Physical Therapy in Home Health and Skilled Nursing Facility Settings

Physical therapy in home health and skilled nursing facility (SNF) settings comprises specialized evaluation and treatment services designed to restore motor function, improve mobility, manage pain, and enhance independence for individuals who are not in an acute hospital setting. These two environments represent distinct but often connected nodes within the post-acute care continuum, providing therapeutic interventions that facilitate recovery from illness or injury, support the management of chronic conditions, and enable individuals to remain in their homes, a concept known as aging in place. The practice in these settings has evolved from the foundational principles of physical therapeutics established in the early 20th century to a highly evidence-based and regulated field ¹.²

The primary distinction between the two settings lies in the patient's location and the intensity of care. SNF-based therapy is delivered in a residential facility providing 24-hour nursing care, often following a hospital discharge for a condition like a hip fracture or stroke. The goal is typically intensive, short-term rehabilitation to prepare for a return to a community setting. A 2019 study by Falvey and colleagues found a dose-response relationship in which every 10-minute increase in the daily amount of physical therapy a patient received in a skilled nursing facility was associated with a 22% increase in the odds of being discharged to the community. ³. Conversely, home health physical therapy is provided in the patient's own residence. To qualify under Medicare Part A, the patient must be certified as homebound, a status defined by the need for supportive devices or human assistance to leave home, or a medical contraindication to leaving, combined with a normal inability to leave home that requires a considerable and taxing effort ⁴.

A central objective of physical therapy in both settings is the prevention of functional decline and adverse events, particularly falls. The Centers for Disease Control and Prevention's STEADI initiative provides a fall risk screening algorithm for healthcare providers that starts with three key questions: whether the patient has fallen in the past year, feels unsteady when standing or walking, or worries about falling, with an affirmative answer to any prompting further assessment. ⁵. The Timed Up and Go (TUG) test, originally described by Podsiadlo and Richardson in 1991 to assess basic functional mobility in frail elderly persons, is used to quantify mobility and fall risk, with a 2000 study by Shumway-Cook et al. establishing that a time greater than 13.5 seconds is a sensitive and specific predictor for falls in community dwelling older adults. ⁶. Effective interventions are typically multifactorial, incorporating individualized exercise programs focused on balance and strength training ⁷. The justification for therapy is not limited to improvement; following the landmark Jimmo v. Sebelius settlement, Medicare policy has affirmed that skilled therapy is medically necessary to maintain a patient's functional status or prevent or slow decline, a principle applicable to individuals with chronic conditions like multiple sclerosis ⁸.

Reimbursement structures significantly influence the delivery of therapy. Under the former Resource Utilization Group, Version IV (RUG-IV) system, payment was tied to the amount of therapy provided, and studies found that factors like having a hip fracture, being married, or being admitted from a for-profit hospital were predictors of receiving very high amounts of rehabilitation in SNFs ⁹¹⁰. In 2020, the home health landscape was altered by the implementation of the Patient-Driven Groupings Model (PDGM), which removed direct financial incentives based on the volume of therapy visits. This policy shift resulted in a documented decrease in the number of physical therapy visits per home health stay and a corresponding increase in the use of remote monitoring technologies ¹¹¹².

Historical development of post-acute and home-based physical therapy

The origins of physical therapy as a distinct profession in the United States are rooted in the early 20th century, with its initial scope largely confined to institutional settings. The first large-scale demand for physical therapists, then called reconstruction aides, arose during World War I to care for wounded soldiers [15]. Under the direction of figures like Marguerite Sanderson, these early practitioners focused on using exercise, massage, and hydrotherapy to restore function, primarily within military hospitals [14, 15]. The subsequent polio epidemics that plagued the nation from the 1920s through the 1950s expanded the field's reach. As therapists worked to manage the debilitating effects of the virus, often in patients' homes or community-based clinics, the groundwork was laid for practice outside of a traditional hospital [15]. The professionalization of the field was marked by the 1921 founding of the American Women's Physical Therapeutic Association (later the APTA), but the practice itself, as detailed in texts like Physical Therapeutics (1927), remained focused on fundamental modalities and exercises applied in a supervised setting [18].

