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Evidence-informed Home Health Management
of Total Hip Arthroplasty

By: By Babatope Olusina, PT, DPT and Olaide Oluwole-Sangoseni, PhD, DPT, MSc.

Osteoarthritis is a degenerative joint disorder that affects the articular cartilage, underlying bone, and surrounding soft tissues. It is the most common form of joint disease in the United States (US), with an estimated prevalence of 27 million people,1 with an occurrence of about 10% in men and 13% in women, over the age of 60 years. 2 Hip osteoarthritis accounts for about 70% of total hip arthroplasties (THA) that are performed in the US due to severe pain, which limits the individual’s functional mobility and negatively affects his/her activities of daily living (ADLs), eventually limiting his/her participation in work and leisure activities. 3 Other indications for THA include but are not limited to trauma and osteonecrosis of the femoral head.4

THA is the surgical replacement of the natural hip joint with a prosthesis. 3 The first THA procedure was completed in the US in 1969 and as the procedure has grown in incidence, the technique has evolved and its efficacy has improved. 2,4 A 2010 prevalence study estimated 2.34% of individuals over the age of SO years in the United States have had THA, corresponding to 2.5 million people (1.4 million women). 4 A detailed breakdown of their study revealed a prevalence of 0.58% at age SO years, increasing to 1.49% at sixty years, 3.25% at seventy years, 5.26% at eighty years, and 5.87% at ninety years of age.4 The original or more popular technique is the posterior or posterolateral approach, with its associated precautions (no hip flexion above 90 degrees, no adduction beyond the midline, and no internal rotation of the surgical hip joint).

In the 1980s, an anterior approach was developed and gained popularity because of improved early outcomes in terms of pain and early functional recovery. 5 Hip hemiarthroplasty is the surgical removal of one of the components of the hip joint, most often the femoral head. Although it is less invasive, the Physical Therapy assessment and management will follow a similar path as for a THA.

Home health physical therapists (HHPT) are part of the multidisciplinary team-approach called upon to manage these patients upon their return home. Orthopedic surgeons seek the involvement of physical therapists (PT), as movement specialists, to facilitate the recovery and rehabilitation of THA patients to maximize their return to full function and participation in the activity. In consultation with the orthopedic surgeons, our home health agency established protocols that can be customized to fit the individual patient’s desired outcomes and surgeon’s preferences. These protocols guide the first few weeks of in-home rehabilitation before the transition to outpatient physical therapy. As a HHPT with a weekly caseload of about 50 percent of total hip and total knee arthroplasty patients, I recognize that no two patients’ status post-THA is the same.

The Medicare home health Conditions of Participation (CoP) require that a comprehensive assessment of each patient be performed by the admitting clinician to start the episode of care. This assessment includes the patient’s past medical history (PMH); a complete review of the patient’s medications, including any changes in dosage and patient’s response; and the integumentary assessment, all of which go into the process of formulating the patient’s plan of care.

Because most home health patients have multiple diagnoses, the evaluating PT incorporates the patient’s past medical/surgical history and the patient’s prior level of function into his/her physical therapy plan of interventions. A detailed assessment of the patient’s home is an essential aspect of the initial visit, as safety hazard/fall risks can be identified, and safety education and recommendations can be immediately communicated to the patient and their caregivers. The purpose of this case report is to highlight the physical therapy management of a THA in the home health setting with a focus on adapting exercise program based on pain and muscle fitness indices.

Case Presentation:

The patient is an 81-year-old female, retired nurse admitted to HHPT following right THA revision with weight-bearing as tolerated precautions. She resides alone in a single level house in a 55+ Age-in-Place community. Before this surgery, she was fully independent with all of her functional mobility, occasionally using a standard straight cane for ambulation. She was independent with all activities of daily living (ADL)s and was active in her community, participating in group exercise sessions every week.

Past Medical History:

Her PMH was significant for multiple comorbidities: hypertension, atrial fibrillation, type 2 diabetes mellitus, anxiety, neuropathy, general osteoarthritis, vertigo, history of lumbar laminectomy and fusion in 2017, reflux disorder, cystocele with prolapse, and recent urinary tract infection. Initial THA was performed in 2002; she had a dislocation in 2017, which resulted in persistent hip joint pain afterward.

Current Medications included:

• Apixaban, PO, 2.5mg, 1 tab, twice daily
• Diltiazem, PO, 240mg, 1 tab daily
• Norvasc, PO, 5mg, 1 tab PRN, if diastolic is above 90mmHg
• Pepcid, PO, 10mg, 1 tab Q 8 hours
• Xanax, PO, 0.5mg, 1 tab daily
• Tramadol, PO, 50mg, 1 tab Q 6 hours
• Purelax PO, 17gram/dose, 1 tab twice daily
• Potassium Chloride, PO, 20mEq, 1 tab twice daily.
• Tylenol Extra strength, PO, 500mg, 2 tabs Q 8 hours

The patient stated her goal is to return to walking independently without the walker.

Objective Examination and Assessment

Physical Status:

On examination, “Nanette”(a pseudonym) was alert and oriented to person, place, and time, and able to follow a multi-level command. She presented with hypomobility of the hip joint and weakness of the proximal muscles of the surgical lower extremity. She required contact guard/minimal assistance to assist her right lower extremity into the bed during bed mobility assessment. She required close stand-by-assistance of the therapist for sit to/from stand and bed to/from chair transfers due to She was dependent on a rolling walker for ambulation, with forward-flexed trunk posture over the device, using a 2-point antalgic gait pattern. The Timed Up and Go test (TUG) was performed, with the “Nanette” requiring 36 seconds to complete. 6 A time greater than 20 seconds is indicative that the patient is dependent on transfers and confirms homebound status. 6 The family had hired a private duty company to provide personal care assistance for several hours during the day to assist her in the first 3 weeks.


Because the initial home PT evaluation was on the same day as the nursing start of care (SOC) visit, PT evaluation referred to the nursing integumentary assessment. However, the physical therapist assessed the surgical incision on each subsequent visit, per our agency protocol, performing dressing changes when needed. The status of the wound was documented and presented at the interdisciplinary case conference with the registered nurse as required.


Per Medicare CoP, Nanette’s pain was evaluated on the initial examination and all subsequent visits, using a numeric pain rating scale (0-10) and verbal description. She rated her pain at level 5/10; her goal was to be pain-free by discharge. The expectation was a gradual decrease in the pain level, and any movement in the other direction and/or a new type of pain warrants additional evaluation.

Clinical Impression:

Based on the hypomobility of the hip joint and weakness of the proximal muscles of the hip and pelvis, the International Classification of Functioning, Disability and Health (ICF) model diagnosis of M25.651 or 652 (stiffness of hip joint, not elsewhere classified) was made.

Plan of Care

It was determined that Nanette would benefit from a skilled PT intervention frequency of 2 times per week for 4 weeks. Her exercise prescription consisted of joint mobilization, ROM and strengthening exercises, instruction in a home exercise program (HEP), functional mobility training (including bed mobility, transfer, and gait training), balance reeducation, equipment training, safety education, to progress to independence in all areas (Figure 1).

