Recovery After COVID-19 Infection: The Role of Home-Based and Outpatient Rehabilitation
Naomi Bauer and Audrey Whitacre discuss the important role that home-based and outpatient rehabilitation have in COVID-19 recovery.
Featured Speakers:
Naomi Bauer, PT, DPT, CCS | Audrey Whitacre, RN, MSN
Naomi Bauer is the Program Director of WakeMed Rehabilitation’s Pulmonary Rehab and Cardiopulmonary Therapy. She earned her Doctor of Physical Therapy degree from Northeastern University in Boston, Mass. She completed her residency training in cardiovascular and pulmonary physical therapy at Duke University Medical Center and is a board-certified Cardiovascular and Pulmonary Clinical Specialist. She practices full-time in outpatient cardiopulmonary rehabilitation and has prior experience in acute and critical care physical therapy. She has presented nationally on topics including Postural Orthostatic Tachycardia Syndrome and Pulmonary Rehabilitation. Naomi recently participated in a webinar series with the American Physical Therapy Association titled "Post-Acute COVID-19-Exercise and Rehabilitation (PACER) Project" as well as a live webinar through the Wake Area Health Education Center both on the topic of Post-Acute and Outpatient Rehabilitation after COVID-19 Infection. Transcription:
Recovery After COVID-19 Infection: The Role of Home-Based and Outpatient Rehabilitation
Deborah Howell: In this crazy Coronavirus year, when we can't visit our loved ones in the hospital, some of us have longed for a hospital in our own homes. In this episode, we'll be talking about recovery after COVID-19 infection and the role of home-based and outpatient rehabilitation. Our guests are Audrey Whitacre, Clinical Director of Home Health Services at Wake Med Health and Hospitals, and Naomi Bauer, Physical Therapist and Program Director of Wake Med Rehabilitations, Pulmonary Rehab, and Cardiopulmonary Therapy. This is Wake Med Voices, a podcast from Wake Med. Health and Hospitals. I'm Deborah Howell, Audrey and Naomi, thank you so much for being with us today.
Audrey Whitacre: Great to be here. Thanks for having us.
Naomi Bauer: Thank you, Deborah. I'm looking forward to it.
Host: Audrey, let's start with you. What is hospital at your home?
Audrey Whitacre: That's a really good question. It's something very new to us. It did begin with some discussions between Wake Med Home Health and our Wake Med Hospitalist teams to see how wake med could better serve the COVID-19 patients in the home. And our goal is to try to free up hospital beds for those patients that require a higher level of care. Our plan is to continue with COVID-19 patients now, but we're working actively with the team to build upon other chronic illnesses that could safely be managed with this model. In the future. Home health is able to provide services to the patients seven days a week, with the ability to see the patient more frequently as necessary based upon their condition. We teach the patient and family regarding best practices for care and isolation. In addition to supplying necessary equipment, our goal is to assess the patient and work toward our positive outcomes and we've shown improvement and competence with the patient and the family that the patient safely can be managed in the home by your hospital at home team.
Host: No that's such good news. And what sort of disciplines are involved in? What do they address?
Audrey Whitacre: Well, it starts with our case manager at the hospital. They work to organize a safe transfer at home to the patient. We have designated advanced practice providers and doctors that get, do daily virtual visits with the patients. Our nurses admit the patient within a 24 hour timeframe and then see the patient daily, as long as they need that visit or more frequently. The other disciplines that may be assigned to the patient might be a physical therapist or an occupational therapist. Sometimes speech therapy is necessary. Also. We can also provide them with a home health aid and telehealth services. And all of these things together do help to meet the needs that the patient has at the home. Most often. We do work closely with mobile critical care and they are available 24 hours a day. Should there be an urgent patient care need that arises. And we also have mobile services like x-ray, imaging, and ultrasound that can be sent to the patient's home and do remote imaging.
Host: Great news. Now, what can a patient expect after a home health referral?
