/20. 8. Mandatory Reporting Statutes for States 2016. Available at: https://www.
3. Elder justice. National Council on Aging. Available at: https://www.ncoa.org/ stetson.edu/law/academics/elder/home/. Accessed 3/16/20.
public-policy-action/elder-justice/. Accessed 1/12/20.
4. Hall J, Karch DL, Crosby A. Elder abuse surveillance: uniform definitions 9. Older Adults Protective Services Act. Available at: https://
and recommended core data elements.CDC.2016. Available at: https://www. www.legis.state.pa.us/cfdocs/Legis/LI/uconsCheck
cdc.gov/violenceprevention/pdf/EA_Book_Revised_2016.pdf. Downloaded cfm?txtType=HTM&yr=1987&sessInd=0&smthLwInd=0&act=0079. Accessed
1/12/20. 1/12/20.
5. APTA Code of Ethics for the Physical Therapist. www.apta.org/ethics. 2019.
10. American Physical Therapy Association. Guidelines for recognizing and
providing care for victims of elder abuse, rev. 2014. Alexandria, VA: 2014.

The Quarterly Report | Summer 2020 Page 23

Here’s a Look at the Abstracts
from the 2019 Poster
Presentations

Poster: Normative Data of Functional Measures in Eyes Closed (REC), 43.78 ± 22.46 sec Sharpened Romberg Eyes
Community-Dwelling Older Adults Open (SREO) 18.63 ± 20.70 sec Sharpened Romberg Eyes Closed
(SREC). Mean times decreased as the decade of life increased.
Authors: Wendy Anemaet PT, DPT, PhD, GCS, CWS, GTC, COS-C, Independent t-tests revealed a significant difference between
Amy Stone Hammerich PT, DPT, PhD, OCS, Colby Dell Balls SPT, males and females on OLSP (t=2.162; df=147.924; p=0.032), OLSN
Ryan Bourdo SPT, Connor Davis SPT, Sophia Fuller SPT, Catherine (t=2.560; df=149.431; p=0.011), TUG (t=2.180; df=157.019; p=0.031)
Munson SPT, Andres Monge SPT, Regis University and FOE (t=2.405; df=29.139; p=0.023). Further, a one way ANOVA
revealed a significant difference between decades of life in females
Purpose/Hypothesis: To identify normative data for balance and (F=6.985-17.106;p<0.001) OLSP, OLSN, TUG, and FOE. A one way
gait measures in community-dwelling older adults ANOVA revealed a significant difference between decades of
life in males (F=3.526-6.194, p<0.026) in OLSP, OLSN, and FOE,
Number of Subjects: 432 community-dwelling older adults with the TUG showing no significance between decades in males
(F=1.770;df=3;p=<0.160). A one-way ANOVA revealed additional
Materials/Methods: This secondary data analysis included 432 significant differences between decades of life in males and females
community-dwelling older adults with an average age of 70.6 (9.5) combined (F=3.960-27.635, p<0.04) in REC, SREO, SREC, FR,
years. Normative data were determined with Statistical Package for 5XSTS, GV, and SMWT.
Social Sciences Version 22 (Chicago, Illinois) to acquire descriptive
statistics including measures of central tendency and measures of Conclusions: This study analyzed a large data set of various
variability. ANOVA with Tukey post hoc analysis and Independent functional tests in the community-dwelling older adult population
T-Tests were used to determine significance between age groups and adds to the existing research by showing there exist significant
and sexes. differences between the decades of life amongst males alone,
females alone, and both combined. Further, this study provides
Results: Mean times for the entire sample were 18.04 + 17.01 data on more decades of life and has larger sample sizes in several
sec on One-Legged Stance Preferred (OLSP), 18.22 ± 16.85 sec decades than has been reported previously.
on One-Legged Stance Non-Preferred (OLSNP), 12.76 ± 8.96
sec on Timed Up and Go (TUG), 5.61 ± 0.95 sec Figure-of-eight Clinical Relevance: Measures of performance on functional
(FOE), 11.94 ± 4.86 sec Obstacle Course (OC), 10.30 + 3.35 inch outcomes are important for healthcare providers as they can
Functional Reach (FR), 1.14 ± 0.28 sec Gait Velocity (GV), 58.08 be referenced to determine if an individual is performing at an
± 7.97 sec Romberg Eyes Open (REO), 55.22 ± 13.06 sec Romberg adequate level or is at a higher risk for functional decline, falls,

