Because of dramatic increases in both patient longevity and prevalence of chronic illness, physical therapists see an ever-widening range of diagnoses in their patients in the community. Global aging is occurring at an unprecedented pace. Worldwide, the number of people age 65 and older is expected to increase from 500 million to 1 billion by 2030.¹⁵ Physical therapist interventions unique to aging populations need to be considered in relation to the available resources, as well as the challenges that present in the community practice setting more often now that patients are living longer (Chapter 38). Chronic conditions that were previously associated with later stages in life are now presenting earlier in life as a result of changing lifestyle behaviors (Chapter 1). Also, the medical community has improved its ability to quickly and effectively manage complicated acute medical situations—premature births, heart failure, cancer. More patients are surviving diseases once considered fatal and consequently requiring more services to safely and effectively manage the morbidity issues that result. Medical interventions in intensive care units have improved greatly, thus decreasing mortality, but morbidity related to myopathy of critical illness, cognitive impairments, and mental health sequelae has been found to have a significant impact on patients’ ability to resume their prior level of independence (Chapters 33–36).^16–21 These patients return home more often and more quickly than in the past, but they often do so accompanied by unresolved cardiovascular and pulmonary impairments. For patients who are too medically fragile to return home or to obtain sufficient medical care at skilled nursing facilities, specialty hospitals have become necessary. These hospitals make it possible for ventilator-dependent or ventilator-assisted patients to receive physical therapy longer and at less cost than an acute care hospital.²²

Practicing physical therapy in the community is distinct from practicing in acute care. When people with chronic conditions are living in the community, their focus is on health promotion and optimal health, rather than recovery from an acute episode of a condition or surgical procedure or trauma with frequent changes in their functional status, as is seen in acute care. In the community setting, the patient’s goals are less focused on safety and more on optimal health. Patients’ participation is vital in order to understand their definition of optimal health. Consistent with values of autonomy and independence, shared decision making should always be used— including the patient and family/caregiver in decisions regarding the patient’s care with guidance from the health care team.14,23 This model is at times challenging for health care team members who may feel more comfortable continuing to use a method in which they prescribe a task and tell the patient what to do, with little collaboration. However, the expected level of practice of every physical therapist is evidence-based practice (EBP) in decision making and treatment. The three aspects of EBP are weighted comparably: external clinical evidence, patient circumstances, and individual clinical expertise.²⁴ In this approach to practice, the patient’s goals and his or her ability to carry out an effective plan are important. A patient cannot carry out an effective plan unless he or she is taught how to identify problems and manage or avoid them in daily situations when health care professionals are not present. Patients need a targeted and tailored education to understand how to make the best decisions about their health and to appreciate their responsibility in their own health management.

Given these practice settings, cardiovascular and pulmonary concerns are often the highest priority. From the young to the old, primary and secondary cardiovascular and pulmonary issues are often the limiting factors in a patient’s rehabilitation progress, thus, need to be addressed in the patient’s standard physical therapy care. The focus in home and long-term care settings is to enable individuals to achieve optimal health in the environment in which they live. This chapter focuses on considerations specific to patients with cardiovascular and pulmonary dysfunction (as either primary pathology or secondary to other impairments) who require physical therapy at home or in a long-term care setting, such as a nursing home, skilled nursing facility, transitional or assisted living facility, adult day program, or outpatient setting.

Chronic Conditions and Self-Management

Many people at home or in long-term care have chronic conditions, often related to lifestyle behaviors. Regardless of whether these conditions are the diagnoses for which they are receiving physical therapy, the related activity limitations and participation restrictions can limit their abilities to participate and progress in their therapy. Chronic conditions can affect the person’s physical capabilities, as well as his or her emotions, attitude, and motivation. Many patients with chronic conditions or functional decline lead full and rewarding lives, but doing so requires the active participation of the patient and the physical therapist to maintain the fullest level of function despite the changes. The choices patients make about their health care, exercises, and methods of self-management will largely determine their health-related quality of life (Chapter 1).

Though people with chronic conditions have multiple impairments requiring adaptation of their lifestyles and schedules, the majority still accomplish what they want and need to do each day. The goal is to augment their knowledge about their symptoms and enable them to work within a collaborative, self-advocacy, and self-help model with their health care team to achieve optimal health. Positive self-management involves a combination of positive emotional outlook, active involvement in decision making, and maintenance of a lifestyle that is as optimal as possible. The interprofessional team needs to engage the patient in his or her care decisions. The physical therapist needs to be caring and fully present with the patient. Although the physical therapist can provide the initial stimulus for the process, effective self-management comes only from within the patient. The physical therapist can continue to be a resource and provide interventions as needed, but the goal is for the patient to be his or her own case manager and decision maker, whenever possible, regarding health care and optimal function (Chapter 1).^14,23

