I’ve encountered a situation with one of my homecare patients that I’ve treated for four weeks and I’m looking for some direction. My client is an 80 y/o female recently discharged from a skilled nursing facility (SNF) sub-acute rehab program s/p an MI and CABG x 2. She lived alone in her own home prior to hospitalization, but family has been staying with her since her return back home. She has been discharged from the SNF with oxygen at home that she wants to get rid of. She came home with a roller walker but previously ambulated with no assistive device. I have been seeing her for approximately one month and she has progressed to independent ambulation with a cane up to 150’. However, her dependence on oxygen continues and her O2 SAT levels don’t consistently reach the 92% level the MD required to discharge the oxygen. If it weren’t for the oxygen question, I would be preparing for discharge. I also suspect that she may have become somewhat lax in the performance of the home exercise program (HEP) since achieving the initial functional progress described above. The HEP includes respiratory exercises and I feel this plays a role in the lack of progress regarding the 02 SATs. Where should I go with this patient?
Your question illustrates the complexity of the homecare patient that often remains unseen by those clinicians with little home health experience. The patient you describe is quite connected to the idea of homecare to restore a previous level of function. The SNF discharge was probably predicated upon completion of the episode through home health, so her participation in and expectations of homecare are real to her. You also describe an involved family with an in-home caregiver, at least for the present time. Initial compliance with the home program probably led to the improvement in ambulatory status. But the issues that present themselves are: 1) Is it possible to achieve discharge of the O2 currently being used? 2) How can we progress ambulation to a more functional distance so the patient isn’t confined only to her home? and 3) What role does HEP compliance play in these clinical areas?
Daily compliance of the home program is a Medicare requirement of all home health cases under the current PPS model. During the evaluation visit, we like to tell patients that their progress will continue even on the days we don’t see them due to their compliance with their home program (usually, therapy programs are referred to as HEPs). Your client is an example of the ongoing difficulty with compliance; as the functional status improves, the relevance of the HEP seems to diminish in the eyes of the patient. Even the presence of caring and involved family members does little to help the situation.
I would guess that compliance also waned as you increased the difficulty and frequency of the HEP in response to strength, function, and endurance improvements. The correct response to the concerns identified above is to orient the patient and her family to the clinical realities of the situation. HEP progression is a desired outcome. The increased difficulty and frequency requirements are a sign of success from the performance levels present at eval. I would only continue after meeting with both the patient and a family member and stressing how 3xday performance of resistive and respiratory exercises are the only timely answer to the need to increase ambulatory and respiratory endurance. The increased oxygen exchange and respiratory efficiency that would lead to the discharge of the 02 from the home will only occur with assertive HEP compliance. It is your job as the PT on the case to identify this for both the patient and involved family member. Upon agreement to participate with the HEP that you identify and progress, I would continue the program until either the desired results are obtained, or full compliance reveals that these goals are unrealistic.
Teri N. Thompson and Arnie Cisneros are physical therapists with more than 35 years of combined home care experience. They are co-owners of Home Health Strategic Management of East Lansing, MI; providing clinical service management and home care consulting expertise. They also lecture and provide OASIS, HHRG, OBQI and P4P training at seminars nationally.