Page 24 APTA Home Health Section

and potential injury. Since performance on some functional tests significant differences in HHD strength values for some muscles
(OLSP, OLSN, TUG, and FOE) differed between sexes, clinicians between decades with a general trend of decline in strength with
should look for gender-specific norms for comparison when using age. No significant difference was found between genders for
these tests. Amongst functional tests, there was a general trend of 6MWT and aerobic capacity values (p > 0.05). Also, no significant
diminishing functional scores as age increased indicating clinicians difference was found between decades of life for aerobic capacity
should not use norms determined with broad age ranges but instead values (p > 0.05). There was a significant difference between 6MWT
should look for norms of specific decades of life. values for ages 50-59 and 90+ (p < 0.05). Furthermore, there was
a significant difference for 6MWT values between ages 60-69 and
References both ages 70-79 and 80-89 (p < 0.05).
1. Aslan UB, Cavlak U, Yagci N, Akdag B. Balance performance, aging, and
Conclusions: This paper establishes normative data for HHD,
falling: A comparative study based on a Turkish sample. Arch Gerontol 6MWT, and aerobic capacity values for older adults between the
Geriatr. 2008; 46:283-292. ages of 50 and 90 years old. General trends in the values reported
2. Blankevoort C, Heuvelen M van, Scherder E. Reliability of six physical are similar to those in previous studies. However, this current study
performance tests in older people with dementia. Phys Ther. 2013;93(1). adds to the existing research by showing there exist significant
3. Bohannon RW. Five-repetition sit-to-stand test: usefulness for older patients differences between the decades of the life of community-dwelling
in a home-care setting. Percept Mot Skills. 2011; 112 (3): 803-806. adults and between sexes for some measures. Further, this study
4. Artaud F, Singh-Manoux A, Dugravot A, Tzourio C, Elbaz A. Decline in fast provides data on more decades of life and has larger sample sizes in
gait speed as a predictor of disability in older adults. J Am Geriatr Soc. several decades than has been reported previously.
2015;63:1129-1136.
5. Peters DM, Fritz SL, Krotish DE. Assessing the reliability and validity of a Clinical Relevance: Having access to normative data for older
shorter walk test compared with the 10-meter walk test for measurements of adults allows clinicians to compare the abilities of their older
gait speed in healthy, older adults. J Geriatr Phys Ther. 2013;23:24-30. patients to that of non-infirm older adults. This can assist in
6. McKay MJ, Baldwin J, Ferreira P, Simic M, Vanicek N, Burns J. Reference determining the severity of deficits, justifying the need for
values for developing responsive functional outcome measures across the treatment, and motivating patients.
lifespan. Neurol. 2017;88(16):1512-1519.
7. Kenny RA, Coen RF, Frewen J, Donoghue, Cronin H, Savva G. Normative References
values of cognitive and physical function in older adults: findings from the 1. Samuel D, Rowe P, Hood V, & Nicol A. The relationship between muscle
Irish longitudinal study on aging. J Am Geriatr Soc. 2013. 61:S279-S290.
8. Peel Nm, Kuys SS, Klein K. Gait speed as a measure in geriatric assessment strength biomechanical functional moments and health-related quality of life
in clinical settings: a systematic review. J Gerontol. 2012;68(1):39-46. in non-elite older adults. Age and Ageing. 2012;41:224-230.
2. Bohannon RW. Literature reporting normative data for muscle strength
Poster: Normative hand-held dynamometry, 6-minute walk measured by hand-held dynamometry: a systematic review. Isokinetics Exerc
test and aerobic capacity for older adults Sci. 2011;19:143-147.
3. Kaminsky LA, Imboden MT, Arena R, Myers J. Reference Standards for
Authors: Wendy Anemaet PT, DPT, Ph.D., GCS, CWS, GTC, COS-C, Cardiorespiratory Fitness Measured With Cardiopulmonary Exercise
Amy Stone Hammerich PT, DPT, Ph.D., OCS, Paul Bernard SPT, Testing Using Cycle Ergometry: Data From the Fitness Registry and the
Alex Davies SPT, Courtney Hardin SPT, Kristopher Heddings SPT, Importance of Exercise National Database (FRIEND) Registry. Mayo Clin Proc.
Sean Salazar SPT, Melanie Seifert SPT 2017;92(2):228-233.
4. Rapp D, Scharhag J, Wagenpfeil S, Scholl J. Reference values for peak
Purpose/Hypothesis: To report average values for handheld oxygen uptake: a cross-sectional analysis of cycle ergometry-based
dynamometry (HHD), 6 Minute Walk Test (6MWT), and aerobic cardiopulmonary exercise tests of 10090 adult German volunteers from the
capacity via Astrand Rhyming cycle ergometer test for older adults Prevention First Registry. BMJ Open. 2018;8(3):e018697.
ages 50-93 years and to determine if differences exist in these 5. Edvardsen E, Hansen BH, Holme IM, Dyrstad SM, Anderssen SA. Reference
values among decades of life and between sexes. values for cardiorespiratory response and fitness on the treadmill in a 20- to
85-year-old population. Chest. 2013;144(1):241-248.
Number of Subjects: 418 community-dwelling adults ages 50-93 6. Loe H, Rognmo Ø, Saltin B, Wisløff U. Aerobic capacity reference data in 3816
healthy men and women 20-90 years. PLoS ONE. 2013;8(5):e64319.
Materials/Methods: Secondary data analysis of data collected 7. Chen H-T, Lin C-H, Yu L-H. Normative physical fitness scores for community-
from 2012 to 2016 using Statistical Package for Social Sciences dwelling older adults. J Nurs Res. 2009;17(1):30-41.
Version 22. Measures of central tendency and measures of 8. Gouveia ÉR, Maia JA, Beunen GP, Blimkie CJ, Fena EM, Freitas DL. Functional
variability were reported by decade and sex. Differences between fitness and physical activity of Portuguese community-residing older adults.
decades and gender were analyzed with ANOVA and Kruskal Wallis J Aging Phys Act. 2013;21(1):1-19.
using Tukey and Mann Whitney U for post hoc testing, respectively. 9. Thaweewannakij T, Wilaichit S, Chuchot R, et al. Reference values of physical
performance in Thai elderly people who are functioning well and dwelling in
Results Normative data for HHD, 6MWT, and aerobic capacity the community. Phys Ther. 2013;93(10):1312-20.
values are reported for each decade of life over 50. A significant
difference was found for HHD strength values between men and
women for all muscles tested except cervical extensors with men
having higher absolute strength than women (p < 0.05). There were