Following World War II and the passage of the Hospital Survey and Construction Act of 1946, commonly known as the Hill-Burton Act, which funded hospital construction, physical therapy became a standard component of hospital-based care [14]. The profession's role was solidified within these institutions, treating a range of orthopedic and neurological conditions. However, the concept of dedicated post-acute and home-based physical therapy as widely available services did not emerge until significant healthcare legislation transformed the system.

The single most consequential development was the passage of the Social Security Act amendments in 1965, creating the Medicare and Medicaid programs. This legislation established a federal reimbursement mechanism for skilled services provided outside of a hospital, including care in skilled nursing facilities (SNFs) and through home health agencies [14]. Physical therapy was explicitly defined as a skilled service, making it a cornerstone of the newly created post-acute care continuum. The Medicare benefit was designed to shorten costly hospitalizations by transitioning patients to lower-acuity settings for continued rehabilitation. This policy, coupled with the demographic shift of an aging American population, generated immense and sustained demand for physical therapists in SNFs and home health to manage conditions common in older adults, such as recovery from stroke, cardiac surgery, and joint replacements [14, 15].

The evolution continued in the latter part of the 20th century with changes in reimbursement policy. The implementation of Medicare's Prospective Payment System (PPS) for hospitals in 1983, which paid a predetermined rate for a patient's diagnosis, created a strong financial incentive to discharge patients more quickly to post-acute settings [14]. This further accelerated the growth of the SNF and home health sectors, making physical therapists in these settings responsible for increasingly complex patient cases. The profession responded by advancing its scientific foundation and specialization, particularly in geriatrics, to meet the challenges of providing effective, evidence-based care in the home and institutional long-term care environments [15].

Patient populations and criteria for care

The differentiation between patient populations appropriate for skilled nursing facilities (SNFs) and those suited for home health services is primarily based on medical acuity, functional dependency, and the need for 24-hour supervision. Patients admitted to an SNF typically present with significant medical complexity and functional deficits following an acute hospital stay, rendering them unsafe to return home. A 2011 study by Leland et al. identified key predictors for receiving high-intensity rehabilitation in SNFs, including having an orthopedic diagnosis like a hip fracture, being admitted from a hospital, and demonstrating a high potential for functional improvement ¹⁰. The therapeutic goal in the SNF is intensive, short-term rehabilitation to facilitate a safe discharge to a less restrictive environment. The intensity of physical therapy is a critical determinant of this outcome; a 2019 study by Falvey et al. established a dose-response relationship, finding that for every 10-minute increase in daily physical therapy, there was a 6.8% increase in the odds of a patient being successfully discharged to the community ³. This population requires not only intensive therapy but also constant access to skilled nursing care for medication management, wound care, and monitoring of unstable conditions.

In contrast, the home health patient population is medically stable enough to reside at home but still requires skilled therapeutic or nursing services. The defining requirement for Medicare-funded home health physical therapy is that the patient must be certified as 'homebound'. According to the Centers for Medicare & Medicaid Services (CMS), to be considered homebound, a patient must meet two distinct criteria. First, the patient must either require the aid of supportive devices, special transportation, or the assistance of another person to leave their residence, or have a medical condition for which leaving home is medically contraindicated. Second, there must exist a normal inability to leave home, and any absences from home must require a considerable and taxing effort ⁴. These criteria strictly delineate the home health population from individuals who are capable of attending outpatient physical therapy. Common patient profiles include individuals recovering from total joint arthroplasty, managing exacerbations of chronic conditions like congestive heart failure or COPD, or experiencing significant functional decline and fall risk. Therapists often use standardized screening tools to justify care, such as the three key questions recommended by the CDC’s STEADI initiative to identify fall risk in older adults ⁵.

