A colleague I met at our State Association’s Annual meeting described how many of her PTs and OTs include respiratory exercises in their care plans.  This never occurs at the agency I work for.  Only in the rare case that includes a respiratory therapist or nurse do I see respiratory treatments on the care plan.  Am I missing something that would help our shortness of breath OBQI indicator improve?

     Yes, you are very likely missing something that could significantly alter your outcome scores in multiple areas.  In addition, you also may be overlooking a main factor in functional ability and progress that translates into clinical goal achievement.  Respiratory stability and endurance plays such an elemental role in all forms of activity that any under-performance in this area will limit the potential to achieve functional goals.  All clinicians included in the episode should be aware of compromised respiratory endurance in order to take appropriate precautions when treating the patient.  But specific disciplines should be assertive in their treatment plans as a means of eliciting efficient and effective outcomes.

     Before delving into approaches therapists can use to improve patient performance in this area, it is important to differentiate between respiratory treatments and respiratory exercises (you used the term treatments in your question).  Respiratory treatments, usually to include some form of mechanical or pharmacological agent, and are the domain of respiratory therapists, nurses, or other clinicians trained and licensed as respiratory specialists. The traditional rehab therapist would be limited to respiratory exercises.  Nonetheless, these activities can significantly alter functional abilities when utilized correctly.

     Rehab clinicians should certainly be aware of certain OASIS information that would be relevant to their treatment plan in all episodes.  Some of the essential information is quite obvious in its connection to a particular therapy domain, but the level of respiratory integrity noted at the Start of Care would be relevant to physical, occupational, and speech professionals in the home.  M0 490 is one of the most applicable (and most overlooked) OASIS findings for therapists to consult prior to establishing plan of care goals.  Therapists for agencies that employ point of care technology find this information readily available before or during the eval visit but agencies that find themselves still on paper can include this OBQI-related info on the therapy referral form. This practice may seem cumbersome given all the external pressures facing agencies today.  I would point out, however, that this area directly affects an OBQI indicator that will comprise the basis of Pay for Performance bonus payments.

     Further examination of the M0 490 question reveals specifics that are quite often un-recognized by agencies and clinicians alike when they discuss OBQI scores and improvements.  Responses 0 – 4 should be reviewed to determine what changes are actually required to render a patient “short of breath less often”.  The difference between response levels 0 and 1, for example, is whether the patient is short of breath when walking more than 20 feet.  Other M0 490 responses also reveal relatively low-level changes required in order to achieve improvement in this area.  Combine these realities with a national average of 61% (in this indicator) and you have an opportunity to improve this specific number and other therapy outcomes simultaneously.

     Any patients that exhibit shortness of breath upon eval should be placed on “breathing exercises” as a function of a well-crafted therapy plan of care.  Likewise, I traditionally include these exercises when treating any patients that are on oxygen, especially those new to 02.  This approach includes not only basic abdominal and diaphragmatic exercises but also thoracic, scapular, and intercostal movements.  Many elderly clients exhibit tonal loss in these areas that serve to further compromise breathing.  These are included as part of the Home Exercise Program that is present and mandatory in all homecare therapy programs.

     Objective progress can be temporarily noted via the use of oxygen saturation readings. Common mistakes seen with this approach are the use of saturation readings as either a gauge of progress or even the primary goal of treatment.  It should be noted that the improved respiratory status must be qualified by functional changes as defined by M0 490.  Well meaning clinicians often find themselves focused on the saturation readings alone, rather than the function associated with improved respiratory integrity.
     So you should take steps to address these types of respiratory issues in your agency.  It will not only help with multiple outcomes, it will also serve to re-enforce the inter-relation between all disciplines required to truly effect change in your homecare clients.

Arnie Cisneros is a physical therapist with nearly 25 years of home care experience.  He is the owner of Home Health Strategic Management in East Lansing, MI,  providers of clinical service management and home care consulting expertise. He is a nationally renowned speaker regarding the PPS refinements of 2008 and therapy utilization under the New Rule.