In my first installment of the home health series, I offered several reasons why new grad physical therapists should consider home health: extra pay, flexibility, decreased physical labor, autonomy, relationships with patients. Are those good reasons to consider home health? Absolutely. But I also want you to be aware of the potential hazards. I don’t want you to get the impression that home health is just bubblegum and rainbows. It can be messy sometimes. That’s why you will have a love-hate relationship with home health. It’s great most of the time, but sometimes you will dream about being somewhere else.
As I write this, I just evaluated a patient in California's Central Valley (a great market for new grads, by the way). The patient was chairfast (meaning, he can’t leave his wheelchair without max assist), had right hemiplegia, was vaping at the front door when I met him, lived in a dirty home, couldn’t hear in his right ear or see through his right eye, and was connected to a Foley catheter. This is the worst of home health, and no practical PT school is going to prepare you for this.
I couldn’t think of a better or more relevant case study. The patient and the home represent some of the most common hazards of home health you will need to know about before you begin your home health career.
I estimate that 80% of the homes I go into have pets, one of many universal phenomena (sex, food, games being others). The most common pets are dogs, and then cats are a distant second. I’ve also seen pet snakes and pet parrots. I’ve seen homes with one pet, and homes that looked like animal shelters.
I started my career in south Texas, and it seemed that every home had at least one chihuahua that barked incessantly. I’ve encountered 100-pound dogs that were ready to eat me. But I’ve also encountered some of the most adorable pets, ones that wanted to sit in my lap.
If you have any pet allergies, then reconsider home health. Some homes will be filled with cat and dog fur. You will be sneezing at best, and you will have a horrible reaction at worst. It’s impossible to avoid pets too. You can’t tell your agency that you will only see patients without pets. You can, but you won’t be seeing too many patients.
Unfortunately in home health, you will be treating a population that grew up in the 1940s, ’50s, and '60s, when it was still fashionable to smoke anywhere and everywhere, (so fashionable, in fact, that patients had ashtrays in their hospital rooms and family members smoked in waiting rooms. Just look at old photos!) Some patients continue to smoke, unable to kick a habit that is slowly destroying their bodies. Fortunately, some patients, including my last patient, have adopted vaping which provides the sensation of nicotine without all the nasty carcinogens that come with cigarettes.
Be prepared to go into some homes that smell more like a bar than a home. You can politely ask the patient not to smoke while you are present, which should drastically reduce the amount of smoke you are exposed to. Some homes will never be completely smoke-free, but you can also try opening windows. A couple of times, I’ve done the evaluation and treatment outside just to reduce my exposure. Other times I’ve done an evaluation with a surgical mask on.
Don’t be afraid to ask your patient to stop smoking during treatment or eval. Politely tell the patient that home health services will only continue if he doesn’t smoke while the clinician is present.
Home health means you will be driving, sometimes a mile or two, or sometimes an hour or two. Driving can be hazardous in several ways. Humans weren’t designed to sit for prolonged periods of time and some suggest that sitting is the new secondhand smoke, but the data on this is not conclusive.
The more you drive, the more chances you have to get into an accident at some point. Driving should scare you more than lightning strikes and plane crashes. The temptation to look at your cell phone or electronic device is always there. The only way to avoid it is to put those devices in the trunk where you can’t access them (I talk about this more in my next installment).
Bad drivers are everywhere, and no part of the country seems to have “good drivers.” Everyone is below average. Watch out for semi-trucks, drivers who speed, elderly drivers, drunk drivers, and drivers who try to pass the car in front on two-lane roads. I’ve had plenty of close calls.
Driving also means exposing yourself to the weather. This isn’t a problem in more temperate parts of the country, but if you live in the northern part of the country in the winter, you are going to have to deal with snow and ice. Drive carefully.
Some of your homes will have obnoxious smells. If I could eliminate one hazard from home health, this would be it. I absolutely hate unpleasant odors. Some odors are so bad, there is no word in the English language to describe them. I can still reproduce in my head the odor of homes I went into two years ago! That’s how unforgettable the odor was. Talk about olfactory memory!
Most homes smell just fine. Most have a neutral odor and won’t bother you. But the combination of poor hygiene, pets, mold, feces, and old food can produce malodorous aromas. Don’t worry. You won’t be in these homes for more than an hour, unless you’re doing an OASIS, which is my next hazard.
The Outcome Assessment and Information Set is required to start a Medicare patient. At most agencies, the RN opens the patient (you can refer to the initial visit as a start, a start-of-care, an admission, or intake) and then PT, OT, and SLP follow. Not all agencies require the physical therapist to do an OASIS but larger agencies do. Even then, the RN will complete most starts-of-care.