Figure 1: Physical Therapy Plan of Care

Since the pain was the chief complaint, it was used as one of the outcome measures. Pain medication was to be taken an hour before the PT session. The patient’s pain level was expected to decrease to level 1/10 at discharge.

  1. Therapeutic exercises on the day of the examination consisted of:
    • Isometric contraction of the quadriceps and bilateral gluteal muscles sustained for 5 seconds or until fatigue.
    • Isotonic exercises, including hip abduction (in standing), hip/knee flexion (in supine via heel slide) and knee extension (in sitting), ankle dorsiflexion and plantarflexion (in supine), up to 15 repetitions or until fatigue, using BORG rate of perceived exertion (RPE) score with a target score of 14 on the 6-208 scale.8 The PT’s focus was on increasing muscle endurance using a high repetition approach. The patient’s positioning during exercise was modified in sitting and standing due to a history of chronic acid reflux; she was unable to tolerate supine lying.
    • Exercise progression/upgrade included gradual addition of hip flexion, abduction, and extension in standing for muscle strengthening-an upgrade of knee flexion, ankle dorsiflexion, and plantarflexion in standing using gravity and bodyweight resistance. Exercise intensity was based on RPE, and the type of exercise was the final two weeks to include external hip rotation in the supine position.
    • Home Exercise Program (HEP): The patient was instructed to perform the aforementioned exercises as her HEP 2-3 times daily on the days that the PT is not scheduled, to maximize her progress and to progress her towards her stated goal. Nanette’s adherence was crucial to her overall recovery, stated personal goal, and physical therapy outcome. HEP adherence was monitored through direct open-ended questions and requested demonstrations during subsequent visits. Nanette was provided education to encourage cooperation with the overall plan of care.

  1. Functional mobility training included bed mobility training with safety instructions given to ensure the patient adhered to the THR precaution during supine to sit and sit to supine mobility. Transfer training included regular sit to/from stand, toilet transfers, shower and tub transfer training, and, later, car transfer training in preparation for discharge. The patient received gait training with the rolling walker, with verbal and visual instructions provided to address the deficits and impairments noticed during her initial examination. This patient received instructions for postural reeducation, and to increase stance time and the amount of weight-bearing in her right LE. As her pain subsided 2-3 points, and her right LE muscle strength improved, she was progressed to the use of a standard cane first on level surface, and later on uneven surfaces. Just before discharge, the patient was progressed to gait training without an assistive device.
  1. Balance reeducation in standing started with transitional weight-shifting patterns in the sagittal and coronal planes. The verbal emphasis was on maintaining upright trunk posture, increasing stance time on the surgical leg, and improving the amount of weight-bearing. The first progression of this was to perform the same activities without upper extremity support. The next progression was the use of transitional stepping patterns in the sagittal and coronal planes. These activities were performed to improve the muscle stabilization action around the replaced hip joint, as well as improve the patient’s confidence in the ability of the surgical hip to sustain her weight. This is essential in the progression of gait training from a walker to a cane, and eventually to ambulating without a device.

  1. Patient Education Patient education was a multi-pronged approach. The patient demonstrated a high level of health literacy; therefore, patient education was a multi-pronged approach. The PT provided education about Nanette’s THA precautions, with emphasis on observing these precautions as she goes through her day-to-day activities. Nanette’s precautions included avoiding turning towards the affected side, sitting in a low chair, and during supine to/from sitting, as these are some of the times when a patient is most likely to break the precautions. Safety education was provided in direct correlation to the safety hazards identified during the initial examination visit and other sessions. Nanette had area rugs in her walking path and a narrow path to her side of the bed. The PT provided suggestions and education regarding fall risks and prevention. Her bed was rearranged to allow a wider path to fit the walker. Area rugs were removed throughout the home. Also, caregivers (daughter and paid caregiver) were provided with education on a variety of topics, including Nanette’s home exercise program, signs, and symptoms of a deep venous thrombosis (DVT), pain medication management, the application of cold modalities for pain management, and if and when to seek medical attention. Researchers have suggested that there is an emergency room visit rate of about 13.4% in the first 90 days following THA, and the most frequent reasons are swelling (15.6%) and uncontrolled pain (12.8%).7 A study by Saleh et al documented these same common surgery-related reasons accounted for emergency room (ER) visits in about 35% of patients.9 These studies underscore the role of home health professionals in patient education regarding the careful assessment and management of swelling and pain in this population, as well as identifying patients that need to be referred to the ER for further evaluation immediately. This PT utilizes Wells’ Criteria for DVT10 as a clinical tool whenever there is concern about a possible DVT.


The patient achieved independence with her bed mobility by the first session of week 2 (3rd visit), and independence with her sit to/from stand and chair to/from bed transfers by the end of the second week (4th visit). She demonstrated independence with her shower stall and tub transfers by the third week (6th visit) and independence with car transfer in the 4th week. The patient progressed to gait training with a standard cane by the 3rd week. She had progressed to independence with gait training on level and uneven surfaces, including on her inclined driveway and to her community mailbox, which is about 450 feet away from her front door, with a numeric pain score of 0/10. Her functional score improved from 36 seconds at initial evaluation to 12 seconds using the TUG test. This score correlates with independence in all transfers and activities of daily living. Her right hip muscle strength had improved to 3+/5, and the patient demonstrated independence with her HEP. Nanette had achieved pain-free status by the final visit.


This patient presented with several impairments that created limitations at the body function level as well as at the activity and participation level, 11,12 as laid out above with the ICF model.

The HHPT used his/her expertise to provide an individualized, person-centered, evidence-informed treatment in the management of this patient. The plan of care was based on the interdisciplinary protocol developed by the surgeon and the home health agency, to help achieve the goals she stated as important to her. Nanette was motivated to return to driving and get back to her normal social life with her friends in the 55+ Age-in-Place community where she resides. The patient had multiple episodes of elevated blood pressure that warranted the notification of her primary care physician (PCP). To err on the side of caution, our home health agency policy requires physician notification for any systolic above 150 and diastolic above 90mmHg. Although her PCP decided not to take any immediate action, her blood pressure was carefully assessed at the start of each visit and response monitored throughout the interaction. The patient had a medical history of anxiety, which sometimes played a role in her exercise response and feedback to the therapist, especially related to her RPE rating and response. She required frequent reassurance, and it was well managed afterward.

Further, consistent with her medical history, constant adjustments had to be made based on observations and findings at the beginning of each visit. Some of her exercises were modified, considering her history of back pain and surgery to avoid aggravating old symptoms. She received a reiteration of education regarding home safety and community re-entry in the last week of the HHPT visit.