Audrey Whitacre: Before discharge, the patient's going to be set up with My Chart on their cell phone. This allows for them to have those tele-health provider visits. Case management at the hospital and our care coordinators confirm that they have good support at home, identified caregiver. They order oxygen for them to take from the hospital to home, and then there's more oxygen available once they get to the home, the hospitalist identifies the necessary disciplines for the home health referral and provides them with the prescriptions necessary for any new or changed medications. The supply company is available to deliver other supplies as necessary.
Host: Excellent. And what sorts of things can a patient expect to work on in the hospital at your home program?
Audrey Whitacre: Yeah, I'm having the daily tele-health visits with the advanced practice provider or MD starting the day of admission, nursing start of care within 24 hours. And they include patient assessments, oxygen use, and management medication, reconciliation and education. And then other disciplines will be working with them as ordered, depending upon the patient needs. Tele-health will continue with the patient, which is a monitoring system, seven days a week and three times a day, they'll check their vital signs and send those to Wake Med home health for the review and follow up with a patient or a physician as necessary.
Host: This is so well thought out. What are the goals and expected outcomes for completion of HAYH?
Audrey Whitacre: That's a really fun thing for us to talk about because we have seen where patients really do progress to stable, vital signs, with the ability to maintain a stable oxygen level. We don't want them to have any new symptoms. We want them to have a good stable home life with support from the family and for those patients without a designated primary care provider prior to the COVID and exposure the medical provider, gives a hand off to the community provider for follow-up appointments to address things like diabetes and DVT management for the future. So I think that the patient leaves us going to a higher level of care with a primary care provider in the field.
Host: Yeah. And COVID is so serious. What are some of the symptoms and difficulties you've seen that patients continue to have after acute illness?
Audrey Whitacre: They do continue to have some pulmonary symptoms like persistent cough. They also have some fatigue. They may have a low grade fever, shortness of breath, some on exertion, anxiety, decreased appetite, decreased intake of fluid, sleeping disruptions, depression, myalgia. They may also need again that management and care of new and change diagnosis in the community by their primary care for diabetes management, DVT management, or memory issues.
Host: Sure. And of course the stresses of the monetary situation. So my next question, will insurance cover the rehabilitation and will Medicare cover it?
Audrey Whitacre: Yes. Insurance will cover the rehabilitation and Medicare will cover it.
Host: Awesome to know. Okay. Naomi, you've been very patient, now to you. What are some of the rehab services that a patient may need?
Naomi Bauer: So once the patient gets to the outpatient setting, they typically aren't needing such close medical management as they do at home. And so typically what we see is patients who need physical therapy, occupational therapy, some may need speech, language pathology, or known as speech therapy. And then some may also need some counseling for stress management or some dietary or nutrition assistance to try and help figure out exactly what their nutrition needs are now that they are recovering from a critical illness.
Host: And what does each of these disciplines address?
Naomi Bauer: So, there is some overlap, physical therapists address, mobility, strength, endurance, assessing oxygen needs with activity. The occupational therapists will address some similar things, but also activities of daily living, return to work, cognitive deficit. The speech pathologist is going to look at speech deficit, cognitive deficit, any difficulties with swallowing, problem solving, again, returned to work. Counseling and dietary are going to be as needed for stress management as I mentioned. Figuring out caloric needs, especially as these patients are starting to increase their activity levels again.
Host: Interesting about the caloric need. I didn't even think about that. What can a patient expect after an outpatient referral?
Naomi Bauer: So, for our program, once we receive a referral for the patient, our scheduling team will call to set up the initial evaluations and the patient will then come in and be evaluated by the physical therapist, occupational therapist, and any of the other disciplines that it's determined that they need. After those initial evaluations, that therapist will decide with the patient, how long they need to come to therapy for how often they need to come to therapy and or if they even need that particular therapy at all. Generally, we are seeing people for about six to 12 weeks, and then they're seen one to three times per week for each discipline. So depending on how many disciplines the patient needs to see, they may have anywhere from one to, I guess, potentially nine appointments per week during their rehab course.