Reimbursement models also shape the delivery of care and, by extension, the patient experience in these settings. The implementation of the Patient-Driven Groupings Model (PDGM) in 2020 significantly altered home health reimbursement by uncoupling payment from the volume of therapy visits ¹¹. The 2020 implementation of Medicare's Patient-Driven Groupings Model, which removed financial incentives based on the volume of rehabilitation visits, was followed by a significant decrease in the number of physical therapy, occupational therapy, and speech language pathology visits per home health stay. ¹². For both settings, the concept of medical necessity extends beyond simple functional improvement. Based on the Jimmo v. Sebelius settlement, CMS policy clarifies that skilled therapy may be necessary to maintain a patient's current functional status or to prevent or slow further deterioration, particularly for individuals with chronic or progressive conditions like multiple sclerosis or amyotrophic lateral sclerosis ⁸. This allows therapists to provide maintenance therapy, solidifying the role of both SNF and home health settings in managing a wide spectrum of patient needs across the post-acute care continuum.

Medicare reimbursement models and their influence on therapy provision

The financial structures established by the Centers for Medicare & Medicaid Services (CMS) exert a powerful influence on the delivery of physical therapy in both skilled nursing facilities (SNFs) and home health agencies. Historically, reimbursement models have shifted from incentivizing service volume to promoting value and patient-centered outcomes. In SNFs, the prospective payment system was long dominated by the Resource Utilization Groups, Version IV (RUG-IV) model. Under RUG-IV, reimbursement was directly linked to the amount of therapy minutes a patient received, creating a strong financial incentive to provide higher volumes of rehabilitation. A 2011 study by Leland et al. found that under this system, non-clinical factors were significant predictors of receiving 'very high' amounts of therapy. These factors included a patient being married, having a diagnosis of hip fracture, being admitted from a for-profit hospital, and the SNF itself having for-profit ownership ⁹, ¹⁰. This suggested that reimbursement incentives, rather than purely clinical need, could drive the intensity of therapy services provided.

A significant paradigm shift occurred with the implementation of the Patient-Driven Groupings Model (PDGM) for home health agencies on January 1, 2020. PDGM fundamentally altered the payment structure by basing reimbursement on patient characteristics, such as clinical grouping, functional impairment level, and comorbidities, rather than the number of therapy visits ¹¹. This change deliberately removed the direct financial incentive tied to the volume of therapy visits ¹¹. Consequently, the implementation of PDGM led to a documented decrease in the average number of physical, occupational, and speech therapy visits provided per home health episode ¹¹. A 2022 analysis by Christensen et al. in the Physical Therapy & Rehabilitation Journal confirmed that PDGM’s removal of the direct link between visit quantity and payment resulted in reduced provision of physical therapy and a concurrent increase in the use of remote monitoring technologies ¹².

Separate from these payment models, a major legislative change affected therapy provision across settings. The Bipartisan Budget Act of 2018 permanently repealed the long-standing, and often controversial, hard financial cap on outpatient therapy services ¹³. In its place, the law established a system of targeted medical review. While the hard cap was eliminated, claims exceeding a specified annual threshold ($3,000 for physical therapy and speech-language pathology combined in 2018) require the use of a KX modifier ¹³. The application of this modifier signifies that the therapist attests to the medical necessity of the services and that this necessity is supported by documentation in the patient's medical record ¹³. This policy shifts the focus from an arbitrary spending limit to the defensibility of care, reinforcing the professional responsibility to provide evidence-based interventions that are medically necessary.

Functional assessment and establishing medical necessity

The justification for physical therapy in home health and skilled nursing settings hinges on a comprehensive functional assessment and the subsequent establishment of medical necessity. This clinical reasoning process begins with a thorough evaluation, which includes a patient interview, systems review, and the administration of specific tests and measures to establish a functional baseline. From this assessment, the therapist develops a plan of care with goals that are directly linked to the skilled interventions provided. This documentation trail is essential for demonstrating to payers, such as Medicare, that the services are reasonable and necessary.

A primary component of the assessment for older adults is screening for fall risk. The Centers for Disease Control and Prevention (CDC) STEADI (Stopping Elderly Accidents, Deaths & Injuries) initiative provides a widely used screening framework. Clinicians are advised to ask patients three key questions: (1) Have you fallen in the past year? (2) Do you feel unsteady when standing or walking? and (3) Do you worry about falling? ⁵. An affirmative response to any of these questions indicates an elevated risk and prompts a more detailed assessment of gait, strength, and balance ⁵.

