A Physical Therapist’s Perspective: The Benefits Of Outpatient At Home

By Katie Schmitt, PT, DPT

Physical Therapist

Geriatric House Calls: outpatient therapy at home. This is one of the fundamental elements that make FOX Rehabilitation different. Our patients do not need to be homebound, as they would in a home health setting.

We have speech-language pathologists (SLP), occupational therapists (OT), and physical therapists (PT) who visit a patient’s home for one-on-one, outpatient-level care. These are patients who have a higher level of function beyond the homebound requirement of Medicare Part A but often aren’t able to consistently get to a clinic.

Finding the right rehabilitation setting shapes recovery. Some patients thrive at an outpatient clinic, while others need a skilled practitioner to come to them. The decision of where to go for rehabilitation can be suggested by a primary care physician or specialist, can come from a PT, OT, or SLP inpatient team if there was a hospital stay, can come from a therapy team after an acute or sub-acute rehab stay and sometimes comes from word of mouth when friends and family share what has worked for them in the past.

How do you select where it is best to get care? Here are some of the benefits of FOX Rehabilitation outpatient at home for speech-language pathology, occupational therapy and/or physical therapy.

CURRENT EVIDENCE, IMPLEMENTED INTO PHYSICAL, OCCUPATIONAL AND SPEECH THERAPIES

Much of what clinicians do is an evidence-based practice. We rely on meta-analysis and randomized control trials to influence how we care for a knee replacement, decrease in function due to Parkinson’s disease, or increased neuropathy post-chemotherapy treatment.

However, there is always the factor of the individual patient. There is always the puzzle of finding the right treatment for that person. No two people are the same. This is what makes us as humans complex and intriguing. This is also what makes being a therapist exciting!

With the literature, we can begin to imagine and anticipate how our patients will present. Then after the initial evaluation, we may have a whole different picture of the person in front of us. As we work, clinical decision making (along with the personality of your patient) comes into play.

That is when change happens. There is a very special relationship between a therapist and a patient. You begin to read the patient. You understand their tells of when they are tired and when you know that they can do a little more.

When things plateau, it is a chance to broaden your knowledge or skill set to learn new intervention strategies. Finally, there is that magic moment when the patient can then do something they couldn’t before and they turn to you and say, “Hey, that was finally normal, that was finally easy!”

What does the evidence say about where should that rehab take place? The evidence on that is mixed. For some, an outpatient at a clinic is better. [Yes, we’re not saying every older adult needs FOX!]. These individuals may benefit from:

• Desire to go out and be part of the community
• Motivation that comes when performing exercises in a group setting
• Tools and techniques found in outpatient clinics
• The use of machines to build strength
• The sense of independence found from going to the clinic
• The sense of family that comes from interacting with many different clinicians and staff members in an outpatient clinic

For some outpatient, rehabilitation at home may be better. Those individuals may benefit from:

• Not having to arrange for someone to drive them to a clinic
• The privacy that comes from one-on-one care
• Building a treatment plan around how they live
• The use of the home to provide space for exercise in order to build commitment to a home exercise plan
• The sense of independence gained from getting better and gaining function in the home
• The sense of family that comes from knowing you have a skilled clinician who knows the ins and outs of your home and your loved one’s challenges and can be reached when you need them.

There are many factors to consider when choosing a rehabilitation setting. Nuances must be considered — those little things that make each person and their home special.

UNDERSTANDING THE UNIQUE CHALLENGES OF PATIENT’S SETTING: THE CHAIR SIT-TO-STAND CHALLENGE

Progress in the clinic and progress at home can look very different.

Recently I had a patient discharged from an inpatient rehab center. While there she was making great progress. She could perform sit-to-stands from a standard height chair without issue and walk 150 feet with a standard walker. All of this looked great from a functional outcome standpoint.

When she got home, she thought the plan would be to sit in the recliner in the living room during the day and then return to her room to bed at night. This patient could not get out of the recliner in the living room without maximum assistance.

The chair was comfortable, soft, had a great deep seat and rocked back. At the same time, the deep chair decreased the angle in her hip to less than 90 degrees, sunk down when she sat and was not steady to stand up from. She could not get out of it.

Had this treatment not been in her home, we would not have seen this struggle. She would ace a standardized Five Times Sit-to-Stand test from a regular height chair. We worked for a month to increase her strength enough to get out of the recliner in the living room. Being in the home afforded the opportunity to see exactly where the need for physical and occupational therapy was.