The Quarterly Report | Summer 2020 Page 25

Continued from pg 2

Announcing the Section’s ‘Bring Your Friends Home Campaign’ That assessment sets the tone for a careful examination of not
The American Physical Therapy Association (APTA) and just the current state of the profession, but what isn’t being done,
what could be done, and how the landscape could change if goals
APTA’s Home Health Section have been built—one member at a were achieved.
time—into an inclusive and impactful community of over 100,000
members, who support APTA’s mission of building a community The lecture, delivered on July 1 and available through APTA’s
that advances the profession of physical therapy to improve website, was developed by the Physical Therapy Learning Institute
the health of society. Along with APTA’s new member referral with collaboration from APTA, the American Academy of Physical
campaign ONE by ONE, the Home Health Section is running a Therapy, the National Association of Black Physical Therapists, and
similar campaign, ‘Bring Your Friends Home’. This campaign allows the University of Delaware.
you to play an active role in building the Home Health Section’s
membership, and earn rewards for doing so. Titled “Who Do We Want to Be? Responsible Stewardship
of Our Profession,” Hicks’ lecture is a carefully constructed,
Any current active APTA Home Health Section member is thoroughly researched dive into the ways the physical therapy
eligible to participate as a recruiter by encouraging a new member profession could change its homogenous makeup through an all-out
to join the HHS, and will be entered to win one of two (2) prizes effort that must address inequities in not only physical therapist
quarterly! The HHS member with the most recruits will receive practice but in research and education. Hicks argues that a more
a grand prize at the end of the year! Examples of quarterly prizes diverse physical therapy workforce is the key to the profession’s
include an Amazon Fire TV Stick and an Amazon Echo Dot. long-term sustainability, and to improved outcomes.

How to Participate: To receive credit for each new or The data speaks for itself. Currently, Hicks explains, while
reinstated member recruited, the joining member must complete the U.S. population is 60% white, 13% Black, and 18% Latino or
the form below and enter the name of their ‘recruiter’ and reference Hispanic, APTA membership is 88.5% white, 1.5% black, and 2.5%
the email address affiliated with the recruiting member’s HHS Latino or Hispanic. And while other health profession education
membership. Forms without the referring member’s email cannot programs — most notably physician education — are showing
qualify toward the quarterly drawings. Once a new member is on improvement in the number of students from underrepresented
board, they are now also eligible to ‘Bring Friends Home’ and can be minorities, physical therapy has actually regressed when it comes
entered into drawings, so recruit early and often! to Black DPT students, who made up 4.7% of the DPT student
population in 2006-2007, compared with 3.4% in 2018-2019.
To submit referral information, use your phone to
scan the QR code here. Hicks leads viewers through practical steps that could be taken
throughout the profession, by institutions and individuals, from
How Have You Survived COVID-19? putting a greater emphasis on disparities-focused research, to making
The Home Health Section seeks feedback, anecdotes, and DPT program accreditation standards more explicit (and measurable)
when it comes to increasing diversity, to individual PTs becoming
strategies from our members on your experience with COVID-19, to more directly involved in community engagement and mentorship.
highlight in the Fall Quarterly Report.
The profession is beginning to realize the gravity of its current
Suggestions for submissions include: state, according to Hicks. That’s a good thing: but it’s barely a start.
• Anecdotal information from the field - what have you seen
as the biggest challenges and how did you overcome them? “The key is that we act on these ideas,” Hicks says, “and stop
• What have you done that is unique to home health? with the lip service.”
• Success stories and strategies; tips for self care, etc.
Hicks’ lecture was followed up a week later with a live Q&A
Please keep in mind that all submissions must be HIPPA session that further explored the central themes of the presentation,
compliant. Please send your submissions to us at admin@ well as the pressure points the profession faces as it moves toward
homehealthsection.org no later than Sept. 1, 2020. greater diversity. A recording of that session is now available.

