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Learning Objectives• Understand factors contributing to evolution of PT
Practice in the Home Health setting
• Identify specific areas where practice change may result in gaps in comfort level with certain skills
• Perform self-assessment of key clinical skill sets
• Develop an individualized plan to own your professional development, starting NOW
©2018 VNA Care. All Rights Reserved.©2018 VNA Care. All Rights Reserved.
Session overview
3
• Why this topic, at this time? • How has care delivery changed?• What does that mean for PT/PTAs in HH?• Essential skills review and self-assessment• Collaboration and communication• Owning our professional development
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Why this topic?
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• PT Role in Home Health has changed dramatically over the years
• PT Scope in ALL settings has evolved• Practicing at the top of your license
©2018 VNA Care. All Rights Reserved.©2018 VNA Care. All Rights Reserved.
Why this topic?
5
We’ve come a long way, baby….
• From our humble beginning as Rehabilitation Aides in 1917
• To today’s entry level Doctorate and pursuing Autonomous Practitioner status!
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Why this topic?
6
• States vary as to Continuing Education licensure requirements
• Curricula have evolved to meet these training needs
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Why this topic?
7
RESULT:
Clinicians who have been in the field for many years may have varying degrees of confidence in some areas of practice
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How Has Care Delivery Changed?Industry Changes
8
COMPLEXITY of PATIENTS
REIMBURSEMENT CHANGES
FRAUD, WASTE AND ABUSE
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Industry Changes: Complexity of Patients
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• Hospital LOS has decreased• ER diversions vs inpatient admissions • MD office/PCP referrals• 80% of our patients in HH have 1 chronic
disease, 25% have 4 or more
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Industry Changes – Complexity of Patients
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Orthopedic cases vs. Chronic Illness Advances in ortho techniques - many
patients will go to outpatient sooner/directly in the future
More of our caseloads will be Chronic Illness Management
Focus on Pre-acute
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Industry Changes – Demographic Considerations
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• The number of Americans ages 65 and older is projected to more than double from 46 million today to over 98 million by 2060, and the 65-and-older age group’s share of the total population will rise to nearly 24 percent from 15 percent.
• 80% prefer to receive care at home
• In the future, bed capacity in SNF would be insufficient if we treat patients as we do today
©2018 VNA Care. All Rights Reserved.©2018 VNA Care. All Rights Reserved.
Industry Changes – Reimbursement
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• Medicare shifting from VOLUME to VALUE
• Risk Sharing ACOs, Bundled payment programs will account for 50-80% of payment models by 2018
• HOME HEALTH – low cost provider
• SHOW OUR VALUE through OUTCOMES
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Industry Changes – Reimbursement
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• Bundles, ACOs, CJR are just the beginning–Reduce cost – lower SNF and rehospitalization
• Innovation will be essential to manage patients at home into the future
• Hospital at Home, Virtual Visits
• Pre-acute management of Chronic Illness
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Industry Changes - FWA
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• Fraud Waste and Abuse
• Obligation to reduce waste
• Duplication of services is considered WASTEFUL
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Industry Changes –Reducing Waste
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Duplication of services across disciplines must be avoided
Areas where scope of practice OVERLAPS Right Discipline, Right Care, Right Time ZPIC audits
©2018 VNA Care. All Rights Reserved.©2018 VNA Care. All Rights Reserved.
What does this mean for PT/PTA Practice in Home Health?
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• Patient Centered
• Every Visit must stand alone and require skill of the practitioner
• Patient interventions vs “nursing” interventions
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You’re It!
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• We all play a role in keeping our patients safely home
• Requires comprehensive assessment, communication
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You’re It!
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• What does this patient need NOW to be safe until the next visit?
• Who else needs to know what I’ve assessed today?
• YOU may be the one to avoid a rehospitalization (don’t wait for the nurse!)
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You’re It!
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Skin -Vitals
Pain - Meds
Risk: Fall -Rehosp
PT
SN
ST
OT
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Challenges & Objections
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• “We never used to have to do this before”• “The nurse does the medications”• “I never learned that in school”• “I don’t have time to do therapy if I’m doing
all of these nursing things”
…sound familiar?
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Handling Resistance
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• Resistance or “pushback” can be due to more than one issue
• Sometimes it is a case of “I-don’t-wanna”• It may also represent lack of comfort with a
particular skillLet’s hone in on what we can do to increase comfort with skills, if that is the issue
©2018 VNA Care. All Rights Reserved.©2018 VNA Care. All Rights Reserved.