HOW TO TAKE THE RIGHT STEPS IN SKILLED CARE: THE STAIRS SITUATION

Stair negotiation is something that a physical therapist will plan for in every setting:

• the hospital setting
• acute and sub-acute rehabilitation
• outpatient clinic and outpatient at-home therapy.

The benefit of stair training in the first two bullets is that you have stairs with a standardized height and bilateral, safe handrails. A patient can gain confidence in tackling these stairs as you reduce the support needed every one-to-two sessions.

At home, stairs are not the same. Stairs may be in the front leading to a driveway, in the back leading out to grass, made of brick or wood, narrow or wide, have two handrails, have one handrail, have no handrails, have carpet, be curved, and the list goes on. According to “the Spruce” there is not a standard height, depth, width, etc. Stairs have some standard dimensions but can vary widely based on the design of the home and the architect. Having one 3-inch step, followed by one 9-inch step can mean a fall for your patient. If the stairs in the front are 7 ¾ inches and the ones in the back are 9 inches, a patient will find the ones in the back more challenging and can trip if they do not have the knee range of motion to lift their knee and clear them. Working on steps in the home makes things more individualized and more specific.

The plan of care for a clinician treating in the home under Medicare Part B may have goals met for the front steps but continuing goals for the back steps. If a patient has had a fall down steps at home, learning how to negotiate all sets of steps is even more important.

NOT ALL HAZARDS ARE THE SAME: THE FIGHT AGAINST FALLS

In an outpatient or inpatient rehab setting, we have a test called the Dynamic Gait Index(DGI). This is a fantastic test for fall risk as it looks at things like walking with head turns, walking around and over objects, and stairs. This test was designed to be standardized and performed in the clinic. Different flooring and reduced gait patterns are top of mind when we think of fall risk and the DGI is great for seeing them. The benefit of receiving physical or occupational therapy in the home is that we can see fall risks that may not be thought of in the clinic.

For example, I have a patient who is doing very well as a result of outpatient at-home rehabilitation. When we met she was worried about falling and was having some dizziness. First, we worked inside, on even floor, then on softer carpet. She became very good at the DGI.

However, her main concern is when she is in her garden. Tree roots and a new puppy nipping at her feet, along with mole holes and uneven ground, were all contributing to falls. The dog, the grass, her specific trees and types of roots, as well as the impact of the hot South Carolina weather, are hard to simulate in the clinic. Having her work on walking in her yard, doing DGI related tasks, and dealing with the challenges she will face every day is an ideal way to facilitate recovery. For this patient having her dog jumping on her could be a hazard but with our intervention, it can be safe.

HOW TO LIMIT COMPLICATIONS AT HOME: TRANSFER OF TRAINING TANGLES

One could argue that all of the above (stairs, dogs, chairs) are things for which a great outpatient clinic could provide skilled therapeutic training. That may be so.

One of the things that make outpatient at-home care the most special is when you consider patients with conditions that affect the brain, patterning of behavior and skilled planning of motor function. Patients with Parkinson’s disease, dementia, stroke, or TBI may all require help with the transfer of training that just cannot be given in the clinic.

For example, one of my patients lives with Parkinson’s disease. It takes some time for him to learn a skill, such as going from sitting to standing with the use of the rollator. It took a month to work on sitting to standing from the chair in the kitchen versus the chair in the living room versus the chair in the office. He had mastered all of this with the rollator. It was beautiful. Then he got a new rollator and could not put the pieces together to turn the right direction and sit at his favorite spot. The transfer of training was not there.

We had guessed that this may be the case and were ready with techniques to make the new learning process easier. If he was working on walking with the new rollator in the clinic and then came home, it may have been a struggle. Being there with him in the home and helping to give his wife guidance for how to cue him when there were episodes of freezing was what he needed. For these patients, we are here, in the home, to offer that individualized care.

THE BENEFIT OF PHYSICAL THERAPY IN THE HOME

Not all patients are the same. People benefit from different things. Some people thrive on the community, and it helps them blossom and gets better faster. Some people have specific needs and difficulty leaving the home for a variety of reasons, and we are lucky enough to be there for them. With the FOX team of physical therapists, occupational therapists and speech-language pathologists, we are here to come to older adults when they need it the most. We focus on helping regain and achieve optimal function.

Have you experienced success with outpatient therapy in the home? Share your story on our Facebook page or in the comments of this article below!