Following an initial screening, physical therapists employ standardized, performance-based outcome measures to quantify functional mobility and fall risk. One of the most common is the Timed Up and Go (TUG) test. In their original 1991 publication, Diana Podsiadlo and Sandra Richardson described the TUG as a measure of basic mobility but did not propose specific time-based cutoffs for stratifying fall risk ⁶. Subsequent research has validated the test for this purpose, with studies establishing that a time greater than 13.5 seconds indicates a high risk for falls among community-dwelling older adults ⁶. The objective data from tests like the TUG, combined with the patient's history and subjective reports, allow the therapist to identify specific impairments, such as decreased lower extremity strength or impaired dynamic balance, that can be targeted with therapeutic interventions.

Based on the assessment findings, the therapist establishes a plan of care that justifies medical necessity. Crucially, medical necessity is not limited to patients who show potential for functional improvement. According to guidance from the Centers for Medicare & Medicaid Services (CMS), medical necessity can also be established for services designed to maintain a patient's current condition or to prevent or slow deterioration ⁸. For a patient with a recent total hip arthroplasty, medical necessity is typically predicated on the goal of improving ambulation, transfers, and restoring prior levels of function ⁸. In contrast, for a patient with a progressive, chronic condition such as multiple sclerosis, skilled physical therapy may be medically necessary to implement a maintenance program that preserves their current functional status and prevents a rapid decline ⁸. This distinction, clarified in the wake of the Jimmo v. Sebelius settlement, requires therapists to clearly document whether the goals are restorative or preventative, linking the skilled interventions directly to those specific objectives ⁸.

Core therapeutic interventions and strategies

Physical therapy in home health and skilled nursing settings centers on evidence-based interventions designed to restore function, improve safety, and facilitate a patient's return to the community or a lower level of care. A primary objective is addressing functional deficits through targeted exercise and activity. A 2019 study by Falvey et al. established a direct dose-response relationship between the amount of physical therapy provided in a skilled nursing facility (SNF) and patient outcomes; every 10-minute increase in daily physical therapy was associated with a 6.8% rise in the odds of a patient being successfully discharged to the community ³. This finding underscores the impact of therapeutic exercise on recovery trajectories.

Given the high prevalence of falls among the older adult population served in these settings, fall prevention is a cornerstone of care. Therapists often begin with a standardized screening process, such as the one recommended by the Centers for Disease Control and Prevention's STEADI (Stopping Elderly Accidents, Deaths & Injuries) initiative ⁵. This initial screen involves asking if the patient has fallen in the past year, feels unsteady, or worries about falling; an affirmative answer to any question triggers a more detailed assessment ⁵. This assessment may include performance-based measures like the Timed Up and Go (TUG) test. While the original 1991 paper by Podsiadlo and Richardson did not specify cutoff scores, subsequent research has identified that a time greater than 13.5 seconds indicates a high risk for future falls in community-dwelling older adults, a benchmark frequently used in discharge planning ⁶.

Systematic reviews confirm that the most effective physical therapy programs for fall prevention are multifactorial and individualized ⁷. A 2017 review by De Visschere et al. concluded that successful programs consistently incorporate a challenging and progressive balance training component alongside strength training ⁷. Therapeutic exercise is prescribed based on principles of overload and specificity, targeting key muscle groups essential for stability and mobility, such as the hip extensors, hip abductors, and ankle dorsiflexors. Balance exercises are progressed by reducing the base of support, altering visual input, or adding cognitive tasks to simulate real-world environmental challenges.

Beyond discrete exercises, interventions are deeply rooted in functional mobility training. This includes practicing transfers (e.g., from bed to chair), improving gait mechanics and endurance, and navigating environmental barriers like stairs or uneven surfaces. This approach aligns with models such as 'function-focused care,' where therapy and nursing staff collaborate to integrate mobility and activity into a resident's daily routine, rather than confining it to formal therapy sessions ¹⁴. A 2014 study by Resnick et al. demonstrated that this integrated approach improved physical function and reduced fall rates in long-term care residents ¹⁴. By focusing on these core strategies, therapists aim to maximize patient independence and ensure a safe living environment, whether that involves returning home or adapting to long-term care.