APTA’s Woodruff Lecture Offers Paths to Improve Diversity Volunteers Needed for PT Home Handbook Update
Within the first 10 minutes of the inaugural Lynda The Practice Committee of the Home Health Section is seeking
D. Woodruff Lecture on Diversity, Equity, and
Inclusion in Physical Therapy, Greg Hicks, PT, volunteers as contributors and reviewers for the Providing Physical
PhD, FAPTA, takes stock of the effects of racial Therapy in the Home Handbook (4th edition—update). The Third
and ethnic disparities in health care, breaks down Edition was well received, but is now in need of revision due to
the demographic makeup of PTs and PT education changing science, the advance of communicable diseases and
programs, and arrives at an inescapable appraisal of changing regulations and payment structures.

where things stand. If you’re interested in joining this Practice Committee Work
The physical therapy profession, the data shows, is “a relatively Group, please go to the HHS website and complete the volunteer
form expressing this interest. Additionally, for any questions please
homogenous group of professionals who exist in a health care contact Kenneth L Miller, PT, DPT, Chair of Practice Committee,
system with significant issues related to unequal access and health HHS of APTA at [email protected].
care disparities based on race, ethnicity, socioeconomic status, and
geographic location,” Hicks said. Correction
For Vol. 57, No 3 of the Quarterly Report, print version: The
“And to date the PT profession as a whole has done very little
to address this public health concern,” Hicks added. “This is where article entitled “Did You Miss APTA CSM 2020? Here’s a Look at
we are right now.” the Abstracts from the Platform Presentations” actually included
the 2019 Platform Abstracts and should have been titled as such.
Our apologies for the error.

Page 26 APTA Home Health Section

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are constructed from durable EVA technology that stands up to heavy lightweight foam slants made of
foam for heavy, repeated use. use and is easy to clean. durable premium closed-cell foam.

Learn more: OPTP.COM
or call 800.367.7393

The Quarterly Report | Summer 2020 Page 27

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

ACHH Live The 2-day live component is a critical element of APTA Home Health’s Advanced Competency in Home Health Certification
Course Is program. The live course requires actual demonstration of skills being discussed and active participation. The 2-day live
Going Virtual portion also offers a huge networking opportunity which is one of the strengths of the program.
For 2020 With
September & However, due to the current and foreseeable future COVID-19 restrictions, hosting this in-person course is not possible
November through the end of 2020. We are aware that there are participants who are on a time crunch to complete the certification
Sessions within the 24-month time window and therefore are pleased to offer this virtual option for calendar year 2020.
Register
Live content will be delivered in a virtual synchronous format with interactive videos and breakout sessions (using a webinar
Early! platform such as Zoom) and will be offered in two seminars. Each seminar will consist of 4 weekend days of 4-hour sessions
numbered 1 through 4 which must be taken sequentially. Below are the seminars that will be offered through the end of 2020.
You may choose to attend all 4 sessions in the same seminar or you may for example choose seminar 1 and 2 in September,
then seminar 3 and 4 in November, as long as you complete all 4 in the correct order.

Seminar 1 (Eastern Time Zone):
• Session One: September 19th - 8:00am – 12:00pm ET
• Session Two: September 20th - 8:00am – 12:00pm ET
• Session Three: September 26th - 8:00am – 12:00pm ET
• Session Four: September 27th - 8:00am – 12:00pm ET


Seminar 2 (Pacific Time Zone):
• Session One: November 14th - 8:00am – 12:00pm PT

• Session Two: November 15th - 8:00am – 12:00pm PT

• Session Three: November 21st - 8:00am – 12:00pm PT

• Session Four: November 22nd - 8:00am – 12:00pm PT


Virtual Seminar Details
• Max 30 registrants per session. Register early!
• The five (5) online pre-requisite core courses must be completed at least 7 days prior to session one of the seminar you
register for.
• Participants would ideally do all 4 sessions within the same seminar, but will be allowed to, for example, do session 1 and 2
in September and then sessions 3 and 4 in November.
• To qualify as having completed the live component of the ACHH certification, all four sessions will need to be
attended sequentially, and must be attended this year (2020).

Register at homehealthseDtion org aDhh