Host: Got it. And you always feel such progress when you're in rehab. I've been through it many, many times and I consider it the fun part. So what sorts of things can a patient expect to work on in rehab?
Naomi Bauer: As you mentioned, there's lots of fun things for us to work on, but we focus a lot on the endurance training and the strength training for these patients in particular and the breathing retraining. They tend to lose a lot of their strength and endurance when they're hospitalized or when they're sick with COVID. And so we really focus on building that back up. They may also need some balance training. The occupational therapists may work on some activities of daily living, such as bathing and dressing, cooking, return to work. Energy conservation is also very important. And then if the speech language pathologist is working with them, they may work on a lot of problem solving. If they had a tracheostomy or required intubation while they were hospitalized, they may have some speaking and swallowing deficits. So they have a lot of fun exercises that they do to work on those muscles as well. It's almost like the
Host: Tip of the iceberg is the COVID and the hospitalization, and then everything under the water is very large as well.
Naomi Bauer: Yes, for sure.
Host: So, what are the goals and expected outcomes for completion of rehab?
Naomi Bauer: It's going to vary a little bit, depending on what level the patient is at when they come in and also what level they were at prior to becoming sick. But in general, the goals for rehab are to get the patient to return as close to their prior level of function as possible. And within that, improving their safety and independence at home and in the community.
Host: Last question for you, what are some of the symptoms and difficulties that patients continue to have after acute illness and is insurance going to cover the rehabilitation?
Naomi Bauer: So, some of the symptoms are going to be similar to the ones that Audrey mentioned earlier, but by the time they come to outpatient rehab, they generally aren't having quite as many of those acute symptoms. What we're seeing primarily is fatigue, shortness of breath. Some patients have an ongoing cough, some don't a lot of weakness and then some difficulty with concentrating and remembering things. All of those things can be persistent for quite some time with these patients. And we often see these even as we get towards discharge, that the patient may not have fully recovered from all of those things. As far as insurance goes, outpatient rehabilitation is covered by most insurances. So there may be a co-pay or co-insurance associated with it.
Host: Okay. Good news. Well, thank you so much Audrey, Naomi for being with us today to share this excellent information and thanks for all the good work you do. That's Audrey Whitacre and Naomi Bauer. To learn more about Wake Meds Home Health and Rehabilitation Services, please visit wakemed.org. And if you enjoyed the podcast, you can find more like it in our podcast library. Be sure to give us a like, and a follow if you do. I'm Deborah Howell with Wake Med Voices brought to you by Wake Med Health and hospitals in Raleigh, North Carolina. Thanks for listening and have yourself a terrific day.
Recovery After COVID-19 Infection: The Role of Home-Based and Outpatient Rehabilitation
Deborah Howell: In this crazy Coronavirus year, when we can't visit our loved ones in the hospital, some of us have longed for a hospital in our own homes. In this episode, we'll be talking about recovery after COVID-19 infection and the role of home-based and outpatient rehabilitation. Our guests are Audrey Whitacre, Clinical Director of Home Health Services at Wake Med Health and Hospitals, and Naomi Bauer, Physical Therapist and Program Director of Wake Med Rehabilitations, Pulmonary Rehab, and Cardiopulmonary Therapy. This is Wake Med Voices, a podcast from Wake Med. Health and Hospitals. I'm Deborah Howell, Audrey and Naomi, thank you so much for being with us today.
Audrey Whitacre: Great to be here. Thanks for having us.
Naomi Bauer: Thank you, Deborah. I'm looking forward to it.
Host: Audrey, let's start with you. What is hospital at your home?
