In-Home Physical Therapy Across the Continuum of Care

In-home physical therapy has long been an integral component of recovering strength and mobility after surgery, illness, or an accident. It’s also increasingly important to support people who don’t need in-home nursing care, but need to maintain strength and mobility so they can remain independent.

Although more than 70% of falls among older adults occur in the home¹, it isn’t just older adults who experience dangerous falls: Those at risk include individuals managing a chronic illness like diabetes, heart disease, or arthritis. 

In-home PT is especially beneficial in New York City, where few people drive and where walk-up buildings with several flights of stairs are common. “Once patients I see are discharged from the hospital after an illness or surgery, they’re essentially home-bound until I can help them regain the strength to walk up and down stairs and leave their building,” explains Feb Cortez, PT, MS, DPT, a senior VNS Health physical therapist who cares for patients in Brooklyn.

Physical Therapists Oversee Patient Care

Cortez and his colleagues often care for patients who need to regain function to perform activities of daily living (ADLs) but don’t require in-home nursing care, such as those recovering from orthopedic surgery. In addition to working with patients on range of motion, balance, and strength, physical therapists can also provide basic postsurgical care such as removing wound dressings and monitoring for infection. Registered nurses are available if a patient requires nursing care.

Often, the in-home physical therapist serves as a bridge between hospitalization and outpatient PT. “In addition to helping people return to their ADLs, my goal is often to help them out the door to more intensive PT facilities,” says Cortez.

A Focus on Fall Prevention

VNS Health PTs also supervise patient care for individuals enrolled on our Fall Prevention Program.

Assessing fall risk is a key element of the VNS Health PT intake process. If any patient is found to have a higher-than-average fall risk, the VNS Health Fall Prevention Program may be recommended.  

Falls are the leading cause of fatal and non-fatal injury among those over age 65²: About one in four older adults report falling every year³, and about 37% of those experienced an injury that limited mobility or required medical treatment. The Fall Prevention Program isn’t just for older adults. Patients may be eligible if they:

• Have a medical condition that impacts gait or balance or causes lower-body weakness, such as Parkinson’s, MS, CVA, OA, or Alzheimer’s or another dementia
• Have fallen at least once in the past year
• Have experienced fall-related injuries
• Have a fear of falling or are homebound
• Take multiple medications that inhibit mobility, cause pain, or affect endurance
• Have visual or balance impairment
• Have muscle weakness or use an assistive device

Are your patients at risk for dangerous falls?

VNS Health offers a special Fall Prevention Program to help patients maintain balance and strength, so they can stay safe at home.

Learn About Our Fall Prevention Program

In this program, VNS Health physical therapists apply a four-step method to reduce each patient’s risk of falling in the home:

• Assessment – An evaluation of the patient’s fall risk factors is taken
• Treatment Plan – A plan is created to improve balance, adapt the home as needed, correct footwear problems, address vision problems, and manage medications that could contribute to falls
• Progress Tracking – The patient tracks how they’re doing with their goals in a log
• Results – During a final visit, an evaluation of the patient’s progress is made and an updated plan created to encourage further progress

In many cases, the goal of this program is to maintain, rather than restore, functionality.

“Many of the patients we see have several conditions that affect their physical function, putting them at risk for in-home falls or long-term home confinement,” says Cortez. “Our role is to optimize these patients’ function so they can safely live at home and get out into the community.”

Better Outcomes, Lower Costs

In-home PT has been shown to help enhance patient outcomes and lower costs of care. In partnership with the Hospital for Special Surgery (HSS), VNS Health examined metrics associated with a unique at-home rehabilitation protocol developed by VNS Health for patients who undergo total joint arthroplasty.

In the study, VNS Health found that patients who received this protocol had improved ambulation, as well as reduced length of hospital stay and lower rehospitalization rate—both associated with decreased costs of care. “Our results help make the case for in-home rehabilitation as a standard of care following total knee and hip TJA,” says Joe Gallagher, Director of Operations Support at VNS Health and a former physical therapist.

A Personalized Approach

Whether a patient is recovering from TJA or requires maintenance PT to limit neurological decline, the goal is the same: to offer tools for independence that help each patient enjoy their daily activities.  

In-home therapy generally begins with simple range of motion and strength exercises using the patient’s own body weight, then gradually incorporates resistance band training, with bands provided by the physical therapists. The care plan is built around each patient’s progress, and winds down as the patient reaches maximum functional potential or is ready to advance to outpatient PT services.

Along the way, nurse supervisors are available for escalated home care services if needed, and other specialists from VNS Health’s multidisciplinary team are brought in on a case-by-case basis. Once a patient is ready for discharge, their therapist will work with them to identify outpatient physical therapy facilities, along with other community resources such as transportation, medication delivery, Meals on Wheels, and assistive devices.

¹CDC. Older Adults Falls Data.

²Kakara R, Bergen G, Burns E, Stevens M. Nonfatal and Fatal Falls Among Adults Aged ≥65 Years—United States, 2020–2021. MMWR Morbidity and Mortality Weekly Report. 2023;72:938–943. DOI: 10.15585/mmwr.mm7235a1.

³Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.