Should I offer physical therapy (PT) to a patient in their late 60s coming from subacute rehabilitation before their follow-up appointment with their primary care provider (PCP)?

Should You Offer Physical Therapy to This Patient?

Yes, you should offer physical therapy (PT) to this patient in their late 60s transitioning from subacute rehabilitation, as early identification of rehabilitation needs and continuation of therapy after hospital discharge improves functional outcomes, reduces disability, and prevents deconditioning—particularly in elderly patients who are at highest risk for functional decline. 1, 2

Clinical Reasoning for PT Referral

Why PT is Indicated in This Scenario

• Patients transitioning from subacute rehabilitation facilities require formal assessment of ongoing rehabilitation needs before and after discharge to prevent functional deterioration and ensure appropriate continuation of care 1
• Elderly patients (late 60s) are at particularly high risk for significant loss of functioning after acute illness or injury, making early identification and continuation of rehabilitation critical 2
• The fact that this patient is coming from subacute rehab indicates they had sufficient functional impairment to require that level of care initially, suggesting ongoing rehabilitation needs are likely present 1, 3

Assessment Framework Before PT Referral

Before making the PT referral, you should quickly assess:

• Current functional status: Can they perform activities of daily living independently? What is their mobility level? 4
• Baseline functional impairment: Are they below their pre-hospitalization functional status with potential for improvement? 5
• Medical stability: Are there any acute medical issues that would contraindicate PT (hemodynamic instability, uncontrolled symptoms)? 6
• Specific impairments: Do they have weakness, balance problems, gait abnormalities, or pain limiting function? 4, 7

Practical Algorithm for Decision-Making

Offer PT if ANY of the following are present:

1. Functional deficits below baseline (difficulty with walking, transfers, stairs, or ADLs) 5, 4
2. Deconditioning (reduced endurance, muscle weakness, limited mobility) 1, 2
3. Safety concerns (fall risk, need for assistive device training, home safety assessment) 7
4. Pain limiting function (musculoskeletal pain affecting mobility or daily activities) 1, 4
5. Recent stroke or neurological event (these patients specifically benefit from continued rehabilitation) 1

Do NOT delay PT referral for:

• Waiting for PCP approval - you can and should initiate the referral as the covering provider if clinically indicated 5, 7
• Concern about "stepping on toes" - coordinating rehabilitation is part of comprehensive medical care and benefits the patient 1, 7

Key Considerations and Common Pitfalls

Timing Matters

• Delaying rehabilitation after medical stabilization leads to unnecessary functional decline, increased healthcare costs, and higher risk of hospital-acquired complications 5, 2
• Starting rehabilitation as early as possible leads to better functional outcomes - don't wait for the PCP visit if needs are apparent 5

Communication is Critical

• Document your assessment and rationale for PT referral clearly so the PCP understands the clinical reasoning 5, 7
• Ensure handover information includes functional status, mobility level, safety concerns, and specific rehabilitation goals 4, 7
• PT serves in an advisory capacity, but the physician makes the final determination - your referral initiates the assessment process 5

Setting Considerations

• Patients coming from subacute rehab may need outpatient PT, home health PT, or continued facility-based therapy depending on their functional level and living situation 1, 4
• Home-based rehabilitation programs can be cost-effective for appropriate patients and may be preferable for those with transportation barriers 5

What PT Should Include

The PT intervention should incorporate:

• Functional exercises and mobility training 4
• Strengthening exercises for affected muscle groups 6, 4
• Endurance/cardiovascular training as tolerated 6, 4
• Education on recovery and activity progression 4
• Assessment of home safety and need for assistive devices 7

Special Populations

If the patient had a stroke:

• All stroke patients should undergo formal assessment of rehabilitation needs before discharge, and continuation of therapy is strongly recommended if functional deficits persist 1, 5
• Patients recovering from stroke who are nonambulatory or have major lower extremity weakness specifically benefit from PT to improve postoperative and functional outcomes 1

If the patient is awaiting joint replacement:

• Do NOT mandate PT to delay surgery if they are already indicated for arthroplasty - this can increase pain without significant benefit 1
• However, prehabilitation (preoperative exercise program) is different and may be beneficial 1

Bottom Line

Offer the PT referral now rather than waiting for the PCP visit. The patient's transition from subacute rehab indicates they had significant functional impairment requiring intensive rehabilitation, and continuation of therapy is standard of care to prevent decline and optimize recovery 1, 2, 4. Document your assessment and communicate with the PCP, but don't delay care that can improve this patient's mobility, independence, and quality of life 5, 7.