The State Of Rehabilitation Options In 2018

Dr. Will Dieter, PT, DPT, GCS, FSOAE: Hi welcome. My name is Dr. Will Dieter. I’m the director of physical therapy clinical services here at FOX Rehabilitation. And I wanted to talk to you today a little bit about value-based care and its movement into the post-acute rehabilitation continuum.

Post-acute rehabilitation isn’t one of the higher costs in the healthcare system. And it wasn’t really the focus for a long time when CMS and everybody else started looking at value-based care. But we’re seeing now that post-acute rehabilitation is right in the middle of the crosshairs of what we’re trying to do and what regulation is trying to improve upon in terms of value. And we’re seeing it in the patient-driven groupings model is an example: A proposed rule for home health beginning next year. And we believe it’s CMS’s attempt to start to enhance the value within home health.

And, as providers of healthcare, what we think is really important for you to understand is for your older-adult clients that you see in the office, when you’re looking at that person and maybe they’re a little bit frail or maybe they just went to the hospital. There are a couple of key things that we think it’s important for you to understand to know what type of rehabilitation that person might need.

And we say a lot, you know, right client, right level of care, right time. And I think up until now the healthcare system hasn’t done a very good job of arming physicians and other healthcare providers with the information to understand that there are different levels of care and when a patient or a client should probably go to each of those. So that’s what I’d like to go through today.

So we need to break away from this status quo of: The person, we wait until they fall down, they go to the hospital, they go to an acute rehabilitation facility, they go to SNF potentially, they go to home health, maybe they go to outpatient. It does not always have to be that way.

So a couple of things to understand. First off, is the patient or client unstable? And by that I mean to have a PEG tube, they have some type of other blood draw, or medications very unstable, is a medical condition varying to the extent that they would need nursing services. If they require nursing services that is a no brainer: They require home health. Absolutely, that is the right level of care for that person.

The other piece of it is homebound status. In order for someone to be on home health, they need to be homebound. So if they have a nursing requirement and are homebound, they would go to home health. If they are homebound and do not have a nursing requirement, there is the option for that person to not go to home health, to really go straight to outpatient services and that’s where we break away a little bit from what we traditionally always do.

“That person’s older. They need therapy in the home. They need to go to home health.”

You could send them to traditional outpatient. Now we know they probably won’t go. We know that most patients don’t go more than three visits. And we’ve got an older person that probably is going to go even less than three visits if they go at all.

So those are all barriers. And that’s why it is important for you to understand that there are models of care where you take outpatient therapy and you bring it into that person’s home.

So they don’t have to get to the outpatient clinic. They don’t have to feel uncomfortable about what’s going to happen. You’ve got enhanced specificity. I don’t have to worry about what your shower set up looks like or what your home environment looks like because I’m standing right there in your home and I understand exactly what it looks like. And we’re going to work through that exact scenario in that exact sequence that we know for the older people that you’re treating is really important.

I can’t go to an outpatient clinic and try to simulate your entire environment. First, I’m not going to get it right because I’m not going to know what it really is and two is it’s not going to translate the way that it would in a younger person.

We also obviously understand all these psychosocial pieces of what’s going on in these people’s lives. Maybe her husband just died recently or maybe they have a dog at home. It’s really a tripping hazard or whatever it might be, but we understand all of what’s going on in the home. So there’s a lot of value to home-based care. But the point is it doesn’t always have to be home health and that outpatient or home health with no outpatient you have different options. And it really depends on how stable someone is.

If someone is fairly stable, they may not need the nursing services for all the reasons I just mentioned. They would probably be appropriate for outpatient on wheels or outpatient in the home.

And it is important to understand that physical therapists, occupational therapists, speech therapists —the training that they are receiving at this point in time is very high level. PTs are required to be at a doctoral level at this point. OTs are a master’s degree and a lot of people are starting to go for their doctoral level degrees. SLPs are masters as well with some doctoral options. But either way, they have a medical background and the key here is it’s not just exercise. It’s exercising people with chronic conditions who have medical issues and understanding how those play into their ability to exercise and how the exercise needs to be modulated for these individuals. So it’s important understanding of the medical background here and these people — these professionals — as part of the inter-professional team of rehabilitation are part of the healthcare team. So that’s the second piece.

And then coming with that or a couple of things that those professionals can do that you should really be aware of. So one is medical screening. And by that I don’t mean blood tests or anything like that. I’m talking about understanding signs and symptoms of decompensating congestive heart failure or cardiomegaly or some type of cardiovascular issue. Now we’re not diagnosing those, obviously, but we are understanding what condition someone has, what signs and symptoms would be clustered together into red flags, and what would warrant a referral back to you, another health care professional, or an emergency department visit. But we understand those things and can look at them and interpret them. That’s the key.

Second is vital sign monitoring. So obviously to be able to do a lot of what I just mentioned, we have to be able to monitor vital signs and understand them and interpret them. So all of our clinicians are trained to be able to do that.

And pain management is another big one. We know the opioid epidemic is an issue. We know this especially in older adults. We don’t think much about this. but they’re more prone to becoming addicted to opioids because of their body makeup and things of that nature. The CDC has actually put out some guidelines from about 2012. That really talk about… Their recommendation is for non-opioid, more conservative treatments, things like physical therapy, to treat chronic pain — things like low back pain or other types of pain — prior to and oftentimes in lieu of opioids. So that is definitely something to consider even for someone that is 85 years old that has back pain, physical therapy is a very good first option for that person because oftentimes if you just get them moving a little better you can get the joints moving appropriately, we will work with them in a capacity that’s appropriate for them and oftentimes can really help that pain and avoid the opioids and maybe unnecessary surgeries and things like that.

So what does this all mean to you. So the ask for you is really to start to think about and break away from the status quo of “this is what post-acute rehabilitation looks like. People who need home therapy go to home health.” That is not the case. They can go to outpatient: a traditional outpatient, which would not be in the home or home-based outpatient therapy. They can do either one of those things, so thinking about that.

A couple other things are making sure that you’re considering is the person stable, are they unstable, and understanding the unique training of these rehabilitation professionals and understanding that they can handle people with chronic conditions and it’s a very appropriate referral for things like pain, for things like balance issues, issues with medication, all kinds of things that a rehab team can really help and is oftentimes alleviating a lot of the pressure on other providers who don’t really know the answer because it’s not a medication problem — it’s some kind of functional, physical issue. So there’s that piece.

And then lastly is considering the fact that people don’t have to wait until somebody has had an issue. You can be proactive. We don’t have to wait until somebody fell or somebody is really de-conditioned to start to refer for rehabilitation services. And if you go to foxrehab.org, we have an entire article on some of the signs that might indicate somebody is appropriate for PT, OT, or speech and just considering those and thinking a little bit proactively.

So at the end of the day, it’s right patient or client, right level of service, right time. Think about these things and if you have any questions please feel free to reach out to us at FOX Rehabilitation. Thank you very much.