The OASIS can be intimidating. Most PTs aren’t prepared to do one, since most clinical rotations aren’t in home health. It is a long and tedious document to complete with as many as 200 questions to answer, not to mention goals, interventions, and the plan of care.
To be clear, the OASIS is not an assessment tool (despite its name), but a data collection tool, so the emphasis isn’t on movement quality but on the current state of the patient. Sometimes the answer isn’t clear, and you have to think for a few seconds about the most appropriate answer (Remember the NPTE?). If you do work for an agency that requires that PTs complete the OASIS, definitely ask about online training or work with another clinician the first two times you do an OASIS. You don’t want to “wing” it, or else the QA department will be calling you real soon.
The difference between an OASIS and a regular exam is that an OASIS covers every system of the human body, all medications, all diagnoses, advance directives, nutrition, the home environment, the level of independence of the patient, prior level of function, and then gait, balance, transfers and the musculoskeletal system. They usually take two hours, but some patients are really involved and require a more thorough assessment, in which case it could take two and a half hours. I’ve heard of RNs spending four hours in a home! As PTs, we have it easy.
Fortunately, the PT only starts a patient when the patient is less involved and doesn’t have as many complications. Patients who need wound care, medication management, or disease management are usually assessed by the RN. If you start a patient, the patient will usually have a diagnosis of total hip replacement, total knee replacement, falls, or fatigue. Expect to complete the OASIS in two hours and then spend another 15 minutes trying to contact the doctor’s office to get approval for the plan of care.
Finally, you might find yourself in the middle of a conflict in the home. At one point, you will be in a home where the patient’s health isn’t the only problem, and the patient’s family members could actually be harming the patient’s health. I’ve been in homes with illicit drugs (cocaine, MDMA, meth) and personal conflict between family members. I have had the temptation more than once to raise my fist and yell, “Jerry, Jerry, Jerry!” Of course, I didn’t do this, but some homes are not conducive to rehab!
Another potential risk is loaded firearms in the home. I was in one home with a loaded gun and open bottles of alcohol. This is an explosive combination. I wrote a note to my home office that I was going to refuse the patient. I wrote an order for a social worker (MSW) to come assess the environment. The patient was eventually transferred to an SNF.
You will be sent everywhere in home health, and there’s no better way to see an area than to do home health. Eventually, you will know every shortcut and every street. However, you might be sent to neighborhoods with high rates of violent crime.
If this happens, you have every right to reject seeing that patient. You are not obligated to risk your safety to do your job. This is especially true if you’re a young female therapist. I’ve done home health in five different areas of the country, and I’ve never felt threatened. I’m lucky. Other therapists have told me that they have refused patients. Another therapist needed a bodyguard. They took a photo and described the neighborhood in a note to justify their decision.
You won’t have a microwave, freezer, toaster, or a Keurig in your car, so you will have to eat non-perishable food or stop at restaurants. You will pass at least 100 fast-food restaurants and gas stations as you do your home visits, and the temptation of convenience will always be calling you.
For most of my home health career, I relied on energy bars to keep me going, but most of these energy bars are just candy bars with a few extra grams of protein. In terms of sugar and fat, they are no different. The combination of sitting in your car several hours a day and relying on junk food can be a horrible combination for your health and physique.
You might want to limit your fluid intake too, at least at the beginning of the day, or you might find yourself in a public restroom. Most of them are just nasty, even for men going number one. You want to avoid them, unless you want to stop at an upscale restaurant during the day. Fast food restaurants and gas stations are notoriously awful.
Don't let the cons of home health PT scare you away!
That’s a good summary of the potential hazards of home health. Don’t be intimidated. Most homes are pleasant. Don’t listen to the horror stories of home health. They’re usually embellished, and they are not typical. Do the disadvantages outweigh the advantages? Only you can decide. Every setting has its pros and cons. Outpatient is cleaner and more sanitary, but offers less flexibility and autonomy than home health. Home health might not require as much differential diagnosis or manual therapy, but it does require you to assess a situation, work with your co-workers, handle your logistics, develop a plan of care, and work in difficult circumstances.
In the final installment, I will explain how to survive home health PT, providing tips and tricks to make home health as safe, effective, and rewarding as possible. In the meantime, you can find me at my website, TheHealthyEatingGuy, or on Facebook!
I would like to thank my classmate and fellow physical therapist, Marisa Gopual, who contributed to this article. She does home health in and around Ocala, FL.