In the home or community setting, the person with a chronic condition needs to make several choices. How does he or she decide what will promote optimal function and health? What resources must be employed to meet these needs (e.g., a maintenance program), or does the person have the potential to improve to the extent that he or she can benefit from further professional services? Many people are discharged from the hospital without referral to home care or outpatient physical therapy to manage their chronic conditions. If they are referred to a pulmonary rehabilitation program, for example, what determines when they have completed the program? Financial support by private third-party payers and insurers is limited, influencing patients’ decisions about which avenues to use to move further toward optimal health. Do they go to a health club or the local YMCA? Do they walk in a shopping mall or take yoga classes? Do they continue to pay privately for physical therapy, continue with a long-term pulmonary rehabilitation program, or simply exercise at home? The answers are as different as the people making the decision about what optimal health is in relationship to their personal circumstances. At times it may be a matter of trial and error; perhaps the patient’s choice is not the same as that of a physician or other health care professional, but it is his or her decision and choice. A patient has the right to try, to succeed or fail, and make other decisions. He or she needs to know how to access the health care system if there are medical problems, and learning to do so must be an integral part of the patient education process.

Actively playing a role in decision making (i.e., self-management) empowers patients, making them more motivated, positive, active, and successful than passive patients who do only what the physical therapist and other health professionals advise.23,25 A decrease in the number of visits allowed by third-party payers has forced a necessary change towards patient self-management and empowerment, which has led to improved efficiency and effectiveness in treatment. The promotion of positive self-management strategies for a more active, healthy lifestyle is one of the most important competencies of contemporary physical therapists.

The physical therapist facilitates this process by being caring, supportive, and respectful of patient goals and priorities. This has been referred to as a “healing presence,” which may lead to a beneficial, therapeutic, positive experience for the patient.26,27 The American Physical Therapy Association promoted this practice philosophy with the phrase “the science of healing, the art of caring.”

Cardiovascular and Pulmonary Concerns in the Community

Patients with either chronic or acute conditions present with primary and/or secondary cardiovascular and pulmonary diagnoses at all levels of independence. Patients may have preexisting cardiovascular and pulmonary impairments such as asthma, hypertension, congestive heart failure, and comorbidities such as type 2 diabetes mellitus, obesity, and one or more types of cancer. Most patients will also have risk factors for one or more of these lifestyle-related conditions; thus risk factors need to be assessed and modified accordingly. Patients may have had problems such as hip fractures, joint replacements, CVAs, MIs, or some combination. The cardiovascular and pulmonary impairments related to the impairments and subsequent deconditioning associated with these conditions may be the limiting factor with respect to progression of physical therapy. These concerns need to be addressed so that the individual is able to reach his or her full rehabilitation potential.

One example is a patient with coronary artery disease, who is fully independent in his or her day-to-day activities but not at a maximal functional level because of limited education on how to further improve function. Another example is a patient who cannot resume his or her prior level of independent function after an acute bout of illness or hospitalization because of limits resulting from primary and/or secondary cardiovascular and pulmonary dysfunction. Both of these examples illustrate the resultant decrease in such patients’ tolerance for, and ability to independently perform, activities of daily living. Because of these decreases, patients must acquire continued support to maintain their safety and improve their level of function. Those with the least ability to care for themselves after an acute bout of illness transfer into nursing homes or alternative long-term care, and those with higher levels of function move into assisted living facilities or return home with assistance and therapy. Such patients may present with decreased strength, endurance, and balance, leading to decreased independence, mobility, and activity level. Returning home with a decrease in independent functioning may be associated with negative emotions, which may further decrease appetite, activity level, motivation, and social/community interactions (Chapter 1).

Nursing homes, assisted living facilities, and senior housing offer residential services for those who can no longer care for themselves. Some facilities offer multiple levels of care within one system, ranging from independent living apartments to skilled-level care. For residents who live in independent apartments when they are well, the facility can offer temporary increased support from a skilled level of care with physical therapy and nursing support upon discharge from the hospital. The goal is for the patient to return to the least level of care with the highest level of independence. Physical therapy services can be utilized at all levels of care to improve independence and tolerance for daily activities to improve patient safety in the community. Patients living in residential facilities should be screened periodically to determine their readiness to benefit from further physical therapy intervention and enable them to live to their fullest capacity.

Functioning depends on the ability of the patient to maintain all of the components of oxygen transport to support activity. One example is a patient who fell in the parking lot of a hospital where she had been attending a pulmonary rehabilitation program. She was fitted with a long leg cast and discharged home. She reported being short of breath with sit-to-stand transfers, and soon she was hardly able to ambulate across the room with the standard walker she used before. When the physical therapist observed this patient using her bronchodilator metered-dose inhaler, she was using it improperly. After she was instructed on how to use the bronchodilator therapy effectively before activity, the patient’s transfers and her walking ability improved markedly. She was able to coordinate her breathing with her activity, and her endurance further improved. Case reports and professional experiences such as this provide important information for the physical therapist to use in conjunction with the findings of research studies when planning and prescribing interventions for patients at home using evidence-based practice.²⁴

Long-Term Care Facilities and Nursing Homes

Practicing in a long-term care facility as a physical therapist opens up an opportunity to work with an interprofessional health care team to carry out therapeutic goals during other tasks of the day. Aides, generalist and specialist nurses, respiratory therapists, occupational therapists, speech therapists, dietitians, and on-call physicians all interact with patients each day and are able to remind and encourage patients to follow through on their exercise and activity goals. In order for this to happen, it is necessary to communicate the importance of the patient’s active participation throughout the day.