Nanette was discharged from home health nursing services in her second week and was discharged to outpatient therapy upon completion of her 8th and final visit. She planned to start driving, first inside her community, once she was released from home health services. An anonymous satisfaction survey was mailed to her by the agency after discharge, and she expressed her satisfaction to the therapist on her last visit, showing how quickly she was progressed to independence with physical therapy. This case report demonstrates a successful progression of an individual with a posterior approach THA from acute care to return to community living through a three-week course of HH services.

About the Authors

Babatope Olusina, PT, DPT, Certificate of Advanced Competency in Home Health (APTA Home Health Section). He is a member of the APTA and Home Health section. Dr. Olusina now works for a home health agency in Richmond, VA, but previously owned and ran a Contract Therapy Staffing Company.

Dr. Olaide Oluwole-Sangoseni, PhD, DPT, MSc, GCS, is an associate professor of physical at Maryville University of St. Louis. She is a Board Certified Geriatric Specialist and a home health PT. Dr. Sangoseni is an advanced physical therapy clinical specialist degree in neuro-orthopedics from the University College London, England. She is an APTA credentialed clinical instructor. She can be reached at osangoseni@maryville.edu.


  1. Lespasio MJ, Sultan AA, Piuzzi NS, et al. Hip osteoarthritis: a primer. Perm J. 2018;22:17-084. DOI: https://doi.org/10.7812/TPP/17-084
  2. United States Bone and Joint Initiative: The Burden of Musculoskeletal Diseases in the United States (BMUS), Fourth Edition, 2020. Rosemont, IL. Available at http://www.boneandjointburden.org. Accessed on June 15, 2020
  3. Siopack JS, Jergesen HE. Total hip arthroplasty. West J Med. 1995;162:243-249, 1995
  4. Kremers HM, Larson DR, Crowson CS, et al. Prevalence of total hip and knee replacements in the United States. J Bone and Joint Surgery. 2015: 97(17): 1386-1397
  5. Wang Z, Hou JZ, Wu CH, et al. A systematic review and meta-analysis of direct anterior approach versus posterior approach in total hip arthroplasty. J Orthop Surg Res. 2018;13(1):229. Published 2018 Sep 6. doi:10.1186/s13018-
    018- 0929
  6. Centers for Disease Control and Prevention: National Center for Injury Prevention and Control. STEADI Tools. https://www.cdc.gov/steadi/pdf/
    TUG_Test-print.pdf. Published 2017. Accessed on June 20, 2020
  7. Kelly MP, Prentice HA, Wang W, Fasig BH, Sheth DS, Paxton EW. Reasons for ninety-day emergency visits and readmissions after elective total
    joint arthroplasty: results from a US integrated healthcare system. J Arthroplasty. 2018;33(7):2075-2081. doi:10.1016/j.arth.2018.02.01 O
  8. Williams N. The Borg Rating of Perceived Exertion (RPE) scale. Occupational Mede.2017; 67(5):404-405, https://doi.org/10.1093/occmed/kqx063
  9. Saleh A, Faour M, Sultan AA, Brigati DP, Molloy RM, Mont MA. Emergency department visits within thirty days of discharge after primary total hip arthroplasty: a hidden quality measure. J Arthroplasty. 2019;34(1):20-26. doi: 10.1016/j.arth.2018.08.032
  10. Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003 Sep
  11. Klapwijk LC, Mathijssen NM, Van Egmond JC, Verbeek BM, Vehmeijer SB. The first 6 weeks of recovery after primary total hip arthroplasty with fast track [published correction appears in Acta Orthop. 2018 Feb;89(1):140]. Acta Orthop. 2017;88(2):140-144. doi:10.1080/17453674.2016.1274865
  12. Bahardoust M, Hajializade M, Amiri R, Mousazadeh F, Pisoudeh K. Evaluation of health-related quality of life after total hip arthroplasty: a case-control study in the Iranian population. BMC Musculoskelet Disord. 2019;20<1>:46. Published 2019 Jan 31. doi:10.1186/s12891-019-2428-0

Evidence-informed Home Health Management
of Total Knee Arthroplasty

By: By Babatope Olusina, PT, DPT and Olaide Oluwole-Sangoseni, PhD, DPT, MSc.

Osteoarthritis (OA) is a degenerative joint disorder that affects the articulating bones, the articular cartilage, and surrounding soft tissues. Other causes of joint pain and degeneration include rheumatoid arthritis (RA), osteonecrosis, post-traumatic degenerative joint disease, and other pathologic conditions. While joint pain is usually the first sign that prompts the decision to seek medical attention1, other symptoms soon develop, including but not limited to joint hypomobility and muscle weakness. The progression of the disease results in the development of functional limitations such as difficulties with transfers, gait abnormality, stair management, and completing activities of daily living (ADLs), eventually having negative impacts on work, pleasure, and quality of life.

The knee joint is the largest weight-bearing joint in the body, and chronic knee pain has been listed as a “leading cause of musculoskeletal disability in the United States (US)”. 2 Total knee arthroplasty (TKA) is the surgical replacement of the natural knee joint with a prosthesis. It was the first performed in the US in 1968, and with ongoing advances in the technique and materials used, significant progress has been made in its effectiveness and success rate. A 2010 prevalence study of TKA by Kremers el al3 estimated 1.52% in the entire US population, and 4.55% in those over the age of 50 years, have had TKA. Prevalence is higher in women as compared with men, and it increases with age. Inacio et al4 projects that the number of TKAs performed in the US will increase by the year 2050 to a prevalence of 2.58%, amounting to 2,854 procedures per 100,000 US citizens. Partial knee replacement is often performed when the degenerative changes are confined to a particular compartment of the knee and mostly in the younger patient. The PT management is similar to that of a TKA, as described later in this study.

Physical therapy (PT) plays a major role in the initial conservative management of the knee pain before TKA, not only for pain management but also to improve function and decrease the limitations afflicted by the condition. Following a TKA, the home health physical therapist is part of the multidisciplinary team approach that manages the patient upon discharge home. Our Home Health Agency (HHA) has developed protocols to manage these patient populations effectively. Based on previously established protocol with the referring Orthopedic Surgeon, a registered nurse (RN) completed the initial visit, performing a comprehensive assessment of the patient, including the past medical history (PMH), assessment and care of the surgical incision, medication review/training, and the OASIS elements. This HHA also has established protocol with other Orthopedic Surgeons where the PT is the admitting clinician. The initial PT evaluation consists of a detailed musculoskeletal assessment of the patient,
a review of the patient’s PMH, gait and balance evaluation, and a home safety evaluation. A PT plan of intervention is formulated to address noted impairments and functional limitations, with the patient’s self-stated goal as the endpoint.

The purpose of this case report is to highlight the physical therapy management of TKA in the home health setting.

Case Presentation:

The patient is a 50-year-old female office worker referred to home PT and Nursing following a right TKA revision due to instability and eventual failure of hardware. She resides with her husband in a single-level house, with 8 entrance steps, and she was fully independent with all of her functional mobility, including ambulating without an assistive device, but she was limited by right knee pain and the knee “locking up”.