Audrey Whitacre: That's a really good question. It's something very new to us. It did begin with some discussions between Wake Med Home Health and our Wake Med Hospitalist teams to see how wake med could better serve the COVID-19 patients in the home. And our goal is to try to free up hospital beds for those patients that require a higher level of care. Our plan is to continue with COVID-19 patients now, but we're working actively with the team to build upon other chronic illnesses that could safely be managed with this model. In the future. Home health is able to provide services to the patients seven days a week, with the ability to see the patient more frequently as necessary based upon their condition. We teach the patient and family regarding best practices for care and isolation. In addition to supplying necessary equipment, our goal is to assess the patient and work toward our positive outcomes and we've shown improvement and competence with the patient and the family that the patient safely can be managed in the home by your hospital at home team.
Host: No that's such good news. And what sort of disciplines are involved in? What do they address?
Audrey Whitacre: Well, it starts with our case manager at the hospital. They work to organize a safe transfer at home to the patient. We have designated advanced practice providers and doctors that get, do daily virtual visits with the patients. Our nurses admit the patient within a 24 hour timeframe and then see the patient daily, as long as they need that visit or more frequently. The other disciplines that may be assigned to the patient might be a physical therapist or an occupational therapist. Sometimes speech therapy is necessary. Also. We can also provide them with a home health aid and telehealth services. And all of these things together do help to meet the needs that the patient has at the home. Most often. We do work closely with mobile critical care and they are available 24 hours a day. Should there be an urgent patient care need that arises. And we also have mobile services like x-ray, imaging, and ultrasound that can be sent to the patient's home and do remote imaging.
Host: Great news. Now, what can a patient expect after a home health referral?
Audrey Whitacre: Before discharge, the patient's going to be set up with My Chart on their cell phone. This allows for them to have those tele-health provider visits. Case management at the hospital and our care coordinators confirm that they have good support at home, identified caregiver. They order oxygen for them to take from the hospital to home, and then there's more oxygen available once they get to the home, the hospitalist identifies the necessary disciplines for the home health referral and provides them with the prescriptions necessary for any new or changed medications. The supply company is available to deliver other supplies as necessary.
Host: Excellent. And what sorts of things can a patient expect to work on in the hospital at your home program?
Audrey Whitacre: Yeah, I'm having the daily tele-health visits with the advanced practice provider or MD starting the day of admission, nursing start of care within 24 hours. And they include patient assessments, oxygen use, and management medication, reconciliation and education. And then other disciplines will be working with them as ordered, depending upon the patient needs. Tele-health will continue with the patient, which is a monitoring system, seven days a week and three times a day, they'll check their vital signs and send those to Wake Med home health for the review and follow up with a patient or a physician as necessary.
Host: This is so well thought out. What are the goals and expected outcomes for completion of HAYH?
Audrey Whitacre: That's a really fun thing for us to talk about because we have seen where patients really do progress to stable, vital signs, with the ability to maintain a stable oxygen level. We don't want them to have any new symptoms. We want them to have a good stable home life with support from the family and for those patients without a designated primary care provider prior to the COVID and exposure the medical provider, gives a hand off to the community provider for follow-up appointments to address things like diabetes and DVT management for the future. So I think that the patient leaves us going to a higher level of care with a primary care provider in the field.
Host: Yeah. And COVID is so serious. What are some of the symptoms and difficulties you've seen that patients continue to have after acute illness?
Audrey Whitacre: They do continue to have some pulmonary symptoms like persistent cough. They also have some fatigue. They may have a low grade fever, shortness of breath, some on exertion, anxiety, decreased appetite, decreased intake of fluid, sleeping disruptions, depression, myalgia. They may also need again that management and care of new and change diagnosis in the community by their primary care for diabetes management, DVT management, or memory issues.
Host: Sure. And of course the stresses of the monetary situation. So my next question, will insurance cover the rehabilitation and will Medicare cover it?
Audrey Whitacre: Yes. Insurance will cover the rehabilitation and Medicare will cover it.
Host: Awesome to know. Okay. Naomi, you've been very patient, now to you. What are some of the rehab services that a patient may need?
Naomi Bauer: So once the patient gets to the outpatient setting, they typically aren't needing such close medical management as they do at home. And so typically what we see is patients who need physical therapy, occupational therapy, some may need speech, language pathology, or known as speech therapy. And then some may also need some counseling for stress management or some dietary or nutrition assistance to try and help figure out exactly what their nutrition needs are now that they are recovering from a critical illness.
