In it for the long haul

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Core- and balanced-focused activities can help improve residents’ balance and reduce the risk of falls for those with Parkinson’s disease, experts say.
Core- and balanced-focused activities can help improve residents’ balance and reduce the risk of falls for those with Parkinson’s disease, experts say.

Caring for medically complex patients is not a new phenomenon for skilled nursing providers, and neither is it for rehabilitation therapists, but the number of people undergoing therapy who have multiple chronic conditions—and therefore are much more medically complex—has grown in recent years. 

With this growth has come gradual recognition that rehab therapy is not just for hip and knee patients or other “traditional” conditions such as stroke.

Gone are the days when patients in long-term and post-acute care settings were expected to endure the painful symptoms and functional decline that often come with chronic diseases such as chronic obstructive pulmonary disease, congestive heart failure, Parkinson's disease and diabetes, according to experts interviewed for this article. Today, there is more and more evidence that rehabilitation therapy for such patients is beneficial on multiple levels. 

“We are becoming increasingly aware — and evidence is supporting this fact — that for many of these chronic diseases not only is early intervention around meaningful functional performance and physical activity potentially effective, it often can mitigate decline and, in many cases, reverse loss,” says Alice Bell, a physical therapist and senior payment specialist
 for the American Physical Therapy Association.

Bell suggests that the Jimmo settlement has heightened awareness of the fact that patients who have a disease state that is not likely to improve “can certainly benefit from interventions that stall or delay, or even prevent further decline.” Jimmo is a recent court case that confirms Medicare coverage is available for skilled nursing and therapy that is needed to maintain a person's condition or slow deterioration, for nursing home, home health and outpatient therapy.

There are many instances in which physicians, patients and families have accepted the trajectory of the disease process and lost out on the opportunity to capitalize on therapy, Bell adds.

“We are seeing more evidence that most chronic conditions are an invitation — not a contraindication — for activity and exercise and therapy,” she says.

In fact, there is a general consensus between Bell and other experts that coordinated and interdisciplinary care, frequent assessments and the ability and ingenuity to detect underlying conditions are key to successful rehab therapy for patients with chronic conditions.

“After analyzing the change in population for 10 years or longer, we are observing that the population in skilled nursing facilities and assisted living are much more clinically complex, with more chronic conditions than ever before,” says Dan Ciolek, PT, associate vice president of therapy advocacy for the American Health Care Association. What's more, the “low and slow” approach is no longer considered to be effective, he explains. “A number of research articles indicate that the current state of art is that if you're doing strength training with someone, you do high-intensity strength training and you don't do real low weights.”

In other words, taking patients to their maximum weight with low repetitions is more beneficial and is demonstrated to be more effective in addressing strength, balance and fall prevention. 

“With aerobic strengthening, it is more effective to do a type of interval program where you're doing high-intensity work for a short period of time and then you slow down for a rest and recovery period and then alternate, versus just doing 30 minutes on a bicycle, which is not as effective,” says Ciolek.

“Rehabilitation therapy has completely evolved from 15 years ago,” adds Brenda Johns, administrator at Heritage Pointe, a continuing care retirement community in Warren, IN. Johns notes that the days of ordering therapy only for surgical patients are gone. “Today, there is definitely more of a team approach. It's different from when I was an LPN — when, if there was a decline, it was expected or assumed that, ‘This is where it's at from now on,'” she says. “I also have full therapy staff here seven days a week.”

Finding the underlying problem, notes Paul Riccio, vice president of finance and development at Vertis Therapy, is critical to getting therapy right for people with chronic and degenerative diseases. 

“People can start to lose core strength as a result of their symptoms, and a skilled therapist will be able to find the weak link in the chain,” Riccio says.

He adds that getting to know the patient's life story is key to uncovering a past occupation and the movements associated with it.

“Something like that is ingrained in their muscle memory, which can explain where the patient is having the problem,” he explains, adding that “interdepartmental, organizational communication and intelligent data about communication” is another factor in successfully managing such patients.