Past Medical History:

Her PMH was significant for multiple comorbidities: Significant for Hypertension, Diabetes Mellitus, Hyperlipidemia, Asthma, Anemia, Cervical spine stenosis, Elevated Hemoglobin, Ehlers-Danlos syndrome, Depression, Metabolic syndrome, and Premature Ventricular Contraction (PVC). Her past surgical history is significant for Bilateral TKA, Anterior cervical discectomy with fusion, and Caesarean Section.


Objective Examination and Assessment

Physical Status:

During her initial evaluation completed on 12/26/20, Valerie presented an alert and oriented to person, time, and place, and able to follow multi-level commands. She presented with hypomobility of her right knee (flexion ROM of 81 degrees and extension at negative 6 degrees) and weakness in her right quadriceps and hamstring muscle strength (2+/5 on the Manual Muscle Testing grade). She had difficulty with her bed mobility requiring close stand-by assistance, and she required supervision for her transfers. She was dependent on a pair of axillary crutches for ambulation using a 2-point gait pattern. She also used an antalgic gait pattern and exhibited poor arthrokinematics in the right knee. Her balance was assessed with the Timed Up and Go test (TUGT)5, with a score of 17 seconds; this identified her as having a high risk of falls.


The patient’s right knee surgical incision was covered with “Aquacell”, a non-removable dressing on the day of PT evaluation. It was removed by skilled nursing during the subsequent visit on 12/29/20. PT assessed the patient’s surgical incision during all follow-up visits, for signs and symptoms of infection. This is part of agency protocol that all clinicians will assess surgical incision and document appropriately; coordination of care is performed weekly with the RN case manager.


The patient’s pain level and description were assessed and documented during the initial PT evaluation and subsequent visits. The PT provided education to the patient and her husband regarding pain management strategies with her prescription analgesics, cryotherapy, and movement.

Clinical Impression:

Based on the hypomobility of her Right knee joint and the weakness of her right hamstring and quadriceps muscles, the International Classification for Functioning, Disability and Health (ICF) model ICD diagnosis of M25.661 (stiffness of right knee, not elsewhere classified), was made.

Plan of Care

PT determined that patient will benefit from skilled intervention with a frequency of 3 times per week for 3 weeks, per previously established protocol with referring surgeon. The intervention included therapeutic exercises (including a range of motion [ROM], strengthening exercises, and joint mobilization), functional mobility training (including bed mobility, transfer, gait, and stair training), instruction in-home exercise program, balance reeducation, safety education, equipment training, patient and caregiver education, and training, to progress her to independence in all areas.

  1. Patient has a diagnosis of Ehlers-Danlos Syndromes (EDS)6, a connective tissue disorder with joint hypermobility as one of its primary symptoms. Her therapeutic exercises, especially her ROM, were modified acccording to her symptoms and feedback. Therapeutic exercises prescription and progression was developed based on the phase of her rehabilitation, described as follows:

Days 1-10 acute phase (with emphasis on ROM, isometric and isotonic exercises)

Days 11-21 the sub-acute phase (with progression to advancing ROM, strengthening exercises, and joint mobilization)

Home exercise program (HEP) – the patient was instructed to perform her HEP 2-3 times daily. HEP was upgraded from Phase 1 to Phase 2 as the joint effusion and pain decreased, the right LE muscle strength and coordination improved.

  1. Functional mobility training – The therapist provided verbal and visual instructions to the patient to quickly teach bed mobility and transfer techniques to progress her independence in both areas. Gait training with a pair of axillary crutches, emphasizing the proper use of the 2-point gait pattern and ensuring the crutches support the right LE, was performed. PT emphasized the need to increase right knee flexion ROM during the non-weight bearing phase of gait and facilitate full knee extension at heel strike. She was started on gait training with a one-handed device by the end of the second full week and progressed to independence by the end of her 3 weeks of home PT.
  1. Balance reeducation – transitional weight-shifting patterns in the anteroposterior and lateral directions in standing, facilitating increased weight bearing on the surgical leg. Later progressed to using a narrow base of support (BOS) in a modified tandem position, where she initially required contact guard assistance and later progressed to supervision level.
  1. Patient education: PT provided detailed instruction to the patient and her husband regarding pain and joint effusion management, signs and symptoms of DVT and infection at the wound site, and edema management. Patient education was specific to the home exercise program. Several studies have identified pain, fear of DVT, and edema as the most common reasons patients visit to the emergency room. (5-7) Therefore, our agency emphasizes patient education regarding symptoms management and patients’ expectations of their recovery roadmap. Safety education was provided, emphasizing the patient safely navigating her house with 2 cats and 2 small dogs underfoot. Her husband was instructed to, and he ensured a clear path to the bathroom from her bed, and he provided assistance that patient required for her first few shower transfers. During her fourth HHPT visit on 1/4/21, the patient reported feeling sick, dizzy, and nauseous after completing her supine and sitting exercises. Her vital signs were initially checked at the time of the therapist’s arrival, and they were within normal for the patient. She was assisted back to the couch, and her vital signs were re-checked; her blood pressure was now 91/53 mmHg, pulse was 94 beats per minute, and respiratory rate was 20 per minute, and her oxygen saturation was 98%. Further, the patient was diaphoretic and quite anxious. The PT re-assured the patient and provided moving air to cool her down. After about 5 minutes in a supine position with her lower extremities elevated, she reported feeling “somewhat better”. Her vital signs were re-checked – BP was 91/59 mmHg; pulse at 93 beats per minute; respiration at 16 per minute, and oxygen saturation at 98%. The patient’s surgeon’s office was contacted and informed about the incident. Her primary care physician (PCP) was also informed per the patient’s request. Both physicians agreed with the therapist that the patient did not require emergency care because her oxygen saturation remained within normal range, and she recovered in terms of her subjective feeling. PT ruled out possible Pulmonary Embolism (PE) using Well’s Criteria and ruled out possible DVT. She subsequently missed the next scheduled session on 1/6/21; even though she reports feeling better, she asked for another day to rest before resuming PT. She had a follow-up appointment with her primary care physician on 1/11/21 and was started on an iron supplement for postoperative anemia.


The patient completed 8 of 9 planned HHPT visits, and she had progressed to independent bed mobility and transfers by her third visit on 12/30/21. By the end of the 3rd week her progress was as follows:


The patient’s plan of care was developed based on a combination of her impairments following her right TKA, functional limitations, and goals. She made steady progress towards her stated goals of independence with all of her functional mobility and all of her ADLs, without pain and locking up of her Right knee joint. The patient regained full AROM of her right knee joint and regained muscle strength to engage in her regular activities. She progressed to and demonstrated independence with all of her mobility and planned to resume telecommuting the following week once cleared by her surgeon.

