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Rehabilitation Services and Palliative Care

An Oxymoron or Best Practice?

Wilson, Christopher, PT, DPT, DScPT

doi: 10.1097/NHH.0000000000000769
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Christopher Wilson, PT, DPT, DScPT, is an Assistant Professor, Physical Therapy Program, School of Health Sciences, Oakland University, Rochester, Michigan.

The author declares no conflicts of interest.

Address for correspondence: Christopher Wilson, PT, DPT, DScPT, Physical Therapy Program, School of Health Sciences, Oakland University, Human Health Building, Room 3171, 433 Meadowbrook Road, Rochester, MI 48309-4401 (Wilson23@oakland.edu).

The care philosophy of palliative care has demonstrated a rapid growth in the past several years (Dumanovsky et al., 2016). Home care agencies and hospital systems have collaborated on reducing excessive costs and focusing on the effective management of patients with late-stage chronic disease. Key outcomes include reducing hospital readmissions and unwarranted or futile medical care that may reduce a patient's quality of remaining life. Palliative care programs have been shown to decrease healthcare costs for patients with chronic diseases including advanced cancer, chronic obstructive pulmonary disorders, heart failure, and degenerative neurological disorders like multiple sclerosis or amyotrophic lateral sclerosis (ALS) (May et al., 2018). These patients frequently experience pain, dyspnea, medical instability, or falls that may prompt unwarranted emergency medical services that may lead to a hospitalization. Many home care providers and palliative care practitioners (including therapists themselves) may not realize that physical therapists (PTs), occupational therapists (OTs), and other rehabilitation professionals have a unique, specialized skill set to assist in the management of these patients.

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Rehabilitation Professionals' Contribution to Palliative Care

Many of the causes of readmission for these conditions can be addressed by interventions that therapists can provide. These include chronic pain and dyspnea, physical and functional debility, limitations in activities of daily living (ADLs), and falls. In addition, therapists can assist by providing education to the caregiver team including problem-solving safe patient handling and mobility techniques with nurses or caregivers. In addition, many healthcare team members who work with palliative care patients may not realize there are different treatment approaches that therapists can use to manage care of these patients. Briggs (2000) described five different rehabilitation patient management models that outline the therapist's ability to modify interventions by reducing the frequency, duration, or intensity of services or providing rehabilitation procedures in anticipation of future physical decline to best serve the needs of the palliative or hospice patient. These practice patterns were further outlined by Wilson et al. (2017) to describe the collaborative role of therapists and nurses to provide optimal management of the patient in palliative care.

As the traditional payment model for rehabilitation historically emphasized the expectation that functional improvement would steadily occur, many providers are not aware of recent practice and payment changes that allow rehabilitation professionals to assist with the management of patients with degenerative or chronic conditions. In 2014, the federal circuit court settled a landmark case in Jimmo v. Sebelius that clearly established that, if a Medicare patient requires the skilled services of a therapist to maintain or slow the decline of a disease or healthcare condition, payment cannot be denied (Centers for Medicare and Medicaid Services, 2014). The caveat to this is that there must be evidence in the clinical documentation that the services were medically necessary and required the skills of the therapist. An example of this would be if a patient with ALS required the services of a PT or OT to maintain their current functional level or slow the expected progressive weakness; as long as the services required the skill of a licensed therapist then these services would warrant payment.

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Palliative Rehabilitation in Action

SG was a 57-year-old male diagnosed with stage IV lung cancer with metastatic lesions to his L2 lumbar vertebral body. Prior to his diagnosis, he was independent in all ADLs and was an engineer at a local automotive corporation. During the course of a hospitalization, he began to experience progressive lower extremity weakness and numbness that devolved into lower extremity paraplegia. At discharge, he was able to transfer to and from a chair with moderate physical assistance but could only ambulate 10 feet with a standard walker. SG was able to return home with his family support but continued to desire rehabilitation services to maintain his current functional level and optimize his mobility and quality of life as his disease progressed. Despite the anticipation of continued physical decline, the PT and OT were able to continue to work with him to optimize his remaining physical capability to provide a richer, more dignified, quality of remaining life and functional capabilities. Initially, the PT focused on lower extremity strengthening and gait training but when the patient was not able to ambulate or transfer, the PT was able to teach the patient and family how to utilize a slide board to transfer to a wheelchair or a bedside commode. This allowed the patient to perform toileting activities and propel himself to his back porch to enjoy his yard. His OT was able to assist SG in modifying his ADLs utilizing durable medical equipment such as a sock aid and a reacher to allow the patient more independence with lower body dressing. The patient verbalized that this ability allowed him to maintain his dignity and reduce his perception of being a burden to his family. As SG's disease progressed, it became more unsafe for him to perform out-of-bed activities. The PT and OT worked with him to perform in-bed ADLs and instructed his family on positioning and range of motion for the lower extremities to assist in controlling pain. If the home care agency had not been proactive in facilitating the therapists' involvement in SG's palliative care, his remaining quality of life would have worsened and the nurses and family would be less successful in managing his symptoms. These issues or a fall may have contributed to an unwarranted readmission to the hospital. In this case, SG was able to die in his home surrounded by his family as per his wishes.

Palliative care is a rapidly proliferating clinical practice approach for management of patients with late-stage chronic or life-threatening illnesses. Rehabilitation professionals are well equipped to assist in mitigating and managing many of the issues that cause pain, distress, or hospital readmissions for these individuals. Historically, payment methodologies by insurance companies did not optimally facilitate rehabilitation professionals' involvement in palliative care. Recent changes to rehabilitation reimbursement now reduce barriers to integration of therapists into the palliative care team. All home care and palliative care providers should consider how they will best leverage the skills of rehabilitation professionals into their palliative care team. This will assist in the goals of reducing costs, falls, and unwarranted readmissions that will ultimately result in improved quality of life and safety of the patient and family.

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REFERENCES

Briggs R. W. (2000). Models for physical therapy practice in palliative medicine. Rehabilitation Oncology, 18(2), 18–19.
Centers for Medicare and Medicaid Services. (2014, February 3). Jimmo v. Sebelius settlement agreement fact sheet. Retrieved from https://www.cms.gov/Center/Special-Topic/Jimmo-Center.html
Dumanovsky T., Augustin R., Rogers M., Lettang K., Meier D. E., Morrison R. S. (2016). The growth of palliative care in U.S. hospitals: A status report. Journal of Palliative Medicine, 19(1), 8–15.
May P., Normand C., Cassel J. B., Del Fabbro E., Fine R. L., Menz R., ..., Morrison R. S. (2018). Economics of palliative care for hospitalized adults with serious illness: A meta-analysis. JAMA Internal Medicine, 178(6), 820–829.
Wilson C. M., Mueller K., Briggs R. (2017). Physical therapists' contribution to the hospice and palliative care interdisciplinary team: A clinical summary. Journal of Hospice & Palliative Nursing, 19(6), 588–596.
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