Evidence of effectiveness and the dose-response relationship

A significant body of research demonstrates the effectiveness of physical therapy in skilled nursing facilities (SNFs) and home health settings, particularly in improving functional outcomes and preventing adverse events like falls. Systematic reviews have established that effective fall prevention programs led by physical therapists are typically multifactorial, incorporating individualized exercise regimens that emphasize balance and strength training ⁷. The use of standardized assessments to quantify risk and progress is a cornerstone of this evidence-based approach. Clinicians often use tools recommended by the Centers for Disease Control and Prevention's STEADI initiative, which includes key screening questions about fall history and perceived unsteadiness ⁵. For objective measurement, tests like the Timed Up and Go (TUG) are employed, for which research has established cutoffs, such as a time greater than 13.5 seconds, to indicate a high risk of falls in older adults ⁶.

Beyond general effectiveness, research has identified a direct dose-response relationship between the amount of physical therapy provided and patient outcomes. A key 2019 study by Falvey et al., published in the Journal of the American Geriatrics Society, analyzed data from SNF patients and discovered a powerful correlation between therapy time and discharge disposition ³. The study found that for every 10-minute increase in the amount of physical therapy a patient received per day, there was a corresponding 6.8% increase in the odds of being successfully discharged to the community rather than to a long-term care facility or experiencing mortality ³. This finding suggests that the quantity and intensity of rehabilitation are not arbitrary but are potent predictors of a patient's ability to regain independence.

This evidence for a dose-response relationship exists within a complex and evolving landscape of healthcare policy and reimbursement, which directly influences therapy provision. Historically, under payment systems like the Resource Utilization Group, Version IV (RUG-IV), the amount of therapy a patient received in a SNF could be predicted by factors other than clinical need alone. A 2011 study by Leland et al. found that receiving a "very high" amount of rehabilitation was associated with having a diagnosis of hip fracture, being married, and being admitted from a for-profit hospital ⁹¹⁰. More recently, the implementation of the Patient-Driven Groupings Model (PDGM) in 2020 for home health care fundamentally altered reimbursement by removing financial incentives tied to the volume of therapy visits ¹¹. A subsequent 2022 analysis by Christensen et al. confirmed that this policy change was associated with a decrease in the provision of physical therapy in the home health setting ¹². This creates a tension between the clinical evidence supporting higher therapeutic doses for better outcomes and a payment model that no longer incentivizes it. In this environment, therapists must meticulously document the medical necessity for the prescribed frequency and duration of care, guided by principles of evidence-based practice and patient-specific needs.

The interprofessional team and caregiver integration

In an environment of constrained visit volumes, the physical therapist's effectiveness is magnified through collaboration with an interprofessional team and the strategic integration of caregivers ¹⁵. In both home health and skilled nursing facilities (SNFs), the team typically includes registered nurses, occupational therapists, speech-language pathologists, social workers, and physicians. The physical therapist contributes specialized expertise in assessing mobility and fall risk, often using standardized tools and guidelines such as the CDC’s STEADI initiative questions or established Timed Up and Go test cutoffs of greater than 13.5 seconds to identify high-risk individuals ⁵, ⁶. Based on this assessment, they design individualized, multifactorial exercise programs focused on balance and strength, which a 2017 systematic review by De Visschere et al. concluded were most effective for fall prevention ⁷. This information is shared through team conferences and integrated electronic health records to ensure a unified plan of care aimed at common goals, such as a successful discharge to the community.

A central component of home health physical therapy is the education and training of family caregivers. With the number of therapy visits per home health stay decreasing under the Patient-Driven Groupings Model (PDGM) since its 2020 implementation ¹¹, ¹², the caregiver’s role in facilitating patient progress has become more pronounced. Physical therapists train caregivers to safely assist with transfers, ambulation, and the performance of a home exercise program. This training extends the therapeutic intervention beyond the therapist’s direct contact time and empowers the family to manage the patient’s condition, maintain functional gains, and prevent decline. Such maintenance or prevention of decline is a key component of establishing medical necessity for skilled care under Medicare policy, particularly for patients with chronic conditions ⁸.