“not enough time during the visit”
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• Not every intervention on the plan of care needs to be done every visit
• Prioritizing and identifying the patient’s #1 priority each visit is critical
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Current Practice
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• PTs admitting more, therapy only cases
• Oasis – comprehensive assessment
• More supervision as PTA utilization increases
• Collaboration is CRITICAL
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• Vitals• Lung Sounds• Pain• Skin• Medication
Management
Comprehensive Assessment
• Risk Assessments • Falls,
Hospitalization, Depression
• Symptom management and monitoring
• Patient/cg ability: self- management
• Mobility, I/ADL
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Essential Skills
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Vital Signs Lung Sounds Comprehensive Pain Assessment Comprehensive Skin Assessment Medication Management Symptom Management/Monitoring In some states – PT/INR testing
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Essential Skill: Vital Signs
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Comprehensive Assessment Each Visit◦ Temperature◦ Orthostatic/positional, rest, peak, recovery HR, RR, BP, SaO2 if indicated◦ Lung Sounds Differentiate what is normal/abnormal, diminished Easyauscultation.com
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Essential Skill: Vital Signs
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• Use Vital Sign monitoring to document skill and progress
• Link to function, activity tolerance, recovery time
• Use objective tests/measures
• Teach patients self monitoring: use RPE/Dyspnea scales to adjust activity
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Essential Skill: Pain
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Comprehensive Assessment Each Visit Use appropriate scale Patient’s pain now, best/worst in last 24
hours, since last visit Observation - facial grimacing? Guarding? How does it relate to prior assessment?
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Essential Skill: Pain
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• Type: dull, ache, sharp, throbbing, etc
• Location• Pattern: constant, frequency, duration, with
certain activities, interrupts sleep?
• Alleviating and aggravating factors
• Medications and Non-pharmacological
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Essential Skill: Skin
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• Comprehensive Skin Assessment– Process by which skin of patient is examined for
abnormalities. Requires viewing skin from head to toe with emphasis on bony prominences and skin folds
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Essential Skill: Skin
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Goal of Skin Assessment Identify any pressure ulcers that may be present Assist in risk stratification Determine if there other lesions or factors that pre-
dispose pressure ulcer development (dry skin, moisture associated skin damage)
Identify other important skin conditions
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Essential Skill: Skin
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Performing the Skin Assessment◦ Always explain to the patient/family that you will be
looking at entire body with the purpose of identifying any potential skin problems◦ Conduct in a private place and minimize exposure
of body parts
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Essential Skill: Skin
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Performing the Skin Assessment, cont.◦ Focus on bony prominences- sacrum, ischial
tuberosities, greater trochanters and heels. Check skin folds, between fingers and toes and under and around medical devices for skin integrity. ◦ Communicate findings to interdisciplinary team◦ If you are unsure how to document/or what you
are seeing, ask!
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Essential Skill: Med Management
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Essential Skill: Med Management
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• Medications effect function (pain, inflammation, airway clearance, CV system, neuro system, falls)
• PTs monitor for medication effects on health, function, impairment and disability
• Comprehensive drug review is within the scope of P.T. practice. We can identify problems/concerns and collaborate with our nursing colleagues when needed to address issues.
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Essential Skill: Med Management
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• ~400,000 preventable adverse drug events annually in the U.S.
• 4 med types account for ~67% of hospitalizations due to med errors: Warfarin, Hypoglycemics, Insulin, Antiplatelet meds
• Beer’s List-guidelines that apply to all elders. Includes a general list of medications to avoid in elderly and a list of medications to avoid based on certain diagnoses.
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Essential Skill: Med Management
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• Medication Issues to Consider during Tx– Parkinson’s: time session when Sinemet is at its peak
– COPD: ½ hour after nebulizer treatment
– Diabetic: best when blood sugar is in range
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Essential Skill: Med Management
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When you see a significant change in patient status, be sure to look back and ask about medication changes, missed doses or incorrect doses. P.T. is often the discipline who picks up on changes in status which result from medication issues.
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Essential Skill: Patient Self-Management
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• Patients must take an active role in their recovery• It is our role to empower patients to self-monitoring
for long term successful management• Utilize patient educational materials to reinforce
teaching• Know when to call agency/MD – “Call us first”Example: COPD pt needs to be aware of S/S to report immediately - increased dyspnea with same activity level, changes in sputum, orthopnea, changes in SaO2.
