Eli's Rehab Report

Published on Fri Nov 20, 2009 PDF

Patient education is just as important as your therapists' education.

Of all post-acute care settings, home health agencies (HHAs) have some of the highest hospital readmission rates. And your home health therapists can't afford to follow this trend if Congress implements post-acute care payment bundling and readmission penalties. (See the last two issues of Eli's Rehab Report.)

The bright side: Your team of therapists can help your home health agency be the exception to the rule with the right tools. Here's how.

Your HHA should be keeping track of its top reasons for readmissions and target those in staff training. For example, Amedisys, a home health agency chain based in Baton Rouge, found that falls was one of its biggest culprits for hospital readmissions. "So we've had a big push in the company to identify fall risk factors, educate the community and our personnel, and follow up with focused interventions," says Kim Marryott Lee, PT, DHS, corporate director of rehab research and quality for Amedisys.

Amedisys makes a point to look for fall risks in physical home environment, such as slippery floors and  clutter. But clinicians also are trained to check for other risks such as vision problems, inner-ear issues, medications that could cause dizziness, and cardiac issues that could contribute to falls, Marryott Lee says. Other conditions you should always keep on your radar include chronic obstructive pulmonary disease (COPD), chronic heart failure, diabetes, and infections (both wound and catheter infections). And keep in mind that your own HHA's readmission stats may reveal other red-flag diagnoses.

Good idea: To exercise good preventive measures, standardize your care, says Steve Allred, PT, vice president of clinical development for Atlanta-based home health care chain Gentiva. "For example, when we have a post-joint replacement patient, we do x, y, and z every time -- that way the patient isn't dependent on the skill set and knowledge base of a particular expert clinician."

Suppose a PT walks into a patient's home to do rehab for a hip replacement. The patient exhibits a faint smell of feces and appears to have poor personal hygiene. Due to other comorbidities, the patient is on a Foley catheter, and the therapist notices that the patient's urine is cloudy. Although the PT is not responsible for addressing the patient's hygiene and investigate a potential urinary tract infection, he should be tuned in to notice warning signs such as these -- and report them to the nurse on the case.

Any mentality such as "these issues are just for nursing; I don't need to pay attention to them" is asking for trouble, Allred warns. "You need to be aware of what's going on so you know when to refer to your nursing partner -- this awareness is thinking as a team."

Strategy: Get everyone on the same page -- regularly. For example, Amedisys holds weekly case conferences. "These meetings are a great source of communication where everyone gets to bring their piece of expertise to the table, discuss it, and figure out what's the best plan for the patient," Marryott Lee says.

Another idea: Ensure all clinicians have access to cell phones and that the minutes are reimbursed so that the  therapist feels comfortable calling the nurse and saying,"I'm seeing x, y, and z. When you come in tomorrow, can you look at these things?" Allred suggests.

No matter how good your therapists are at spotting risk factors early, if a patient isn't confident with her condition, she may unnecessarily admit herself to the hospital. "It really gets down to the patient in the home knowing when they need to go to the hospital and when their condition is something they can manage for themselves," Allred says. "We want to help that patient get to a point where they can say, 'I don't need to go to the hospital,' or 'I'm confident that I need to go right now.'"

Here's how: Suppose a COPD patient gets shortness of breath, feels like he can't breathe, starts to panic, and considers going to the emergency room. "A PT or OT on the case is in a unique position because the therapy session is a safe environment where you're taxing the patient's effort and can educate him on what's happening, how to get his breathing under control, and when his shortness of breath is truly a danger that calls for an ER visit," Allred says.

Another example: A post-joint replacement patient may not know what to expect in terms of pain and swelling, and the therapist can help educate the patient on this so the patient doesn't visit the hospital for pain or swelling that's normal, Allred adds.

Other tactics: Therapists can also play a huge role in prevention education, namely on fall risks. "We do a lot of  community education about identifying fall risk factor such as throw rugs, poor lighting, cords running across the middle of rooms, how to properly install grab bars, not to use towel racks as stabilizers, etc.," Marryott Lee says.