older adult PT settings

where do we encounter older adults?

- acute care

- long term acute care (LTAC)

- inpatient rehab facility (IRF)

- subacute rehab (SNF/TCU)

- long term care (LTC)

- home health (HH)

- outpatient (OP)

statistics in acute care

>40% of those >65yo

- avg LOS = 4.5 days and costs $10,400/day

- older adults spend 83% of time in bed and 12% in a chair

why do older adults spend so much time sedentary?

- pts are frail, hurt, and scared

- hospitals and pts are scared of pts falling

- lines and tubes

- staff shortages

- procedures that require bed rest

immobility on lean body mass

you lose 1.5-2% lean body mass everyday you spend in bed

functional decline statistics

- 60% dec ability to complete at least 1 ADL

- 40% dec ability to complete at least 1 IADL

- 30% fully recover 1 year after admission

- 56% of adults >85 yo require a d/c to a post acute location

age related changes + immobility =

inc risk for iatrogenic effects

vulnerability to acute care

- pressure injuries

- delirium

- hospital acquired pneumonia (HAP)

- functional decline

- MRSA/C diff

- DVTs

acute care delirium

abrupt change in cognition and behavior

causes of acute care delirium

- age related changes

- unfamiliar environment

- disruption in sleep/wake cycle

- medical issues

- medications (ex: opioids, benzos)

prevention of acute care delirium

- minimizing risk factors

- physical therapy

- integrate more cognitive tasks

geriatric acute care PT role

- assess abilities

- promote and facilitate safe physical activity

- make SAFE d/c recommendations

- collab with healthcare team

strong predictors of 1 month readmission

- inability to stand without using hands

- gait speed

acute care considerations - ICU

- need training

- early mobilization

acute care considerations - open heart surgery

monitor vitals and sternal precautions

acute care considerations - orthopedic surgeries

- see pt on day 0, d/c day 1-3

- control pain

- protocols following surgery

- referral to other level of care

acute care considerations - post op complications

- n/v

- anemia (hgb >8)

- orthostatic hypotension (test supine, seated, and standing)

- delirium

acute care considerations - critical illness and sepsis

catabolic effects on muscles

- can trigger acute inflammatory process

- prognosis for this pt is much longer

acute care considerations - trauma

common injuries from falls = brain injury, fractures

- trauma = 7th leading cause of death in older adults

- falls = #1 trauma

clinical pearls for acute care

- assimilating large amounts of info

- clinically reason if pt is appropriate for PT at that time

- plan 4 steps ahead, anticipate A-Z scenarios

- quick thinking and responses

- make sure needs are within reach

- prevent iatrogenic effects

- don't let hospital timelines pressure you

LTAC

long term acute care

- average LOS = 25 days

- treat serious medical conditions

- usually d/c from ICU to LTAC

- PT = same as acute care but with more treats and less evals

what types of medical conditions are treated in a LTAC?

- chronic respiratory

- cardiac failure

- complex wounds

- osteomyelitis

- septicemia

IRF/ARCs

acute care facility that provides multidisciplinary, team-oriented services

- must meet specific criteria

- average LOS = 12.4 days (

specific criteria of IRFs/ARCs

- require coordinated care between at least 2 disciplines PT/OT/SP

- participate in 3 hours of therapy 5x/wk

- must have significant rehab potential

- therapy need must be "reasonable and necessary"

insurance coverage for IRFs/ARCs

- 60% = CMS-13 (medicare criteria)

- 40% = any diagnosis

- primary payer = medicare

CMS-13 diagnoses

- stroke

- spinal cord injury

- congenital deformity

- amputation

- major multiple trauma

- hip (femur) fracture

- brain injury

- burns

- active, polyarticular RA, psoriatic arthritis, and seronegative arthropathies

- neurological conditions

- systemic vasculidities with joint inflammation

- severe or advanced OA

- knee or hip joint replacement (B/L, BMI > 50, ≥85 years old)

role of a PT in IRF/ARC

- work on restoring function

- provide compensatory training

- complete home evaluations

- provide patient and caregiver training

- make safe recommendations

- discharge to least restrictive environment

what happens to the patients who do not go to an IRF but need rehab?