There are many technologies that benefit chronic care rehab, but Riccio prefers those that engage patients, such as Jintronix, a rehabilitation therapy system that uses games and functional assessments, as well as real-time data, for use in generating objective outcome measures. CEO and co-founder Mark Evin says he wanted to “transform therapy into something engaging and motivating” for older adults, so he created the system about six years ago. Today, it is used mostly in skilled nursing and rehab facilities, as well as home health.

Alexa Brett, an occupational therapist and client success coach with Jintronix, explains that the system enables therapists to engage patients in activities that help them improve their balance and increase core strength, which can reduce fall risks for those with Parkinson's and other conditions that affect gait and balance. “Clinicians can go in and increase or decrease level of intensity to adapt to their patients' needs,” she says.

Many therapy companies are training their clinicians to better serve adults with chronic conditions. At Aegis Therapies, all of its therapists are trained in what it calls the “Older Adult Model of Care,” which encompasses a Restore, Compensate, and Adapt (RCA) approach for patients. RCA is ingrained into all of Aegis' clinical programming, says Mark Besch, vice president of clinical operations. 

“As part of the training, our therapists are taught how to spot underlying conditions, restore functioning and help patients learn how to compensate for a loss of strength or coordination,” he says.

Select Rehabilitation, a contract rehab therapy company based in Glenview, IL, also puts a heavy emphasis on training its clinicians. “It's important for our therapists to know what do when someone comes in with six diagnoses and 12 different medications,” notes Lisa Milliken, director of education. As an example, she explains that people with COPD are at high risk for aspiration in the middle to late stages of the disease. “Treating dysphagia and teaching some swallowing strategies can make a huge difference in helping someone maintain independence longer, as well as keep them out of the hospital.”

Louisville-based Kindred Healthcare has moved away from providing for patients to facilitating engagement with patients who have chronic diseases, says Mary van de Kamp, senior vice president of quality and care management. 

“We focus on improving transitions back to the community, and getting to know the patient helps in that regard,” she says. “Some are reluctant to tell you about their home life, but having an honest conversation about how they will manage and what their greatest needs are is important.”

“It's important for our clinicians to understand that when someone is functioning at a certain level they can still improve within a given range, and what that range will be you don't always know until you work with them,” adds Matthew Mesibov, clinical physical therapist with Centrex Rehab. The company employs a range of “integrated solutions” that are tailored to the patients' needs. For example, the Balance Solutions program identifies older adults at risk for falls and provides fall risk assessments, tailored treatments and fall-prevention education classes.

Readmissions kit

Of course, all providers in the long-term and post-acute care continuum are ever-vigilant about preventing unnecessary hospitalizations, and it is with this in mind that McKesson, a medical supply company, recently developed a hospital readmission resources kit for its customers and their patients. Launched in July, the kit contains information about care protocols and clinical support and products. McKesson also offers a complimentary online learning portal that includes educational videos that address treatments and interventions for COPD and CHF.

Adjunct solutions that offer real-time data are valuable in nearly any healthcare setting. EarlySense, which focuses on using technology to help patient safety with fewer patient falls, has been used at a Bronx-based nursing home as a continuous patient monitoring solution that fits under the mattress of a patient's bed. The system provides data on heart rate, respiratory rate and motion, to potentially allow the clinical team to manage deterioration, prevent falls and stave off pressure ulcers. 

The system has met a need, says Zachary Palace, M.D., CMD, medical director at the Hebrew Home in Riverdale, NY.

“For our residents with chronic diseases, we need to intervene earlier, before it becomes exacerbated and more severe,” he says. “Nurses cannot always see every patient at every moment.”

Palace adds “slight changes such as an increased heart rate, a rise in respiratory rate” can be early signs of an infection. These are important aspects of maintaining and preventing loss of function for patients with many of the chronic conditions, he notes. 

APTA's Bell reiterates the importance of movement and engagement for older adults with chronic conditions: 

“The presumption has been that it was too taxing to engage folks in rehab or exercise, but we know now from evidence and literature that this is not true.” n