Reaching Rural Patients

Riding with physicians demonstrates the role of occupational therapy in home health.

Home Health

Almost three years ago, Maleshea Dunning, DO, director of Pikeville Medical Center’s Family Practice Clinic in Pikeville, Ky., instructed her residency students to begin spending a partial day with the clinicians of Pikeville Medical Center’s home health agency (PMCHHA).

The purpose would be to experience what home health in rural Appalachia entails, and how it might benefit the patients they refer to home health.

Pikeville Medical Center (PMCC) is affiliated with the Mayo Clinic, and offers over 400 services in the middle of the Appalachian coalfields. One of those services is comprehensive family practice clinics.

The University of Pikeville’s Kentucky College of Osteopathic Medicine (KYCOM) works in conjunction with the hospital, and houses a residency program that trains future physicians for family practice. This has allowed for a much-needed influx of family practice physicians into Appalachia.

The hospital-based home health agency, of which I am an employee, offers comprehensive home care services to Pike, Floyd, and Letcher Counties in Kentucky.

A Tour Through Appalachia

Having lived and worked in the Appalachian coalfields for over 20 years, I have seen first-hand how the expansion of PMCC has provided quality healthcare to the residents of this region without requiring them to drive for hours.

I was one of the clinicians chosen to mentor the residency physicians, which involves having them ride to patients’ homes, observing treatment intervention, and educating them on the patient services provided inhome health care.

I recognized immediately that this was an opportunity to not only educate physicians on home health services, but also on the meaning and purpose of occupational therapy. Primary care physicians can be a valuable referral source for OT, and I became the clinician whom the doctors rode around with for the vast majority of the time.

It’s difficult for nurses, OTs, and physical therapists to arrange for someone to ride around for a four-hour period, because schedules in home health can change with a moment’s notice. The patient must be contacted and asked permission to bring along another visitor. Your car is your office, and to have someone ride with you requires rearrangements of that office.

However, I enjoyed taking on this responsibility, and residents have noted how much they have learned and enjoyed riding with me. I see the same students on a rotational basis, and have gotten to know them, their families, their interests, where they are from, and their future plans. I have a captive audience, and time to educate them about the field of occupational therapy and home care.

Challenges in Home Health

Many physicians are not aware of the challenges that home health personnel endure on a daily basis. A study by Boucher quantified many of these obstacles: isolation, weather, terrain, distance, lack of anonymity, rural poverty, rural unemployment, difficult access to healthcare, and increased and hidden costs of healthcare.1

Today’s Appalachia, even with its advancement in healthcare, infrastructure, education, and economic opportunities, continues to present challenges such as high poverty and unemployment rates, as well as severe health problems.

I was interested in the opportunity to educate future family doctors, who are a valuable referral source for OT. I have educated residents about the history of OT, what the term occupation means, the use of occupation as treatment, and the difference between OT and PT. But most important, residents experience first-hand observation of OT treatment in the home, from assessment to goal development to the treatment of various diagnoses.

An important part of that education is what insurance will cover, and what can or cannot be done in home health. In one recent case, I took two residents to visit a bed-bound patient who needed to establish a local physician to continue receiving his medications.

Medicare, under most circumstances, will not reimburse an ambulance service to transport the client to a doctor’s appointment, and the patient’s family was unable to get the patient out of the home, into a car, and to the doctor’s office.

An ambulance transport would have cost $800. The patient had two appointments, so the ambulance service wanted to charge him for two trips. This is a common problem with many home health patients on limited incomes.

Residents were able to experience first-hand the challenges that patients endure just getting to the doctor’s office. Hopefully, when they begin practicing, they will be aware of what families face when trying to gain access to their physician. Perhaps this experience will better prepare them to pre-plan and alleviate this burden.

Educating on the Role of OT

Over my 27 years in practice, which have mainly been spent in rural home health, I have seen the acuity level of my patients continue to expand. It was once a cliché that one had to have experience to work in home health; this has never been more true than today. These future family practice physicians now have a clearer understanding of the obstacles faced when treating home health clients, and they observe first-hand how valuable occupational therapy can be.

One ADL that patients and caregivers consistently have concerns about is bathing. Bathing demonstrates the OT’s skill in developing safe routines and adapting safe access with the use of durable medical equipment that’s typically covered by insurance.

Most patients in rural homes are unable to afford expensive home modifications. Having the patient involved physically, and training caregivers to safely bathe the family member they are responsible for, helps the patient become more independent.

Medicare limits the amount of durable medical equipment it will provide. The future physicians that ride with me see first-hand what Medicare will and will not provide. Many believe that Medicare will adapt bathrooms, when it will not even provide a shower seat or tub seat.

Another opportunity to educate comes in the form of orders for a bedside commode. Many physicians will not sign these orders, to encourage the patient to walk to the bathroom. This is logical.

However, in many homes, the bathroom and the toilet are not accessible to those with a disability. A bedside commode can also serve as an elevated toilet seat, because many patients are unable to sit on a standard toilet seat — for example, those with recent hip fractures.

An excellent example of how OT is able to help patients immediately is providing training and education to caregivers. Occupational therapists in home health train and educate caregivers on bathing, dressing, transfers, adaptive equipment, exercise programs, health education, and home accessibility for the people they’re responsible for, at the lowest cost. On several trips I was able to demonstrate to residents how I use a patient lift system so caregivers can get their family members out of bed and into a chair or wheelchair safely.

One of the residents I was riding with happened to have seen a patient I was treating. This patient had recently requested a power chair, and was sent to an outpatient physical therapy clinic for an evaluation of need. Since this patient had good upper-body strength and was able to propel a standard wheelchair in an outpatient setting, his request for a power chair was rejected.

Knowing the patient’s home, his accessibility needs, medical precautions, and conditions, I knew a self-propelled wheelchair was unacceptable. I wrote a letter to the provider and reviewed it with his resident physician, who agreed with my assessment.

This demonstrates the importance of educating others on the holistic nature of our profession, as well as how important it is for home health OTs to review requests for adaptive equipment from other professions before these requests become an issue for the patient and the insurance provider.

What One OT Can Do

Riding with resident doctors has been an excellent opportunity for educating and promoting occupational therapy and home health services. It’s also been a great learning experience for me; physicians can teach you many things about medical treatment, and offer a doctor’s perspective of treating patients.

It’s also an excellent opportunity to review and educate patients about their current medications. Home health patients are very appreciative of physicians’ knowledge regarding prescription medications.

I am very proud of this endeavor. I believe I’ve done as much as one person can for occupational therapy in rural Appalachia. This statement cannot be quantified, of course, and no one else knows about this program except my current co-workers.

However, my experience demonstrates what one person can achieve when given an opportunity to promote occupational therapy and home health.


1. Boucher,M. A. (2005). Qualities Needed For Rural Home Care Nursing, Home Health Care Nurse, 23, 1-3


American Ostopathic Association,(2015).About Ostopathic Medicine. Retrieved from

Appalachian Regional Commission (n.d.). Appalacia’sEconomy. Retrieved from

Piersol,C.V., (1997). Show and Tell Promoting OT in Home Health Care. Retrieved from,–OT-in-Home-Health-Care.aspx

Pikeville Hospital,( 2015). Employment opportunites at Pikeville Medical Center.Retrieved from,

University of Pikeville (n.d.). At a glance. Retrieved from

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