In the wake of falling out of bed, an 87-year-old woman undergoing dialysis and with a host of comorbidities develops an intense fear of moving around inside her home, including negotiating steps to the outdoors. With the help of a health exercise program, a physical therapist helps boost her balance, confidence and mobility.

A 71-year-old woman with multiple cardiopulmonary comorbidities has abnormally high blood pressure readings at home. A physical therapist, alert for red flags, quickly contacts the physician and rallies emergency services to transport her to the ED, preventing a stroke or MI.

Those are just a couple of examples of many instances in which physical therapists in Metropolitan Jewish Health System's HomeFirst program are making a difference in the lives of their patients.

HomeFirst is a managed care long-term care plan designed for Medicaid-eligible residents in New York City with chronic or disabling conditions. The program currently provides services for more than 3,200 members in the five boroughs.

When members enroll, they are assigned a nurse health partner to help coordinate home care needs with a multidisciplinary team that includes physical therapists.

Safe at Home

As its name implies, the main focus of HomeFirst is to help members remain in their homes. "The therapists become case managers in terms of being able to look over their patients, contact the doctor and communicate with the nursing and rehab teams," said Sandra Flickstein, PT, MA, COS-C, rehabilitation educator, Metropolitan Jewish Home Care. "If there's a particular problem we work as a team to resolve the issue."

If members cannot remain in their home safely, they are referred to one of Metropolitan Jewish Health System's skilled nursing facilities. As a participating agency, the 9-year-old HomeFirst program has access to a 102-year-old organization that also includes hospice, palliative care, SNFs, home care and two adult day health ­centers.

When registered nurses or physicians flag members with a fall or other safety risk, physical therapists are tapped to evaluate and determine if they need two to three visits to restore their safety and functioning under the HomeFirst Medicaid program, or more restorative care under Medicare.

Holistic Approach

"Our patients have multiple diagnoses," Flickstein added, "so our role is to not only look at their safety in the home, but also to look at the whole patient and help manage multiple diagnoses."

Physical therapists add a "different set of eyes and ears" looking and listening, said Gary Jackson, PT, who has more than 35 years of clinical experience assessing patients.

"When we go into homes," he said, "we get to know not only the patients, but also their whole social network, questioning them not only on clinical aspects, but also how they live their lives at home."

Physical therapists in the program play many roles, including helping coordinate care with the member's family if there are social issues, Flickstein said.

Jackson and Edgar Biazon, PT, use their professional expertise and personal qualities to coordinate care for their patients.

"We've worked in myriad clinical situations," Jackson said, "and bring our experience, evolved over many years of practice, to the home setting. Our assessment encompasses not only physical therapy, but also assessing if patients are safe in the home, if their equipment is safe for them to use, and if they are capable of still using that equipment. Then we try to implement some type of change to improve their safety in the home."

Self-Directed

In the HomeFirst Fall Prevention program, the therapist engages the member and family in a self-directed program in which the member signs an agreement to follow the home exercise program and all safety recommendations the therapist provides.

Many members are fairly sedentary, "so you give them exercises just to keep them from getting stiff, because with a lot of rest comes a lot of rust," Biazon said. "They tend to watch TV, so we encourage them to exercise during commercials-kick their feet, stretch their arms, stand up for a second or two-to keep them as active, functional and strong as possible."

Forgetfulness and members' resistance to change are some of the biggest barriers the therapists face. "Asking someone who has never exercised to exercise is one of the most difficult to sell," Jackson said, "so we have to show them how change like exercise can improve their situation."

Jackson and Biazon use a variety of strategies. "I give them choices and written instructions," Biazon said, "and I tell them to do one thing every time they see a commercial because they last two to three minutes. They think it's funny and question why they should. But just one exercise an hour during one set of commercials can make a big improvement in their inactive lifestyle."

Jackson breaks his exercises into three positions, starting in bed, sitting in a chair, and standing someplace very stable like the kitchen sink, "where they can hold on, feel safe and not [be] overwhelmed by a long list of exercises."

Family Connections

The therapists collaborate with families to keep patients safe. During visits, many family members are at work or see [the therapists'] arrival as a chance to dart out and do errands. "But I tell them, you need to see what your family member can and cannot do," Biazon said.

Family is the "first line of defense in keeping their loved ones safe," he said. "Education for family is probably more critical because often, the patients are not independent and need some assistance. Caregivers need to be educated on guarding techniques and strategies for keeping family members from ending up on the floor."

Building rapport with members and their families is critical to the effectiveness of the physical therapists. "It's not necessarily the number of visits you have with a client," Jackson said, "it's the quality of the time you put in while you're there. You're giving and taking, getting to know them a little and they get to know a little about you."

Biazon empowers members by involving them in the decision-making process. "This is their rehabilitation, so I ask them what they want to work on," he said. "Often they are startled because they may not get that question. I put them in charge of their program. Sometimes they are receptive and other times they don't know what they want and trust that I will do the right thing that week."

Clearing Language Barriers

Often, the give and take requires clearing language hurdles. Some 60 percent of Jackson's patients in Brooklyn are non-English speaking. "It's very important to be able to say hello to a person in their primary language," said Jackson, who said he has "a little ability in Italian, Spanish, a few Russian words and a Greek word or two," but admits, "Chinese is a big problem for me at this point."

To supplement help from younger family members and a language line, the therapists draw on creativity, using gestures, diagrams and pictures to illustrate or demonstrate an exercise or functional maneuver. "You get a lot of laughs out of it," Jackson said.

Flickstein feels very fortunate to have the caliber of physical therapists on the team. "Gary and Edgar are very valued employees and great therapists with multiple letters of thanks from patients," she said. "It's not so much the language, it's what you bring to the patient and what they allow you to bring to them."

The therapists derive a great deal of satisfaction from developing relationships with members and families. "By helping the patient improve," Jackson said, "we're not only gaining their trust, but also gaining their respect. It's very rewarding."

For Biazon, the satisfaction may come years later. "I'll see a patient out in the neighborhood and hope I had something to do with that. I get a big kick out of seeing my patients walking into a supermarket or waiting for the bus or coming back from a nice walk outside."

Flickstein sees the impact Biazon and Jackson have on the members. "They engage their patients who respond to them and say 'I love my therapist.' We give our heart to the patient. It's a creative and physical experience and behind that, our hearts because we touch the patients. We don't stand back and tell them what to do. We make their lives better and provide a safe haven."

Kathleen Waton is a freelance writer in the New York area.