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Essential Skill: Patient Self-Management
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TEACH BACK is essential at every visit◦ Patients forget as much as 80% of what we teach
them during visit, only 50% of what they recall may be accurate◦ Example: “please tell me in your own words what
I told you about when to call the VNA based on your symptoms. I want to be sure that I was clear in my instructions”
©2018 VNA Care. All Rights Reserved.©2018 VNA Care. All Rights Reserved.
The Minimum Standard
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The skills we reviewed are the expected standard of care within our scope as PTs
Challenge yourself to grow beyond these in order to best serve your patients◦ Postural drainage◦ Percussion/Vibration (BPH) “chest PT”
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Self Assessment
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Rate your comfort level with each skill from:
1 Least confident - “I REEEEEALLY need to practice/learn this one” to
5 MOST confident - “I do this routinely and could teach this skill”
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Self Assessment
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SKILLSKILL 1 2 3 4 5
Vital Signs – RESTING
Blood Pressure
Heart Rate
Respiratory Rate
Oxygen Saturation
Pain
Vital Signs – ORTHOSTATIC
Vital Signs – PEAK EXERCISE
Vital Signs – RECOVERY TIME
Vital Signs – integrating into documented patient goals
Lung Auscultation – identifying presence of diminished/abnormal breath sounds
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Self Assessment
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SKILLS 1 2 3 4 5
Comprehensive Pain Assessment • using proper tool/scale• aggravating/alleviating factors• impact on function
Comprehensive Skin Assessment – baseline assessment
Skin assessment – turgor
Skin assessment – wound assessment/measurement/staging
Wounds: basic dressing changes
Medication Reconciliation
Using Teach Back with Patients
Using RPE and Dyspnea scales
Integrating symptom/patient self- management into goal writing
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Collaboration and Communication
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• With Patient/Family– Teachback
• With MD/Case Managers– SBAR – situation, background, assessment,
recommendation, be concise and clear
• With Manager and Team– Case Conferencing, Email, Voicemail, other
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Collaboration and Communication
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Coordinate visit days/times with other disciplines
Update team members on status/findings
Document coordination of care Coordinate discipline discharges and
discuss status throughout episode
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Collaboration and Communication
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“But I don’t have time!!!!!”• Under new CoP, Collaboration even more critical
• NOT AN OPTION not to communicate with the team
• Provision of patient schedule required
• During the visit when able - Use tools for efficient communication (email, vm)
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Collaboration and Communication
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• Better Care
• Better Patient Satisfaction– Knowing that we communicate gives patients
confidence in the care we are providing
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Owning Professional Development
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Use your LIFELINES◦ Call your manager, peer◦ Ask for a co-visit
Know what you know, ask questions Don’t be afraid not to know it all
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Owning Professional Development
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APTA Code of Ethics and Guide for Professional conduct states that professional development, continuing competence, and life-long learning are integral to providing evidence based high quality patient care.
Standards of Practice state that the “Physical Therapist is responsible for individual professional development.”
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Owning Professional Development
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Individual clinicians are responsible to enhance their own practice development
Identify areas where you are not comfortable and seek assistance.
©2018 VNA Care. All Rights Reserved.©2018 VNA Care. All Rights Reserved.
Owning Professional Development
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Journal Articles Courses Joint Visits with manager, peers E-learning - modules and videos Case Conferencing OTHER
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MY INDIVIDUALIZED PLAN• What are the skill
sets I need to develop?
• What resources are available to me at my agency?
• APTA Resources
• What is ONE thing I will do right away to OWN it!
53
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References
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•“Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions from Hospital to Community”. Physical Therapy, Vol 96, No 8, August 2016. Jason R. Falvey, Robert E. Burke, Daniel Malone, Kyle J. Ridgeway, Beth M. McManus, Jennifer E. Stevens-Lapsley.
•“A Validation Study of the Missouri Alliance for Home Care Fall Risk Assessment Tool”Home Health Care Management and Practice, Volume: 25 issue: 2, page(s): 39-44 Article first published online: September 6, 2012;Issue published: April 1, 2013 DOI: https://doi.org/10.1177/1084822312457942Mary Calys, DPT, PT1, Kendra Gagnon, PhD, PT2, Stephen Jernigan, PhD, PT2
1North Kansas City Hospital, North Kansas City, MO, USA2University of Kansas Medical Center, Kansas City, KS, USA
•APTA Official Statement: The Role of Physical Therapists in Medication Management
•Minimum Required Skills of Physical Therapist Graduates At Entry-Level (BOD G11-05-20-49)
•APTA Guide to Physical Therapist Practice
•Easyauscultation.com
•http://www.prb.org/Publications/Media-Guides/2016/aging-unitedstates-fact-sheet.aspx