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Risk Reduction in the News – Response from the NLN Medical Advisory Committee
2012 Conference featured in Oncology Times
Clinical Trials - Patient Participation
NLN Position Papers: Risk Reduction, Risk Reduction Summary, Diagnosis and Treatment, Exercise, Training, Breast Cancer-Related Lymphedema, Supplement BC-Related LE
Q: How would you describe the typical home health LE patient?
A: With the rising cost of health-care, the major goal of home health is keeping the patient out of the hospital. As such, the home health patient often has multiple diseases requiring a multidisciplinary team of home care clinicians. The home health lymphedema patient is, therefore, a much "sicker" patient than that seen in other lymphedema treatment settings. Some common co-morbidities seen in the home health setting are diabetes, COPD, dementia, generalized de-conditioning, balance and gait disorders, peripheral neuropathy, and non-healing wounds.
In order to qualify for home health care, the patient must be considered "home bound," where "leaving home requires a considerable and taxing effort" (see www.medicare.gov). As lower extremity LE tends to cause greater mobility issues that might prevent ease of community mobility than upper extremity lymphedema, the typical home health lymphedema patient will most often have lower extremity involvement. Chronic venous insufficiency is a common ailment of the senior population due to decreased mobility and sedentary lifestyles. Chronic venous insufficiency, when left untreated and uncontrolled, will often progress to secondary lymphedema. While published data are scanty, in my experience, most home health lymphedema patients have lower extremity lymphedema associated with venous insufficiency, many complicated by venous stasis ulceration and a variety of other pathological conditions.
Q: What have you found to be the appropriate frequency and duration of lymphedema therapy for the home health patient?
A: The standard of care for lymphedema therapy is Combined Decongestive Therapy (CDT) which is comprised of Manual Lymph Drainage (MLD), skin care, compression bandaging, remedial exercises, and education in self care and home maintenance. Many experts in the field of lymphedema describe optimal frequency and duration of care as daily treatment for at least 3 to 6 weeks (see NLN Treatment position papers). However, extended daily treatment in the home health setting is usually unrealistic.
Many home health patients have a variety of complicated co-morbidities that require a multi disciplinary team of clinicians and may limit their tolerance to daily treatment, especially if they are seeing multiple clinicians in any one given day. Also, a very limited number of qualified LE therapists working in the home health field, in conjunction with the great demand for home health LE therapy, limits availability of therapists for daily care. A lesser frequency of treatments scheduled over a longer duration of care is often more realistic, and is more easily tolerated by this population of patients. Experience has found that, for most patients, aggressive daily treatment for five visits in the first week of care enables the therapist to establish tolerable compression to meet the needs of each individual patient, especially where heavily draining wounds or weeping tissues are involved. By the end of that first five-day week, the patient should have developed a comfort level with the compression bandaging, and any heavy drainage should have reduced to the point that daily dressing changes are no longer necessary. After that initial week of five visits, treatment can often be reduced to three times weekly for four to six weeks until edema stabilizes and compression garmentry for home maintenance can be obtained. Any less than three times weekly during the active reduction phase of LE therapy would seriously reduce the effectiveness of treatment and is not recommended.
The major goal for duration of care is completion of therapy and patient/caregiver independence with home maintenance by the end of one eight-week episode of CDT. However, some patients may experience complications during the course of therapy, for example, infection or exacerbation of other co-morbidities, which may slow progress toward edema reduction and control. These complications must be taken into consideration and duration of care altered accordingly. Most importantly, documentation of progress and/or complication must be thorough to justify continuation or discontinuation of care.
Q: What is the greatest obstacle to effective home maintenance for the home health lymphedema patient?
A: Home maintenance for this patient population can be especially challenging. These patients are often advanced in age with cognitive issues, decreased ROM, arthritic joints, and limited strength. Many of these patients are dependent for ADL's on family caregivers with similar disabilities. Compression garmentry for LE patients in any setting is often the greatest challenge of all. Many home health patients are on limited/fixed incomes prohibiting the purchase of expensive compression garments. During the initial evaluation of these patients, the therapist must carefully explain expectations for patient/caregiver home maintenance to insure continuation of care upon completion of therapy. A discussion of long-term compression options must be addressed at this first visit so that the patient/caregiver can start making plans for home maintenance compression during the treatment phase. This may include saving money for the purchase of appropriate compression garments upon completion of therapy, contacting charitable organizations when personal finances are an issue, or, where necessary, finding a dependable caregiver to assist with dondoff of garments and/or long term compression bandaging as an option to compression garments. If effective home maintenance including the use of some form of compression is not realistic or agreeable to the patient, then CDT may not be appropriate for this patient.
Q: What are some of the challenges to this type of treatment in the home health setting?
A: The home health setting poses major physical challenges for the LE therapist. Without the benefit of a high-low table to bring the patient up to optimal treatment height, ergonomic treatment in this setting is especially difficult. Excessive clutter, tight living quarters, nesting behaviors, and limited mobility, will often limit therapist access to affected tissues resulting in awkward treatment positions and leading to back strain/injury or upper extremity tendonitis on the part of the therapist. Even if the therapist were to bring a massage table to the home, many home-bound patients are not physically capable of transferring to high surfaces and/or excessive clutter in the home would not allow space for table set up.
