Role of Physical Therapy in the Interdisciplinary Team for Safe Transitions for Elderly Persons (STEP)




Camp, Kathlene E.
Johnson, Valerie
Bugnariu, Nicoleta
Lardner, Dana
Knebl, Janice


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Background: Managing an effective transition from hospital to home is challenging due to the medical complexity of multiple diagnoses and care needs, especially in low income seniors. Early hospital readmission has been linked with many factors, including impaired mobility and ineffective management of diseases. Physical therapy (PT) can have an impactful role on addressing safety with mobility and supporting education on disease management. Purpose: The purpose of this report is to describe the role of PT on an interdisciplinary care team, describe the PT intervention, highlight fall risk assessments and results, and identify leading environmental hazards and supports that can impact fall risk. Methods: The STEP care team was comprised of a medical director, nurse practitioner or physician assistant, social worker, physical therapist, pharmacist and registered dietician. PT performed a comprehensive evaluation, appropriate fall risk assessment, and home safety evaluation. Recommendations and assistance were provided to improve home safety, education and intervention were implemented to address specific needs to improve safety with mobility, care was coordinated with home health resources, and community resources were utilized to access additional needs not met by insurer coverage. Final assessments were made at time period of 30+ days in accordance with successful transition in medical care. Results: 126 out of 161 patients enrolled into the STEP program received PT. Patients were in the STEP program for an average of 42 days and received an average of 3 PT visits. The most prevalent home safety hazards identified were lack of grab bars (45%), lack of supportive equipment for shower/tub (42%), unsafe bathroom tub/shower surfaces (30%), narrow/cluttered pathways (33%), and cluttered/soiled living areas (30%). The most common supports were adequate lighting (39%), appropriate commode height (58%), stable/supportive seating (40%), clear/accessible walkways (44%), and secure floor coverings (38%). Home modification opportunities were greatest for adjustment of commode and seating heights (79%, & 2%), providing adequate lighting and chair dressing support (60%), securing floor coverings (50%), and installing night lights (50%). For ambulatory clients, fall risk assessments indicated 96% were at risk for falls. There was an average of 9% of hospitalizations in the first 30 days; however none were related to falls. Conclusion: Reasons for falls are multifactorial and require an interdisciplinary approach to have effective reduction in risk. PT has a significant role in this reduction by addressing both the physical impairments and the environmental factors. Interprofessional collaboration on patient performance in the home can be instrumental in avoiding falls and preventing early hospital readmissions for this high risk population.