During HH services, the patient was diagnosed with postoperative anemia by her PCP, which is common among surgical patients.7 Following the initial incidence, her vital signs and symptoms were monitored more frequently. Her surgeon and PCP were contacted to report her symptoms, and because the patient was discharged from home health skilled nursing services on 12/29/21, the PT provided education to the patient regarding the possible drug interaction of her iron supplement prescribed by her PCP. Ferrous Sulfate can bind to Doxycycline in the Gastrointestinal tract, which may decrease their absorption and bio-availability. They should be taken 3-4 hours apart to avoid or minimize this interaction. The therapist also provided education to the patient and her husband regarding food rich in Iron to complement her medication.

Several studies have identified the common reasons for visits to the emergency room after TKA. (7-9) A study reported 15.6% of ED visits were for swelling, and 15.8% were uncontrolled pain.8 Another study reported that among patients who had ED visits after THA and TKA, the primary diagnosis in 17.84% was pain.9 To decrease unnecessary visits to the ER, our agency has developed a comprehensive education program for post-op THA and TKA patients. PTs share the information with the patient on the first visit regarding the red flags of infection and possible DVTs; and education regarding pain and edema management. The same information is reviewed on the 2nd and 3rd visits until the patient can verbalize the previously provided information.

This case report highlights the effective management of a TKA patient in the HH setting while incorporating the patient’s unique PMH and postoperative complications. Her exercise program and joint mobilization were modified to accommodate her Ehlers-Danlos condition and her vital signs more closely monitored with the postoperative anemia. Her exercise program was progressed from the initial set more suited for the immediate acute phase to more advanced exercises in the sub-acute phase. She was progressed to independent ambulation without an assistive device on a level surface and with a one-handed device on uneven surfaces.

About the Authors

Babatope Olusina, PT, DPT, Certificate of Advanced Competency in Home Health (APTA Home Health Section). He is a member of the APTA and Home Health section. Dr. Olusina now works for a home health agency in Richmond, VA, but previously owned and ran a Contract Therapy Staffing Company.

Dr. Olaide Oluwole-Sangoseni, PhD, DPT, MSc, GCS, is an associate professor of physical at Maryville University of St. Louis. She is a Board Certified Geriatric Specialist and a home health PT. Dr. Sangoseni is an advanced physical therapy clinical specialist degree in neuro-orthopedics from the University College London, England. She is an APTA credentialed clinical instructor. She can be reached at osangoseni@maryville.edu.


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  6. Corrado B, Ciardi G. Hypermobile Elhers-Danlos syndrome and rehabilitation: taking stock of evidence-based medicine:a systematic review of the literature. J Physical Therapy Science. 2018 Jun; 30(6): 843-847.
  7. Perelman I, Winter R, Sikora L, et al. The Efficacy of Postoperative Iron Therapy in Improving Clinical and Patient-Centered Outcomes Following Surgery: A Systematic Review and Meta-Analysis. Transfusion Medicine Reviews, 2018 April, 32:2, 89-101.
  8. Kelly MP, Prentice HA, Wang W, Fasig BH, Sheth DS, Paxton EW. Reasons for ninety-day emergency visits and readmissions after elective total joint arthroplasty: results from a US integrated healthcare system. J Arthroplasty. 2018;33(7):2075-2081. doi:10.1016/j.arth.2018.02.010
  9. Finnegan MA, Shaffer R, Remington A, et al. Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care. Journal of Bone and Joint Surgery: 2017 June 21. 99 (12), 1005-1012.
By: Patricia Hudak, RN and Chelsea Cassidy, LCSW Stress Management Most individuals can relate to the feelings of stress even if they are not able to relate to the specific circumstance you may be experiencing.  There are different responses to feelings of stress, depending on your own coping techniques and how you address the stressor in your own life.  Stress depends on the duration of the stressor, intensity of the stressor and capacity of the individual to withstand the stress. What is Stress? Stress is primarily a physical response. When stressed, the body thinks it is under attack and switches to ‘fight or flight’ mode, releasing a complex mix of hormones and chemicals such as adrenaline, cortisol, and norepinephrine to prepare the body for physical action. This causes several reactions, from blood being diverted to muscles to shutting down unnecessary bodily functions such as digestion. The challenge is when our body goes into a state of stress in inappropriate situations. When blood flow is going only to the most important muscles needed to fight or flee, brain function is minimized. This can lead to an inability to ‘think straight’; a state that is a great hindrance in both our work and home lives. If we are kept in a state of stress for long periods, it can be detrimental to our health.  The results of having elevated cortisol levels can be an increase in sugar and blood pressure levels, and a decrease in libido. FIGHT: When your body goes into a state of stress, we may feel agitated and aggressive towards others; this can be due to our bodies’ natural reaction being “fight”. This can be a helpful reaction to ward off predators, but in unnecessary situations, it can negatively affect relationships and ruin reputations. FLIGHT: Some of us avoid our stressors, removing ourselves from the situation instead of tackling it. This can be a sign of the “flight” survival instinct; a function that can save our lives if we find ourselves in dangerous surroundings. However, in everyday life, this instinct can lead to a stressful situation escalating and increase our stress levels when we realize that the stressor is not going away and we need to face it. FREEZE: Unknown by many, there is a third mode that stress can cause; freeze. For some people, becoming stressed sets the stage for ‘dysregulation’.  The energy mobilized by the perceived threat gets “locked” into the nervous system and we ‘freeze’. This response sometimes reveals itself when we breathe. Holding our breath and shallow breathing are both forms of freeze. The occasional deep sigh is the nervous system catching up on its oxygen intake. Mindfulness is a great practice to implement when under stress.  Mindfulness is about being present with what is happening without judgement.  Often our stress will raise when we allow our thoughts to take us to the past and re-experience the event over and over (ruminate) or place our thoughts in the future.  We create a larger space mentally for the stress by giving energy to the past and future.  The purpose of mindfulness is to stay in the present with your feelings and emotions.  We then can react from a place of intelligence and kindness. (NPR) RAIN is an acronym that can remind you how to practice mindfulness: Recognize Sense the feeling that you are having in the moment Allow Pause. Give space for the feelings.  It is okay to not be okay. Investigate Take a screening of your body internally and externally.  Can you identify places of pain or discomfort? What has your attention? What are you believing right now?  What thought patterns can you track? What do you need in this moment? Nuture Be kind to yourself.  Give grace to yourself.  Place a hand on your heart and make a positive affirmation statement. The goal of RAIN is to practice mindfulness by being present with yourself which can create a shift in the way you feel.   Breathing technique: 4-7-8 Breathing techniques are great to have in your stress management tool kit.  They can be done any place without others even noticing.  This provides quick interventions during high moments of stress.  The 4-7-8 breathing technique is designed to reduce anxiety, help people fall asleep, manage cravings, and reduce anger (Medical News Today). To start, get yourself into a comfortable sitting position and place the tip of the tongue on the tissue right behind the top front teeth. As with anything, including mindfulness and breathing techniques, the more you practice it, the easier it becomes.  One will also see the positive effects of mindfulness and breathing techniques over time.  A good starting point is to practice these techniques twice a day – morning, and evening.  Giving your first thoughts and last thoughts to yourself.  Emily Ley has recently stated in her podcast “be where your feet are”.  Take the challenge to be fully present in body, mind, and spirit where your feet are and watch the stress dissolve.
In honor of National Healthcare Decisions Day today, we invite you to take a moment to think about what your wishes are in the event of a medical crisis. This past year, COVID-19 has highlighted the importance of discussing your wishes with your loved ones and documenting these wishes in the form of an advance directive. Far too often, this conversation gets put on the back burner and people find themselves in a medical crisis with no plan. When this happens, it may be too late to receive the care you wanted.