The morbidly obese patient, where morbid obesity is defined as 100 lbs or more above normal body weight, further complicates issues of home health LE therapy as many of these patients are too challenging for one therapist to handle within a limited treatment period and without the assistance of another set of hands. Many therapists that treat in this setting have, therefore, found it necessary to limit the size of the patient that they are able to treat in this setting without assistance, or may find that they are not physically able to treat the patient within the limited confines of a tightly furnished home. This being said, there is a great need for LE treatment of the home bound patient, and wherever creative treatment strategies can be used safely and effectively, LE therapy should be made available to this patient population.
Q: Are there any patients that are inappropriate for LE therapy in this setting?
A: Treatment time per visit is a major factor in the home health setting. For treatment to be cost effective, the goal is to be able to provide effective treatment within a 90 min visit. The morbidly obese patient is a major challenge to this goal. These patients often have very complicated LE which requires a great deal of time to treat. While there would be no hesitation to treat these patients in the acute and/or outpatient setting, in a home setting they are often too challenging for one therapist to handle alone without optimal treatment surfaces and/or access to assistance from a therapy aide.
A home-bound patient with limited mobility and morbid obesity may also put the treating therapist at risk of injury and, therefore, may be inappropriate for treatment in the home setting. If the treating therapist finds the patients to be inappropriate for home health LE therapy, they may refer the patient for treatment at an outpatient or L-TAC (Long-Term Acute Care) facility.
Many patients live in extremely unsanitary conditions where effective skin and/or wound care is not possible. If these patients qualify for L-TAC care, CDT should be initiated in the L-TAC setting with home health follow up where necessary and appropriate. Any potential patient, regardless of the treatment setting, must be assessed for their ability to maintain progress made during the course of treatment. If the patient/caregiver is unable or unwilling to comply with consistent use of compression upon the completion of therapy, either via appropriate compression garment or long term compression bandaging, they must be considered inappropriate for CDT.
The usual contraindications and precautions for LE therapy may limit appropriateness of care, most notably: untreated cancer, uncompensated CHF, recent DVT, active infection. Another complicating factor that may prohibit therapy is poor kidney function, where the body is unable to effectively process and excrete the fluid mobilized though treatment.
Q: How do you handle "frequent flyers," patients who are referred for lymphedema therapy multiple times in any given year?
A: Repeat patients are a fact of life in the home health setting. In an attempt to keep these patients at home and out of the hospital, they are often referred for home health care with exacerbation of their morbid conditions. LE patients are no exception, except that an integral part of LE therapy is education in home maintenance and prevention of symptom exacerbation and disease progression. In assessing the home health patient for lymphedema treatment, it is important that the patient and/or caregiver understand their role in LE therapy. Lymphedema therapy does not end when the patient is discharged from the care of their lymphedema therapist. Phase II of lymphedema therapy is a lifelong process of self-care including basic MLD, skin care, consistent use of appropriate compression, and a home exercise program.
The most critical component of home maintenance is consistent use of compression to keep LE under control. The home health patient must be willing and able to maintain edema reduction by some means of compression, be it compression garments or long term compression bandaging. Many patients refuse to wear compression for a variety of reasons: expense, heat-related discomfort, donning issues, or because compression garments "just do not fit" into their lifestyle and/or fashion statement. Other patients may be unwilling or unable to afford custom-made compression garments when ready-made garments will not control their LE. Still others are unable to don a compression garment with a high enough compression factor to maintain their edema reductions. Without long-term use of appropriate compression, the patient will not be able to maintain the progress made through the course of LE therapy, and will soon be back on the home health census for additional therapy (if not back in the acute care setting with complications)-another frequent flyer.
Even the most diligent LE patient will often have an exacerbation of their symptoms requiring professional treatment to re-establish control. However, the patient must be able to demonstrate a conscientious effort at home maintenance including the use of some form of appropriate compression for at least 6 months, the lifespan of a typical compression garment, before they should be considered for repeat lymphedema therapy.
On-going communication with the referring physician is essential to increase awareness and support of the patient/caregiver role in home maintenance. Obviously, there may be exacerbation of symptoms due to unforeseen complications, (for example an unexpected fall, or onset of infection) in which case exceptions should be made. Unfortunately, if the patient is unwilling or unable to integrate the components of home maintenance, and most importantly the use of appropriate compression into their self-care regimen, the likelihood of an optimal outcome decreases and the patient may be inappropriate for additional LE therapy at this time. However, while circumstances may, at times, prevent optimal lymphedema therapy in the home health setting, patient motivation to manage their lymphedema condition may change over time. With this in mind, re-assessment on a regular basis is important as symptom exacerbation due to infection or other situation may lead to a renewed commitment to self-care and partnership with the therapist for more effective treatment and improved outcomes.
Ruth Moseley, MS, PT, CLT-LANA
Amedisys Home Health
ruthmoseley_pt@yahoo.com
Please address questions to: Editor c/o NLN, 116 New Montgomery Street, Suite 235, San Francisco, CA 94105 or e-mail: nln@lymphnet.org. Deadlines for submissions (for the following issue) are: Feb 1, May 1, Aug 1, Nov 1.
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