Host: And what does each of these disciplines address?
Naomi Bauer: So, there is some overlap, physical therapists address, mobility, strength, endurance, assessing oxygen needs with activity. The occupational therapists will address some similar things, but also activities of daily living, return to work, cognitive deficit. The speech pathologist is going to look at speech deficit, cognitive deficit, any difficulties with swallowing, problem solving, again, returned to work. Counseling and dietary are going to be as needed for stress management as I mentioned. Figuring out caloric needs, especially as these patients are starting to increase their activity levels again.
Host: Interesting about the caloric need. I didn't even think about that. What can a patient expect after an outpatient referral?
Naomi Bauer: So, for our program, once we receive a referral for the patient, our scheduling team will call to set up the initial evaluations and the patient will then come in and be evaluated by the physical therapist, occupational therapist, and any of the other disciplines that it's determined that they need. After those initial evaluations, that therapist will decide with the patient, how long they need to come to therapy for how often they need to come to therapy and or if they even need that particular therapy at all. Generally, we are seeing people for about six to 12 weeks, and then they're seen one to three times per week for each discipline. So depending on how many disciplines the patient needs to see, they may have anywhere from one to, I guess, potentially nine appointments per week during their rehab course.
Host: Got it. And you always feel such progress when you're in rehab. I've been through it many, many times and I consider it the fun part. So what sorts of things can a patient expect to work on in rehab?
Naomi Bauer: As you mentioned, there's lots of fun things for us to work on, but we focus a lot on the endurance training and the strength training for these patients in particular and the breathing retraining. They tend to lose a lot of their strength and endurance when they're hospitalized or when they're sick with COVID. And so we really focus on building that back up. They may also need some balance training. The occupational therapists may work on some activities of daily living, such as bathing and dressing, cooking, return to work. Energy conservation is also very important. And then if the speech language pathologist is working with them, they may work on a lot of problem solving. If they had a tracheostomy or required intubation while they were hospitalized, they may have some speaking and swallowing deficits. So they have a lot of fun exercises that they do to work on those muscles as well. It's almost like the
Host: Tip of the iceberg is the COVID and the hospitalization, and then everything under the water is very large as well.
Naomi Bauer: Yes, for sure.
Host: So, what are the goals and expected outcomes for completion of rehab?
Naomi Bauer: It's going to vary a little bit, depending on what level the patient is at when they come in and also what level they were at prior to becoming sick. But in general, the goals for rehab are to get the patient to return as close to their prior level of function as possible. And within that, improving their safety and independence at home and in the community.
Host: Last question for you, what are some of the symptoms and difficulties that patients continue to have after acute illness and is insurance going to cover the rehabilitation?
Naomi Bauer: So, some of the symptoms are going to be similar to the ones that Audrey mentioned earlier, but by the time they come to outpatient rehab, they generally aren't having quite as many of those acute symptoms. What we're seeing primarily is fatigue, shortness of breath. Some patients have an ongoing cough, some don't a lot of weakness and then some difficulty with concentrating and remembering things. All of those things can be persistent for quite some time with these patients. And we often see these even as we get towards discharge, that the patient may not have fully recovered from all of those things. As far as insurance goes, outpatient rehabilitation is covered by most insurances. So there may be a co-pay or co-insurance associated with it.
Host: Okay. Good news. Well, thank you so much Audrey, Naomi for being with us today to share this excellent information and thanks for all the good work you do. That's Audrey Whitacre and Naomi Bauer. To learn more about Wake Meds Home Health and Rehabilitation Services, please visit wakemed.org. And if you enjoyed the podcast, you can find more like it in our podcast library. Be sure to give us a like, and a follow if you do. I'm Deborah Howell with Wake Med Voices brought to you by Wake Med Health and hospitals in Raleigh, North Carolina. Thanks for listening and have yourself a terrific day.