So what is advance care planning?

It includes completing an advance directive, also known as a living will. This is a written statement that details your wishes for medical treatment should you be unable to communicate these to your doctor or healthcare provider yourself. Advance care planning also includes appointing a power of attorney (POA). This person will be responsible for making your healthcare decisions if you are unable to speak for yourself.

Why is it important?

These are important steps to take to ensure you receive the care you want in the event of a medical crisis. NHPCO President and CEO Edo Banach says, “It’s also important to remember that having these thoughtful discussions with your family and documenting your wishes can be a gift to your loved ones should you become critically ill and unable to speak for yourself. Your priorities will be clear to them,” So for yourself and for your loved ones, please take some time to come up with a plan, discuss it with your loved ones, and document it in an advance directive.
See below for some resources from the NHPCO that can help with your advance care planning:

Personalize Your Plate with National Nutrition Month® 2021

This year’s theme of “Personalize Your Plate” emphasizes the importance of understanding there is no ‘one-size-fits-all’ approach to nutrition and health. We are all unique and our approach to healthy living should be, too!
Creating healthy eating habits can be a daunting task, with an overwhelming amount of information thrown at us, the latest eating trends, and buzz-worthy ingredients. However, good nutrition really is all about having a well-rounded diet.

Nutrition Made Simple

Keeping in mind that we all have different nutrition goals which require different approaches, the CDC website provides the following four general tips for working towards a well-rounded diet:
  1. Add healthy fats, such as avocados, nuts, olives
  2. Reduce overall sodium intake – start by reading ingredient labels and recipes to find alternatives to sodium
  3. Increase fiber for digestion
  4. Aim for a variety of colors on your plate during every meal

Test Your Culinary Skills!

National Nutrition Month® is the perfect time to learn new and healthy recipes! With the internet at our fingertips, there are endless resources available to you. Most recipes include the nutrition information at the bottom that will help you to determine if the recipe meets your nutritional needs. For those of us who just don’t know where to begin, there are meal kit services like ‘Hello Fresh’ and ‘Blue Apron’ that delivers recipes and the necessary ingredients to your home based on your nutritional preferences at a frequency of your choosing. These services can be a great starting point and helpful resource in a busy world where we don’t always have the time to dedicate to planning our meals. If you are still lost on who to turn to for help, Registered Dietician Nutritionists can assist with developing a customized plan tailored to our unique bodies and nutritional needs.
So let’s use National Nutrition Month® as motivation to put our healthiest foot forward and strive for a well-rounded diet. And remember to Personalize Your Plate!
By: Patricia Hudak, RN and Chelsea Cassidy, LCSW Dr. George J. Mehfoud, MD is a Primary Care Physician with Commonwealth Primary Care in Richmond, VA.  Dr. Mehfoud is an Internal Medicine Specialist with over 32 years of experience in the medical field.  He graduated from Eastern Virginia Medical School in 1989.  He believes knowledge is power and takes his time to educate the hospice team on best practices on quality of care on numerous topics.  Recently, he in-serviced hospice clinicians on the impact of COVID-19 in long term care facilities. The geriatric population and residents of long-term care facilities were the hardest impacted and most vulnerable to COVID since the beginning of the pandemic.  In the beginning, lack of PPE, COVID testing, staff ratio, staff education, proper protocols, financial support, inadequate spacing (shared rooms/bathrooms or dining areas), worker fatigue and fear were all key factors in these facilities being at risk of infection and transmission.  Certified Nursing Assistant (CNAs) have been true pandemic heroes for their dedication on the front lines and financial sacrifice.  Many CNAs work multiple jobs to provide for their families and were forced to choose one job at a specific community for safety and transmission reasons. Our state went through a period of lockdown to lower the curve of positive COVID-19 cases and needed time to develop and have access to adequate testing, PPE and educate as well as train on protocols for safety and providing care. Once testing was readily available, facilities were then able to test residents and staff on a regular basis to have a more proactive approach to contain the spread.  Many of these facilities remain closed to the public.   Measures to prevent infection such as restricting visitors, wearing masks, symptom screening and adequate testing of both residents and healthcare personal continues to have a lasting effect on our elderly.   The result of these protective measures has led to social isolation which has caused residents to experience depression and anxiety, increase in dementia by 50% (according to the CDC), promotes Failure To Thrive (FTT) and hastens premature death. Hospice historically has been centered around maximizing an individual’s quality of life.  Although this pandemic has created challenges for all healthcare providers, we as a hospice team have looked holistically at providing care in person and through a virtual lens for patients, families, and the communities we serve.  With the establishment of Medicare waivers for telehealth services our team can continue to provide the maximize support available.  Dr. Mehfoud outlined specific ways we can care for our patients during the pandemic: In the caring words of Abode Healthcare CEO, Mike McMaude, he has reminded our company that at our primary purpose is taking care of patients and taking care of each other.  When we do this – we can certainly come out of this pandemic hand in hand.By: Patricia Hudak, RN and Chelsea Cassidy, LCSW