Therapeutic goals and treatment plans for patients should be designed with solicited input from the patient and family or significant other. Clear and achievable goals must be developed and revisited as the patient progresses or regresses in therapy. If the patient’s goal is to transition to a more independent living facility (i.e., home or an assisted living facility), then the plan would be more aggressive than if the goal were to maximize function within the current living facility. In order to achieve the patient’s goals, a holistic approach to care that is mindful of cognitive, psychological, and pathophysiological impairments should be used. As goals and interventions are determined, quality-of-life issues need to be considered in order to comprehensively address each patient’s needs. To increase patients’ ability to achieve their therapy goals, therapy sessions may need to be scheduled based on the time that is thought to be most efficient in relation to the patient’s medication schedule and other events of the day, rather than the most convenient time that fits into the therapy schedule.

The patient’s ability to participate in therapy may be driven by multiple system impairments. Nutritional concerns are a priority. It is important to monitor whether the patient is losing or gaining weight. Poor denture fit and the impact of medications on taste and appetite can affect the patient’s ability to eat. The patient may be depressed, also limiting appetite. The patient may not want to drink because of difficulty getting to the bathroom independently. Determine whether the patient is taking a diuretic and whether he or she has urinary incontinence. Patients who have difficulty managing urination because of frequency or urgency may be less likely to drink sufficient fluids, increasing the risk for hypovolemia, hypotension, decreased cerebral perfusion, and falls.²⁸

Patients with severe breathing problems, such as those with heart failure or COPD, can become extremely short of breath doing even such simple tasks as eating. Nurses and aides, as well as family and friends, can make observations about these occurrences. As much as 30% of can be attributed to labored breathing, which places considerable metabolic demand on the patient simply to breathe, let alone the challenge of pausing breathing to eat. A nutrition consult can be initiated to assess the patient’s caloric intake and supplement this intake if indicated.

Ineffective sleep can be a problem after surgery, trauma, or CVA. Multiple factors may be involved, but sometimes the problem is simply the fact that the required positions for sleep are driven by joint precautions or the need for joint and skin protection, rather than what is comfortable for the patient. Nurses and care staff can help by being receptive to positioning options that may increase the patient’s chance for effective sleep but that still meet the criteria for joint and skin protection. If the patient has difficulty waking in the morning or has headaches or difficulty following directions, sleep apnea or other sleep disturbances need to be considered. A wide range of issues—incontinence, anxiety, depression, chronic pain, a busy environment outside the patient’s door—may contribute to sleep deprivation and should be addressed.

Functional gains may be achieved sooner when physical therapy is incorporated into the patient’s daily living with the help of the nurses and aides. This can improve physical capabilities by aiding the learning process, as well as increasing the number of repetitions performed for motor planning. For example, if the patient is taught to use ventilatory strategies with movement, such as inspiring when extending the trunk (Chapter 23), this should be communicated to other caregivers and encouraged during movements that extend the trunk, such as dressing. If the goal is for the patient to walk to meals, the physical therapist and caretakers can have the patient transition from walking as far as he or she can toward the dining room for one meal each day, then walking to two meals each day, and finally, to all meals. The next progression would be to set more functional goals, such as walking to daily activities, to social settings, to the car, and so on; thus walking is no longer associated only with therapy. In-services for nurses and care staff that help reinforce physical therapy interventions can be conducted individually and in formal classes. Instruction can be incorporated into the staff competencies upon hire and annually. One-on-one therapist/aide education sessions should not be replaced by the competencies; rather, they should occur as needed when unique patient needs arise. Educational opportunities such as this can help to make patient education more consistent.

When all facility programs collaborate to follow through with therapeutic goals, the patient’s progress can be realized sooner. It may be helpful to make the activity department aware, for example, of patients who need extra time or help with oxygen in order to participate in activity programs. Events such as an open house for staff in the physical therapy department would allow staff members to visit and ask questions about physical therapy and to better understand what role they can serve. Offering educational materials about the physical therapy profession and patient information pamphlets may help the staff to better understand what physical therapists do for patients.

In many long-term care facilities, not all patients are on the present physical therapy caseload. Other staff members of the facility may have helpful input and suggestions for additional patients who may benefit from physical therapy. In addition to chart reviews and discussing patients with the staff, it is also helpful to screen for patients in the dining rooms, activity sessions, and halls.