Progressing Home Health Rehabilitation for Older Adults

Declines in physical function as a result of acute illness are strongly and independently
associated with a number of adverse health events for older adults. Home Health (HH) physical
therapy may be the ideal venue for addressing these declines in physical function because
around 3 million older adults receive HH services following discharge from acute or
post-acute facilities. However, as currently structured, HH care does not appear to
adequately restore function, as evidenced by poor long-term outcomes and high rates of
hospital readmission. Diminished physical function has been particularly implicated as a risk
factor for re-hospitalization --older adults with lower levels of ambulatory activity are 6
times more likely to be re-hospitalized than those with greater ambulatory activity. A more
intensive approach to HH physical therapy for older adults has great potential to maximize
physical function and reduce hospital readmissions. Therefore, the investigators have
developed a high intensity home-based, progressive, interdisciplinary, multi-component (PMC)
intervention that directly addresses the functional deficits seen after hospitalization. This
intervention will include intensive rehabilitation, a care transitions program, and daily
protein supplementation. The investigators will conduct a two-arm, randomized clinical trial
(RCT) of 200 participants admitted to HH from an acute or post-acute facility. Participants
will receive either 1) an intensive, PMC intervention using resistance exercise and
evidenced-based motor control training to improve physical function, along with nutritional
supplementation and emphasis on functionally enhanced care transitions or 2) usual care (UC)
physical therapy. The primary goal of this investigation is to determine if PMC intervention,
initiated upon admission to HH, improves physical function, as measured by performance and
self-report assessments, more than UC physical therapy. The investigators will also examine
the effects on fatigue, balance confidence, and activities of daily living. In an exploratory
analysis, the effects of the PMC intervention on re-hospitalization rates, nursing home
placement, emergency room visits, and falls after discharge from the acute care hospital will
also be examined. All outcomes will be examined at baseline, 30, 60 (primary endpoint), 90
and 180 days. If successful in improving patient function and decreasing re-hospitalization
rates, PMC intervention holds potential for future health care cost savings.

Inclusion Criteria:

1. 65 years of age and older

2. Referred to home care physical therapy following acute medical deconditioning

3. Have at least 3 comorbid conditions including those listed below:

- Chronic Obstructive Pulmonary Disease

- Gastrointestinal Bleed

- Urinary Tract Infection

- Pneumonia

- Chronic ulcerative wounds

- Diabetes

- Hypertension

- Depression/mental health

- Irritable Bowel Syndrome

- Hernia

- Post-op pancreatic surgery

- Osteoporosis/OA/RA/Gout

- Heart Disease

- Hypercholesterolemia

- Peripheral Arterial Disease

- Spinal Stenosis

- Dehydration

- Syncope

- Atrial fibrillation

- Hypo/Hyperthyroid

- Renal Failure (no dialysis)

- Post-op bowel surgery

- Congestive Heart Failure

4. Be ambulatory without human assistance prior to hospitalization

5. Be English-speaking

Exclusion Criteria: (one or more):

1. Acute lower extremity fracture with weight-bearing restriction

2. "Elective" joint replacement surgery

3. Lower extremity amputation

4. Acute cardiac surgery

5. Terminal illness

6. Active cancer treatment in which exercise is contraindicated

7. Deep vein thrombosis/pulmonary embolus (DVT/PE)

8. Recent stroke (within 1 yr)

9. Score of <20 on SLUMS

10. Inability to ambulate 10 feet without human assistance at time of hospital discharge

11. Gait Speed <0.3m/s or >1.0 m/s

12. Progressive neurodegenerative diagnosis (e.g. Parkinson's, MS, ALS)

13. Use of illegal substances