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D/C to home care.

You are a busy physical therapist in the acute care setting and you have been made aware of the above physician's order. Your patient is a 78-year-old female who you have been following for a little over 2 weeks. Her current pathology is pneumonia and COPD exacerbation. She also has a positive history of CHF, moderate aortic valve stenosis, and anxiety. While working with this patient, you note her hemodynamic and oxygen saturation response to exercise-when she ambulates with a slower gait speed, she has no major problems, but when she is allowed to ambulate at a gait speed that approximates normal, she usually desaturates. Your concern is that you have noticed this patient's tendency to become anxious when up, and that if she ambulates too fast she may de-saturate and this may result in a fall.

Do physical therapists in the home care setting need this type of information? Absolutely. Home care therapists frequently receive referrals from settings where a good amount of therapy was rendered. Many times patients are able to inform the home care therapist what they were able to do and how they tolerated therapy. However, for true continuity of care, a better degree of information is needed in order for the home care therapist to expeditiously take the patient to a higher level of function. This need is even more important going forward as Medicare resources become more limited.

We acknowledge that continuity of care, effective care management to preserve Medicare dollars, and setting the stage for safe care underscore the need for communication; but what can we do to ensure conveyance of critical information to therapist in the home care setting? Therapists practicing at an acute care hospital may not simply call the tentative home health PT and discuss the case given HIPAA regulations. Therapists at acute care hospitals should first invest a good amount of thought into documentation.

Documentation will probably not top the list of favorite activities that therapists do daily in any setting. Therapists practicing in acute care hospitals must realize that therapists practicing in home care are usually scraping for any clinical insight from a rehab professional who has worked with the patient in question. Therapy notes, when available, are therefore read prior to the initial assessment. Sometimes the psychosocial dynamic may change when the patient returns home. The patient may assume the "sick role" and not exert the best effort during the initial assessment. If therapy notes from the acute care hospital illustrate higher patient capabilities are available, the home care therapist may use data from the notes in an attempt to recruit better effort from the patient. If the therapist who treated the patient while in acute care realizes any precautions to take with a patient, clear documentation of these precautions and realizations may help prevent patient injury. One must not assume that the patient will be forthcoming with information on precautions that therapists in the acute care hospital may have taken. As an example, if the therapist at the acute care hospital noted the patient's tendency to de-saturate with higher gait speed, this information realized prior to assessment by the home care therapist establishes the grounds to obtain orders for pulse ox assessment during exertion in order to further "scope" this patient tendency. Appropriate balance testing may also follow in order to correlate blood oxygen levels to fall risk.

All therapists must be patient advocates. Therapists in acute care facilities must promote the dissemination of their documentation to home care agencies.

This should probably not occur in the form of one therapist faxing notes to another. HIPAA laws apply to faxed notes as well as verbal information. Discharge planners or case managers who work in acute care facilities are typically responsible for sending all referral information to home health agencies. What the therapist acute care seeing the patients in these facilities should assure is that vital rehab information is sent to the home care agency in order for the home health therapist to review. A good amount of information surrounding the pathology will usually be sent with the referral. The case manager (for example) may be so consumed with a given patient receiving a vital IV service that therapy data is overlooked. The home care therapist may be in the home with the patient all alone, and precautions followed as outlined in the hospital may mean the difference in a patient tolerating an assessment with no problems, or a 911 call. All players should understand that the home care setting can be considered an extension of the hospital. Though appropriate channels should be taken, assurance of the conveyance of vital rehab information may actually improve the level of care, and possibly prevent rehospitalization.

With all that said, the key terms in this perspective include; documentation, advocacy, HIPAA, precautions, conveyance, continuity of care, and most important--the patient.

We all want our efforts to be fruitful. Assuring that information obtained during therapy sessions in the acute care setting is passed along to home care therapists is one way to influence how your patient is managed by the home care therapists.

Robin Pierce, PT, DPT

Robin Pierce, DPT, BSPT is Area Rehab Director for Tar Heel Home Health (a Gentiva Company). He can be reached at 252-531-8593 or
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Author:Pierce, Robin
Publication:Acute Care Perspectives
Geographic Code:1USA
Date:Sep 22, 2009
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