“I am a new P.T. and my home health agency recently started using programming protocols for orthopedic patients such as total joint replacements and hip fractures. As part of the regimen, I have begun to use home exercise programs (HEP). My colleagues are discharging those patients who are not doing their exercises but I am not sure I know when a patient is compliant with their HEP or not. How can I tell if the patient is actually doing their exercises?”
This is a question most physical therapists can answer intuitively. Even the most seasoned of home care clinicians may have to stop and think about exactly how they know, but they do. As you gain that “clinical gut feeling”, learn to trust it. You too will be able to best serve your clients by calling out those who are not following your clinical instructions with regard to exercise. Those who do will perform at their maximal potential and achieve their goals.
For every patient, the first visits are spent developing an individualized exercise program that will address the Range of Motion (ROM), muscle strength, coordination, balance, or other deficits that render the patient unable to safely carry out daily functional tasks in their home. This exercise program must be based on the patient’s tolerance so that it can be repeated by the patient on a daily basis. We firmly believe that geriatric patients are not going to become functionally improved if they do not perform their HEP frequently enough. Frankly put, performing exercises two or three times per week will not cut it for this population.
As therapists, we remind patients that if they don’t use it, they’ll lose it – and to make gains they need to use it more often. However, if the exercise program is too difficult or too strenuous to be carried out, then the chances of non-compliance are high. The initial regimen needs to be simple enough for the seeds of compliance to be sown. Open and frank discussion at the initial visit must occur to spell out the expectation of 100% participation in the Medicare insurance program. If non-Medicare insurance is primary, treat the patient exactly the same way – expecting that functional rehabilitation will be advanced only when skilled and progressive therapeutic exercises are provided and then performed.
So after giving these instructions to your patient, how do you tell if the exercises are being carried out? First, take all necessary steps for successful completion. Be sure the program is written out in terms the patient can understand and see (bold type, large print or pictures that are clear)? Provide clear demonstration and engage caregiver participation for correct technique if cues are required. The patient should then be able to repeat the exercises. If they are not able to recall the exercises by simple lay terms (i.e. – heel slides or ankle pumps), chances are they have not done them.
We do not advocate discharge of a patient for not knowing their exercises on its own, however. In order to give the patient the benefit of the doubt, make a dated chart at the bottom of your written page so that the patient can mark off when they have completed the 2 or 3 most important exercises. This way if they do the exercises, you can provide positive reinforcement and progress the HEP each subsequent visit. Have the conversation with them about the fact that you are the expert and in order for them to meet their own goals; they will need to follow your instructions. It is also required for Medicare to continue to cover the homecare costs at 100% that they make progress toward those goals and by not doing the prescribed exercises, they are jeopardizing that coverage.
During the next return visit, be consistent in your expectation that the program will be performed, but if the patient is not able to show you what they have done, they are not doing it. You will also not see the functional progress in activities – transfers, mobility and walking – as ROM and strength do not improve as rapidly as you expect them to in another patient with similar issues who is compliant with their HEP. Keep your emotions out of it – it is not your professional failure to have a non-compliant patient. You are successful if you identify those patients who fail to comply. Make it a skilled component of your practice to help those you can, explain the consequences of non-compliance to those who aren’t, and then move on to help other patients who will participate in HEP programs once the non-compliance has been well documented.
Teri N. Thompson and Arnie Cisneros are physical therapists with nearly 40 years of combined home care experience. Co-owners of Home Health Strategic Management in East Lansing, MI, they provide clinical service management and home care consulting expertise. They are nationally renowned speakers regarding the PPS refinements of 2008 and therapy utilization under the New Rule.