History of American Heart Month

It’s February – American Heart Month – a time when the nation spotlights heart disease, the number one killer of Americans. President Lyndon B. Johnson, among the millions of people in the country who have had a heart attack, issued the first proclamation in 1964. Throughout the month, the American Heart Association’s “Heart to Heart: Why Losing One Woman Is Too Many” campaign will raise awareness about how one in three women are diagnosed with heart disease annually. The first Friday of American Heart Month, Feb. 5, is also National Wear Red Day as part of the AHA’s Go Red for Women initiative. This campaign recognizes that the risk factors of this silent killer can be vastly different in women than in men. Knowing and understanding your risk factors, whether male or female can literally save your life.  We encourage you to talk to a health professional about risk factors and prevention. Traditional risk factors common to both women and men: Risk Factors Specific to Women: Since COVID-19 pandemic struck our world, people have been engaging in less than healthy activities while in lockdown. These activities may include overindulgence in food and beverage, isolating, lack of routine, and less than average movement can and do increase a person’s risk factors. The heart is an organ that acts like a muscle. The more you work a muscle the stronger and more supportive that muscle becomes even to the surrounding tissue. Everything in our bodies needs oxygen to function properly. COVID-19 has now become an added risk factor- for males and females. Atrial Fibrillation is a known heart related effect of COVID-19 in some patients as well as long term respiratory problems. Pictured above is Anna Laughlin.  Anna is married to Dr. Jeff Laughlin, Pediatric Dentist (Virginia Family Dentistry) and they have three children, Charlie (15), Garnes (11) and Helena (8) and they live in Richmond, Virginia.  Anna is an educator and founder of Mission Equip, a non-profit organization focusing on the professional development of teachers and doctors in their Teacher to Teacher and Doctor to Doctor program. Anna was unfortunately diagnosed with COVID-19 in March 2020 when our country was first digesting the news of coronavirus and the sudden impact it was having on our lives.  Anna recalls developing her first symptom on March 21, 2020 of chest pain.  She had run five miles that day and was unsure if the chest pain was related to her physical activity.  Her symptoms continued and five days later she was tested for COVID-19.  Nine days later her primary care doctor and the Virginia Health Department contacted her by phone to notify her that she was positive for COVID-19. During this time, she had mild to moderate symptoms that continued to improve 10 days following the diagnosis. However, on the 11th day, she experienced a steep decline. She had ongoing chest pain, breathing difficulty, and was fearful to go to sleep at night not knowing what could come next.  She felt the need to go to the emergency room several times though she was advised to only go to the hospital if she could not finish verbalizing a sentence.  She had feelings of fear and frustration throughout the process. Anna voiced she felt “beyond alone” throughout this process. She was often asked “how did you get COVID?”  Her guess was as good as anyone’s and this type of question lead her to feelings of guilt and embarrassment.  She was one of the first to be diagnosed in Richmond even though she followed all the regulations to protect herself and her family. Our polarized political climate in 2020 increased her feelings of despair.  There was misinformation given from a wide variety of sources causing our nation to have strong divisive opinions on COVID-19 and how to respond.  Our whole world has been in isolation which limits our support system in the ways we can be cared for.  One of the lessons she and her family have learned throughout this experience is how to respond to those suffering – she states the best response to someone experiencing a hardship is to say  “I am so sorry you are going through this.”  This statement gives acknowledgment, empathy, and validation of the person’s experience.  Her children are now implementing this into their conversations which will enhance their ability to connect and support others.  The best gift we can offer those in a crisis is no judgment. Anna was one of the first people seen at VCU hospital cardiac and pulmonary clinic to be considered a “long hauler” which is now medically termed “long COVID”. Her COVID-19 symptoms lingered well into the summer and the most concerning physical symptom has been heart palpitations.  At first, she was unsure what was happening and labeled the symptom as anxiety, however she noticed that after experiencing the heart palpitation she would have a cough.  She had times that she could barely walk upstairs without being fatigued and sometimes even collapsed. Anna spent time researching medical journals to best guide her.  One of the hardest realizations she has had to come to terms with is that each day is like a grab bag full of COVID-19 symptoms – you never know what symptoms you will get. In September, Anna’s condition deteriorated, and her A-Fib episodes were increased from every two weeks to every 2-3 days. She reports that the most severe episode led to her to falling on the stairs and passing out in front of her young children. After consulting a Cardiologist at VCU Health she was admitted to the hospital for testing and what is considering ‘drug loading’.  She was unable to tolerate the medications, was discharged home, and was scheduled for a heart ablation procedure several weeks following. She is now three weeks post procedure and showing gradual signs of improvement of A-Fib.  The goal is for her A-Fib to be managed so she can focus on her ongoing healing and return to a healthy lifestyle to include participating in Yoga Therapy. Healing Your Heart This month is a reminder to evaluate your own heart health, and those we love.  Look at how we can make better choices to reduce and improve the risk factors that are within our control.  Practice relying on our health professionals, being honest if you are experiencing unusual symptoms such as shortness of breath, chest pain, indigestion, arm pain, and confusion.  These could be symptoms you may have not responded to in the past, however, please use these warnings signs to take care of you – and your heart. COVID-19 has not only impacted our lives – it has also deeply affected our bodies.  Our bodies may be experiencing many forms of grief all at the same time.  Loss of jobs, income, people, lifestyle, homes, freedom, independence, and travel are just to name a few.  This can make the grieving process complicated and messy.  When grieving, people often refer to having a “broken heart” or feeling “heartbroken”.  Grief is a feeling and mourning is the action of grief.  These feelings can be intense at times and have significant impacts on our bodies – particularly, our hearts. For example, high blood pressure, chest pain, heart palpitations, irregular heartbeat and/or heart attacks can be associated with the stress of grief on the cardiovascular system.  This condition is more clinically referred to as Takotsubo Syndrome (Psychology Today).  It is important for a person in the grieving process to be mindful of their body and assess how they are feeling, emotionally, physically, and spiritually.  Your body may feel torn apart and it needs extra attention and care.   When the body is under stress, it is more vulnerable to physical problems or chronic conditions could be exacerbated due to the emotional trauma you are experiencing.  During the grieving process, it would be good practice to notify your primary care physician of your recent loss.  Your physician may recommend scheduling an appointment to offer support and further asses your health.  When a patient under hospice services has a significant loss in their lives, the hospice team offers to increase their visits, makes a referral to the bereavement coordinator, and notifies the medical director.  This extra layer of communication and support is to help the patient have safe and healthy outlets to express their grief and monitor their health.  The medical director understands the impact of grief and that it can have a significant impact on the patient’s health. (Center for Loss and Life Transition) Now that we have discussed the history and significance of heart health, as well as, the impacts grief can have on our body, let’s review good and nurturing tips on how to care for our heart: We want to sincerely thank Anna for her open discussion and vulnerability walking us through her COVID experience.  Our hope and prayers are to watch her make a full recovery.By: Patricia Hudak, RN and Chelsea Cassidy, LCSW The COVID-19 vaccine has arrived and is being distributed throughout the country to every state.  The first phase included healthcare professionals and residents of long-term care facilities.  We are aware that within our healthcare community and even outside, the question for many of us, specifically the minority population, remains “Can I trust those in authority that the vaccine is safe-particularly from long term effects and not getting sick?” The healthcare community as well as the nation remains divided on this question. We are looking to our leaders for guidance and education to make the best personal informed decision. In today’s climate there are many more aspects that we are aware of that need to be considered when making this decision.  For instance, how does race and cultural differences impact this decision?  As a company, we are committed to continually look at our perspectives and policies on equality for our employees and the people we serve. In efforts to better educate and inform ourselves, we had the privilege to interview one of our AT Home Care Chaplains, Reverend Justin House, regarding his decision-making process for receiving the vaccine. Reverend House has been a Chaplain with AT Home Care Hospice since December 2019.  He has joined the healthcare community at a challenging time, considering the COVID-19 pandemic began to affect the United States just four months after he joined our team.  He has three children and is also the Senior Pastor for Tabernacle Baptist Church in Chesterfield, VA. Initially, Reverend House viewed the COVID-19 vaccine similarly to his decision to not receive the flu vaccine.  They are both viruses, right?  You receive some active dead virus for the flu virus to build antibodies to fight the flu.  Reverend House looked collectively for the common ground to make an informed decision.  He reports he took comfort in hearing from professionals and the CDC website that reports “none of the authorized and recommended COVID-19 vaccines or COVID-19 vaccines currently in development in the United States contain the live virus that causes COVID-19. This means that a COVID-19 vaccine cannot make you sick with COVID-19.” This statement and reassurance from professionals helped to decrease his fear of getting ill due to the vaccination.  He shared with us that like many others, he hoped that COVID-19 would “just go away” and eliminate his need to make a decision.  Unfortunately, time has shown that even our best human efforts to fight COVID-19 with mask wearing, remaining 6 feet apart, and social distancing is not enough to stop the spread.  Reverend House has adapted well to the mask wearing mandate and takes his style to the next level in wearing a comfortable and appropriate mask for each occasion. Reverend House shared that he recognized the need to look for the collective effort of information and implementation of our leaders for their example of following best practices, learning from our history and looking towards today which can move him and minorities to change now and for the future. When asked, “what would you say to someone that is fearful about receiving the vaccine?” Reverend House responded he wants to offer hope, he stated “we need to acknowledge the past but find ways to move forward and make a change today.” He is looking forward to taking a courageous step to build confidence that could lead to systemic change.  He recognizes there are unknowns, real fears and concerns however, in his process he can clearly see there are more pros than cons. He stated, “someone has to start it” and he is glad he can play a part for the next step in unity. We want to sincerely thank Reverend House for his vulnerability and transparency for sharing his reasons for getting the vaccine.  This is a great example of how the healthcare community is taking steps to unite for the greater good.By Joelle Y. Jean, FNP Due to its busy nature, providers in the Emergency Room (ER) may not immediately identify patients for hospice care. Approaching patients or family members about hospice can also be challenging-especially if they have specific questions. This hospice checklist can help guide providers on when they should consider a patient for hospice.

