March 24, 2026

Downtime

Sometimes I hate to call her on it because I cannot imagine the pain of having bone on bone knees, but Mom tends to thoroughly complete the PT exercises that involve her moving her arms and legs in various ways while sitting or lying down, but struggles to motivate herself to choose weight bearing exercise for her knees. So far she has gotten one knee replaced about a month and a half ago now and her recovery was slow but steady at first as she transitioned from the smallest local inpatient hospital where the procedure took place to our favorite local rehab facility for intensive PT and OT. She was certainly making progress with daily therapy.

Then she qualified for home health which we greatly appreciated because I am her primary driver, advocate, and support person and I work two part-time jobs (one from home where I primarily set my own hours and one in an office two days per week) and I have 4 children of varying ages and a husband and we all have a home to care for. It’s a lot and reducing the number of appointments we have to take Mom out to is very helpful because she does not drive due to her bad knees , not always being able to get in and out of vehicles and buildings without help, and many years of no longer driving. I also accompany Dad to many of his appointments so that I can be an advocate and a second set of ears. My dad is a back up driver for her but they do tend to stress one another out and he is a cardiac patient with a quadruple bypass surgery in his medical history so having him take Mom to appointments can be exhausting and some of the physical help she needs at times involves him exerting himself in ways that are questionable. But the options are limited when we have to get out to appointments for Mom. So we like it when the providers are able to come to the home.

But as the weeks go by she no longer meets criteria for them to stay and they discharge her one by one. The nurse goes and will come back if signs of infection or another issue start, and really it’s a good thing to see Mom improve of course and we don’t want her to need providers, but sometimes it’s more that she does still need providers but not badly enough that they will drive to us. Next OT usually discharges Mom as she is very resourceful with her ADLs even when she has to make a lot of her own accommodations. She is brilliant that way and teaches the therapists tips and tricks that they have not thought of at times.

The one who stays the longest given Mom’s condition is the Physical Therapist, but even when the Home Health PT first starts seeing Mom the most she ever has gotten approved for is 3 days a week with sometimes having a 4th or 5th day with another provider having eyes on her or working with her (nurse or OT) and I get it, staff is limited and funds for this kind of service paid for by insurance are limited as well. But coming from an inpatient rehab where Mom was doing exercises with a therapist typically 6 days a week or at least 5 to cutting that on half right away is a bit of a bummer of a drop off. She is supposed to do the exercises herself on the off days and she will tell you she does, but she is not doing any extra walking without a therapist standing right there pushing her because it hurts.

And the biggest bummer, which quite frankly feels like a gap in the care plan and does not make sense, is when they say she can still qualify for home health PT but PT will only come to the home once weekly because that is all they will approve and she cannot (as far as I know- I have not yet asked a physician to order outpatient PT while Mom is still having home health PT but I doubt it is permitted) have two levels of care at one time in the same speciality.

So then the therapist asks us to decide do I want her to discharge Mom and just go ahead and start her on outpatient PT (which she actually has never actually started before- she completed an intake before but then something happened such as a worsening condition or a hospitalization and she never started the outpatient PT). Well this home health PT has specialized training in lymphodema, which is another one of Mom’s complicating conditions, and does such a great job and we don’t want to lose her and I don’t want us to have to drive mom to and from PT 3 days a week selfishly as that adds to the schedule so we say “sure stay on for 4 more weeks.” But she’s only coming once weekly and she was just off for a week and they will usually send a fill-in therapist but it sounds like she got Mom to say it was fine to skip a week and Mom does not choose to do the weight bearing exercises when the therapist is not there. So Mom is only getting the full benefit of the PT one day per week because there are so many family-related factors that keep us dragging our feet when it comes to setting up outpatient PT and Mom certainly isn’t begging to go.

Wondering if insurance companies and treatment teams have considered that if they just pay for a few times a week of home health PT for a patient who is not fully exercise-compliant on the off days the patient might have better outcomes and then discharging a patient like that (who is not going to do the hardest exercises on her own on off days- especially when the hardest ones are the ones she needs the most) directly to outpatient PT so that she is going from at least 3-4 days of working out with a PT coming to the home and motivating and guiding her though fears and roadblocks to 3-4 days a week of working out at outpatient PT so the number of days participating remains consistent in the transition to a lower level of care.

And I realize that different patients have different needs and (seemingly even more importantly unfortunately) different funding sources approve different numbers of days and types of care, but patient outcomes are important too. And speaking about a patient like my mom who has had so many readmits and is not fully compliant with the hardest exercises that are the ones that will really build back her strength and have the potential to improve the outcome of the next knee surgery and recovery, wouldn’t it make sense to keep that at home PT coming four days a week for maybe a couple fewer overall weeks and then transition to 3 or 4 days of outpatient PT a week so someone is getting her to do the exercises instead of so much sedentary time?