Looking well beyond the diagnosis
by Dr. Tim Fox
January 1, 2018

Congestive heart failure, pneumonia and chronic obstructive pulmonary disease (COPD) are three of the top 10 reasons Medicare beneficiaries are re-admitted to the hospital.

Congestive heart failure alone has a 25 percent hospital readmission rate within 30 days of discharge. These chronic conditions cost Medicare more than $3.7 billion annually.

Being diagnosed is just the beginning for most people with a cardiovascular disease. Once diagnosed, management begins. Management may include medications, dietary changes, changes to activity level and frequent visits to the physician for blood work and changes to the management plan.

As the general population ages, it becomes increasingly difficult for aging adults to access necessary services to maintain their cardiac health. This is primarily due to the cost of health care and increased difficulty accessing the community. As a result, chronic disease management accounts for 66 percent of the U.S. health care budget.

Looking Beyond the Referring Diagnosis

Imagine this: You are a physical or occupational therapist treating someone in their home. You receive a referral for a new client, Mr. Smith, an 84-year-old male recently discharged home from the hospital after suffering a fall. You are confident you can work together to achieve his goals of returning to an independent lifestyle and decreasing his risk for future falls. When you arrive, you learn that Mr. Smith is one of the 5.7 million Americans living with congestive heart failure, and his fall resulted from shortness of breath after climbing the stairs to the second story of his home. Your mind begins to race; how will your clinical approach change based on his diagnosis of congestive heart failure? What do you need to do differently? How do you make sure Mr. Smith stays safe throughout his course of care and after discharge from therapy?

Housecalls, Cardiac Rehabilitation and Reducing Readmissions

Physical, occupational and speech therapists have the education and training to understand and manage chronic conditions during exercise. Their broad practice, which requires vast knowledge and a collaborative approach, enables them to play a unique role in reducing hospital readmission in older adults. What is even more unique is providing this level of expertise in the comfort of one's own home under a model that allows Mr. Smith to establish goals that aim for optimal function—the housecalls model.

Accessibility of care and adherence to plans of care are much less of an issue in this model because clinicians go to the client’s home. Additionally, this model provides the clinician with the autonomy to provide services that push a client towards “functional wellness” and not just “medical maintenance.”

In the case of Mr. Smith, he needs to be educated on the need for daily weight checks, monitoring of his signs of symptoms, modifications to his current routine to increase his safety and ability to perform the tasks that allow him to be who he once was and whom he wants to be.

A condition should not prevent someone from participating in their life; it, at times, has the potential to build barriers, but barriers can be overcome by helping someone achieve what they once thought impossible.

Practices that offer housecalls provide clients with chronic conditions the opportunity to progress toward their goals, such as using the stairs or walking the distance required to get their mail, and to receive educational strategies on how to prepare a meal in their kitchen.

The housecalls service model allows a client with a cardiac issue the ability to properly self-monitor the condition with the tools to adequately do so. For example, by performing weight checks in areas set up in the client’s home to ensure compliance, he or she now is given the tools to know if gaining more than two pounds in one day or five pounds in one week is a sign of worsening congestive heart failure, that requires a phone call to the physician to communicate a change in condition, thus possibly preventing further exacerbation.

Identifying worsening congestive heart failure in its earliest stages may make the difference between managing the condition at home and being admitted to the hospital. The housecalls model offers the opportunity for clinicians to better understand the client’s culture and the actual social, physical and emotional contexts in which they live instead of a medical environment where tasks are re-created to simulate daily life.

According to Gitlin, et al. (2006), older people perform self-care in their home at the maximum potential that allows for better outcomes.

The Role of Occupational Therapists

Typically, occupational therapists have not been known to have a large presence in cardiac rehabilitation, but in the housecalls model, they have a role that can sometimes be more important than that of the physical therapists.

When a client returns home with a cardiac condition, much of the focus is on getting the person stronger to be able to perform the tasks required to maintain their daily participation. But who is asking them how they will achieve these tasks in the interim?

The occupational therapist has a role in assessing one’s current lifestyle and analyzing the need for modifications or change.

Mr. Smith might require assistance in the beginning to manage all of his medications that need to be taken several times a day; the occupational therapist would provide techniques to set him up for successful medication management. Maybe Mr. Smith has a difficult time completing his evening shower independently because of his fatigue and shortness of breath; the occupational therapist might recommend a morning shower to conserve his energy and would properly educate Mr. Smith’s wife on strategies to keep him safe but also allowing him the ability to participate in the task rather than her just completing it for him.

The Right Kind of Exercise Is Key

Rehabilitation professionals have an advanced skill set that is well within the practice act of understanding the impact of medical conditions and medications on exercise tolerance, monitoring and dosing. Exercise is used as medication in many chronic conditions including coronary heart disease, hypertension and heart failure—to name a few.

As a type of medication, exercise must be prescribed by a highly-skilled rehabilitation professional at the right intensity, dose and frequency with real-time adjustments depending on the physiological responses of each patient.

Monitoring vital signs, such as heart rate, heart rhythm, blood pressure and oxygenation levels are just part of determining a patient’s response to exercise which can guide a physical or occupational therapist to adjust the prescription of exercise.

A skilled clinician knows that identifying elevated or abnormal blood pressure responses can save a person’s life, but it also permits the safe and effective delivery of a powerful medicine—exercise.

Monitoring physiological responses to exercise can identify risk factors or warnings of unresolved conditions, ensure lifestyle changes, and assist physicians in determining if medications are working effectively. For example, if the patient’s heart rate does not recover at least 12 beats per minute within a minute after aerobic training, the client has a significant impairment in cardiovascular status and is at increased risk for cardiac death.

When patient monitoring and interdisciplinary communication are performed routinely, patient care is more effective, efficient and health care costs may be reduced.