What is hospice?

Hospice is for patients who are at the end of life. Patients can have a terminal illness or declining health from a chronic illness. The hospice team can coordinate care with health care providers to manage and treat patients.

Benefits of hospice

Initiating hospice early in the disease process has many benefits for the patient and family members. Hospice is there to improve the quality of life and provide comfort for patients during their end of life. Benefits of hospice include:

Barriers to initiating hospice

Studies have shown that providers initiate hospice too late- patients die within weeks of entering hospice. There are barriers that cause ER providers to wait or not consider hospice. Some barriers include:

Head-to-toe hospice checklist

Alzheimer’s disease and dementia

Patients in the late stages of Alzheimer’s disease or dementia are candidates for hospice. At this stage, they start to lose activities of daily living (ADLs) and cannot complete basic functions on their own. These functions include: Other signs providers should consider patients with Alzheimer’s disease or dementia for hospice are:

Heart disease

Patients in their late stages of heart failure (HF) are candidates for hospice. Providers should consider hospice if the patient has:

Lung disease and lung cancer

Patients with end-stage lung disease and lung cancer are hospice candidates. Providers should consider hospice if the patient:

Liver disease

Patients with end-stage liver disease are candidates for hospice. Liver disease is the 12th leading cause of death in the United States. Patients with liver disease are often overlooked for hospice care. Providers should consider hospice for patients with end-stage liver disease if they are:


ER providers can opt for hospice for patients with cancer if treatment is no longer working or there are no other treatment plans. Patients also at the end stage of their cancer can benefit from entering hospice early. Other signs a patient is ready for hospice are if the patient:


It’s not always easy to identify patients with sepsis who qualify for hospice. However, some patients meet the criteria. Providers should consider patients with sepsis for hospice if the patient: Hospice is available to patients who are at the end of their life. They can entire at any stage in their disease process. Initiating hospice early benefits the patient. Studies have shown that hospice improves mood, decreases medical interventions, and enhances the patient’s overall quality of life.By: Elizabeth Townsend, RN People are social beings. With COVID-19 introducing social distancing guidelines and restrictions on visitations, social isolation and loneliness are increasing. A report referenced by JAMA discussed the need for solutions for social isolation and loneliness in older adults. There is significant documentation that social isolation and loneliness are related to a higher rate of major mental and physical illnesses, including: According to the National Institute on Aging, people who participate in worthwhile activities with others tend to live longer and have a sense of purpose.

Assessing seniors for isolation and loneliness

COVID-19 has made it difficult for seniors to participate in: Home health clinicians assess patients for social isolation and loneliness. Asking patients about their social needs is important to identify who needs assistance, easing isolation and loneliness. The home health agency provides tools or guidelines with questions for the clinicians to ask. Examples of questions to ask:
  1. Do you feel you have no friends or loved ones?
  2. Are you lonely?
  3. How are you staying active?

5 ways to relieve isolation and loneliness

After assessing and finding that your patient is suffering from social isolation, consult with their caregivers and healthcare team —specifically the agency’s social worker—to find ways to relieve their isolation. Daily Caregiving suggests some ways to help:
  1. Encourage a sense of purpose. Suggest activities such as knitting blankets and caps for newborns at a local hospital, making masks for healthcare workers or family members, or writing letters to their grandchildren to encourage them. Allow the patient to have a responsibility, such as taking care of a plant or dog. This would be giving them a meaningful purpose.
  2. Encourage interaction. Encourage interaction with others via phone, computer, or if in person, socially distant, wearing a mask.
  3. Encourage physical activity. Take Into account the patient’s physical ability. They can do gentle exercises such as walking, stair-climbing, yoga, or group exercises via computer. If they cannot get out of bed or are not able to walk, find appropriate activities. Consult with the physical therapy team who can provide resources for exercises for those with limitations.
  4. Assess the food they are eating. Encourage fiber-rich foods like fruit, vegetables, whole grains, and lean proteins. Consult with community services such as food banks, churches, or meal delivery services.
  5. Show them they are loved. Find ways to show that they are loved and needed. Listen to what they have to say. Encourage family members, if they are in the home also, to hug the patient and talk and listen to them.

Social workers can help seniors with social isolation and loneliness

Social workers can ensure that patients have access to available resources. Local churches may have “shut-in” outreach for those unable to leave their homes. They may provide phone calls, run errands, provide food baskets, and communicate by mail with the seniors. Local library programs have online programs and can arrange to have books available for the patient to check out. The social worker can also refer the patient to transportation programs that take seniors to doctor appointments.

Encourage virtual connections for seniors

Advancing States created a resource to help reduce social isolation and loneliness.
  1. If the patient can use a smartphone, show them how to google Earth National Park Tours so they can “visit” the parks and talk about what they saw with others via telephone or with you when you visit.
  2. Patients can meditate through Journey Meditation.
  3. Put the patient in contact with Well Connected by Covia, who will help them participate in virtual classes, conversations, and activities by phone and computer.
There are helplines for mental and emotional support, which include:
  1. Friendship Line by Institute on Aging- 1(800)971-0016
  2. Happy– a free app that provides emotional support 24/7
  3. National Alliance on Mental Illness Helpline- 1(800)950-6264
  4. Substance Abuse and Mental Health Services Administration National Helpline- 1(800)662-4357

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