they go to subacute or a transitional care unit

- focus is still on getting someone home but you get more time

- cheaper than IRF

common diagnosis in subacute rehab

- joint replacements

- heart failure

- kidney

- PNA

- sepsis

- UTI

subacute rehab

- primary payer = medicare

- PT role is same as IRC/ARC

- subacute has less therapy time (30 mins)

- subacute has a longer LOS

medicare A guidelines for skilled nursing admission

- qualifying hospital stay 3 days or more (not including d/c day)

- admitted to STR within 30 days after d/c from acute care

- meet criteria to be considered a "skilled need"

what does "skilled" need mean?

meet at least 1 of the criteria

- requires skilled therapy and/or overall management of skilled personnel

- intravenous or intramuscular drugs at least every 12 hrs

- parental feeding or enteral feeding at least 26% diet

- wound care that requires at least a daily dressing

- device/drain management

- ventilator and/or trach weaning

medicare A coverage

as long as someone meets the criteria

- medicare covers days 1-20 at 100%

- day 21 it covers 80% (20% coinsurance or out of pocket)

- lasts for 100 days (resets every 60 days out of the hospital)

long term care (LTC) - leading reasons for admission

cognition, incontinence, falls

long term care (LTC) - payor

- out of pocket

- medicaid

- private LTC insurance

LTC ≠

"skilled"

- it is someone's home so medicare will NOT cover it

LTC PT in a nursing facility

- payor = medicare B (same as OP)

- attain max functional potential, prevent unreasonable decline to later d/c to exercise program

- usually referred by nursing s/p change in status (ex: functional decline, contractures, wounds, etc)

medicare B requirements for therapy

- services require the judgement, knowledge, and skill of a qualified therapist

- positive expectation for improvement

- services are acceptable standards of practice

- services are reasonable and necessary

can you provide therapy to someone who is not expected to improve?

- before 2013, no

- now, yes = maintenance therapy

Jimmo vs Sebelius Case

nationwide class-action lawsuit against Centers for Medicare and Medicaid Services (CMS)

- as long as the patient requires the need of a skilled provider, they will not be denied based on potential for improvement

maintenance therapy

we can treat patients to prevent decline, or slow the progression of decline

- MUST require a therapist (skilled)

- documentation must support this

- applicable to anywhere medicare services are utilized

example of PT treatments in LTC

- strength, power, endurance, balance, gait, flexibility, w/c mobility training

- contracture prevention and management

- positioning for safety, comfort, pressure relief

- patient, family, staff education

- pain management

- wound care

- restorative nursing program development (RNP)

fall prevention

- minimize risk factors

- improve balance, safe mobility, and strength

- figure out why they are falling (BP, dizzy, impulsive, etc)

wheelchair fall prevention adaptations

- anti tippers

- anti roll backs

- extended brake handles

- chair alarms

- chair height and pitch changes

- w/c cushions

bed fall prevention adaptations

- bolsters

- wedges

- lowering bed

- fall mats

- bed alarms

home health

nearly all older adults prefer to age in their homes (aging in place)

- must be considered "homebound" if receiving medicare services

payors of home health

- medicare A or B

- medicaid

- private insurance

documentation for home health

outcome and assessment information set (OASIS)

homebound criteria 1

- AD, special transportation, or the assistance of another person to leave the home

- OR have a condition that leaving the home is medically contraindicated

homebound criteria 2

- normal inability to leave home

- AND leaving home must require considerable and taxing effort

role of PT in home health

- restore function

- ensure home environmental safety

- dec risk for falls

- provide compensatory training

- caregiver education

- promote reintegration into community or transition to OP

clinical considerations for home health

- creativity

- guests in someone's home

- neglected homes

- may need to contact your supervisor and/or area on aging

- speak up if you are fearful of your safety

- be prepared for emergent situations

outpatient payers

- medicare B

- private insurance

role of PT in outpatient setting

- return to PLOF

- maximize physiological reserve

- manage pain

- prevent falls

- encourage wellness

outpatient setting

seen 1-3x /week

- look out for sedentary lifestyles, passive leisure activities, falls