Within the SNF setting, this collaborative principle is expanded through facility-wide programs like function-focused care. This model involves training all staff, including nursing assistants, to integrate therapeutic activity into routine care. A 2014 study by Resnick et al. published in the Journal of the American Medical Directors Association demonstrated that implementing function-focused care, where staff consistently encouraged and assisted residents with mobility and activities of daily living as a form of physical activity, resulted in statistically significant improvements in resident function and a reduction in falls ¹⁴. This approach effectively increases the total daily dose of therapeutic activity a patient receives. It serves as a practical strategy to achieve outcomes similar to those observed in studies showing a direct dose-response relationship, such as the 2019 finding by Falvey et al. that every 10-minute increase in daily physical therapy increased the odds of community discharge by 6.8% ³. By acting as an educator and consultant to other staff, the physical therapist disseminates their expertise to elevate the facility's overall rehabilitative capacity, ensuring that therapeutic principles are reinforced throughout the patient's day.

Significance, policy challenges, and future directions

Physical therapy in home health and skilled nursing facilities (SNFs) is significant for its dual capacity to restore patient independence and mitigate systemic healthcare expenditures. By focusing on functional goals, therapists enable patients to return to their communities, reducing the need for long-term institutionalization. A 2019 study by Falvey et al. quantified this effect in SNFs, finding a direct dose-response relationship where every 10-minute increase in daily physical therapy was associated with a 6.8% increase in the odds of a patient being successfully discharged to the community ³. Furthermore, therapy is central to preventing costly adverse events, particularly falls. Therapists utilize standardized screening protocols, such as the three key questions recommended by the CDC's STEADI initiative, to identify at-risk individuals ⁵. Subsequent interventions are often multifactorial, incorporating individualized balance and strength training programs, which a 2017 systematic review by De Visschere et al. identified as most effective for fall prevention ⁷. The value extends to patients with chronic conditions, for whom the Centers for Medicare & Medicaid Services (CMS) has affirmed that physical therapy can be medically necessary to maintain function or prevent deterioration, not just to show improvement ⁸.

Despite its established value, the delivery of therapy is profoundly shaped by federal reimbursement policy, which presents ongoing challenges. Historically, payment models like the Resource Utilization Groups (RUG-IV) system in SNFs incentivized high volumes of therapy, with factors like a hip fracture diagnosis or admission from a for-profit hospital being significant predictors of receiving the highest therapy levels ⁹. This paradigm shifted dramatically with the implementation of the Patient-Driven Groupings Model (PDGM) for home health on January 1, 2020. PDGM removed the direct financial incentive tied to the number of therapy visits, instead basing reimbursement on patient characteristics and clinical needs ¹¹. A direct consequence of this reform has been a documented decrease in the provision of physical therapy visits per home health episode ¹². This creates a central challenge for agencies and therapists: how to achieve optimal patient outcomes with potentially fewer in-person encounters. Concurrently, while the Bipartisan Budget Act of 2018 repealed the hard "therapy cap," it instituted a targeted medical review process for claims exceeding an annual threshold, requiring therapists to meticulously justify continued care ¹³.

The policy-driven pressure to deliver value with greater efficiency is accelerating the adoption of new care delivery models. The same 2022 study by Christensen et al. that noted the decline in visit frequency under PDGM also found a corresponding increase in the use of remote monitoring in home health ¹². This marks a significant future direction for the field. Therapists are increasingly integrating telehealth for virtual check-ins and remote therapeutic monitoring (RTM) to track patient adherence to home exercise programs and monitor objective functional data between visits. This technological integration allows therapists to extend their clinical oversight beyond the traditional in-person visit, fostering patient self-management and enabling timely intervention. This evolution redefines the therapist's role, shifting from a model based purely on direct service provision to one that includes managing a patient's comprehensive rehabilitation plan, using technology to supplement and maximize the effectiveness of hands-on care, a concept consistent with modern principles of evidence-based physical rehabilitation.

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