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Home Health Therapy:Is Improperly Prescribed Exercise Contributing to Re-Hospitalization?

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I have been making the case for individually prescribed and appropriately dosed exercise programs in home health for as long as some of you have possibly known me.Years of practice, and a look at many, many records over the last 3 years just further convinces me many therapists in post-acute care settings are not following evidence based practice related to muscle strengthening.However, this has served as purely anecdotal musings (or rantings, at times) . . . until the publication of “Rethinking Hospital-Associated Deconditioning:Proposed Paradigm Shift” authored by Jason Falvey, PT, DPT, Kathleen MangionePT, PhD, FAPTA, and Jennifer Stevens-Lapsley, PT, PhD, in the September 2015 Journal of Physical Therapy.Have you read it??

It’s been almost a year since this perspective was published, and I keep waiting for the “revolution” to happen.I am not sure you could have read it and not be driven to action.I don’t want to assume this one was passed over by any therapist in their reading of the professional literature, but (again, anecdotally) I am not sure how any post-acute clinician could have read it and continue to practice as they did prior to this read.Take my word for it – a charge has been set forth and we must rise to meet it.Ample evidence is available in the research literature related to what appropriate standards of practice should include.

But before we go there, let me summarize some of the facts this perspective succinctly lays out based on research related to the effects of hospitalization on older adults:

Ultimately, the functional decline experienced by older adults during acute hospitalization, termed “hospital-acquired deconditioning” (HAD), shows a higher-than-average rate of hospital re-admissions and lower rates of discharge to the community than those placed in a specific diagnostic category (i.e., total joint replacement). Additionally, those we tend to label as “medically complex” or “frail”- those with multiple system involvement - are more susceptible to HAD due to a compromised baseline at time of hospitalization.We have all seen those patients who go through the proverbial “wringer” but are able to discharge home, while others require extensive inpatient periods as their first post-acute stop following hospitalization.It all appears to be based on their pre-hospitalization “reserve.”An older adult hospitalized with a higher, prior functional level “bounces back” more quickly than their lower, less functional prior level counterparts.

So, where does my original statement on individually prescribed and appropriately dosed, exercise programs fit in?Given that older adults with HAD exhibit impaired muscle strength, we must evaluate if we, as home health clinicians, are properly prescribing exercise (i.e., frequency, intensity, time, type – ACSM’s FITT principle) to address deficits.To answer this all-important question the article’s authors confirm that there is a paucity of literature regarding “usual” interventions with older adults with HAD (problem #1), and those applicable studies described low-intensity, generalized treatments (problem #2) as most common for this group of older adults.The unfortunate result of this approach to the older adult with HAD is a continued risk of re-hospitalization, further functional decline, and increased mortality rates.If you understand this as I do, it seems to boil down to the following:

Rectangle: Rounded Corners: Frail older adults receiving high intensity resistance training produces improved physical performance & reduced risk of health events.Rectangle: Rounded Corners: Therapists treating older adults in post-acute care settings do not provide appropriate resistance training to address HAD in older adults.Bottom line, low intensity resistance programs “do not support an optimal return of function, nor do they contribute to increased functional reserve in older adults with HAD.”To be absolutely, 100% clear, underdosed resistance training is ineffective.

In essence, it is tantamount to either fraudulent practice, or malpractice, is it not?If you provide sub-therapeutic services, who do you expect to pay for it?Is it really practice to the highest level of your expertise (skill)? What quality outcomes can you expect?Think about it.What if you were diagnosed with hypertension and your physician prescribed an anti-hypertensive medication in a sub-therapeutic dose?An improperly prescribed medication will not achieve the intended effect of lowering your blood pressure.It will not reduce the likelihood of you having a stroke or heart attack.Would you be agreeable to this treatment, and the associated costs, if you weren’t going to reduce your “risk?”So, ask yourself, what is the difference if you are providing low-intensity resistance training (or no resistance training at all), in association with general mobility (gait, transfer training) to the home health therapy patient following hospitalization?Seems to me there isn’t one…..

I would like, on behalf of all my colleagues in APTA’s Home Health Section, and clinicians working in the home health setting, to thank you, Jason, Kathleen and Jennifer for putting the evidence in front of us.We need to demonstrate the value of therapy in post-acute settings.Let’s not miss this opportunity.We have everything we need to get it right.The time is now.Join the call to action.Get on board. #noexcuses

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