Defining Moment Beyond Limitations Extending coverage and horizons. By Neal B. Finkelstein, PT, MPT, LMT, MS | April 2018 Listen to 'Beyond Limitations' They were 3 very different individuals who cumulatively have had a major impact on my life and those of others. I've worked in a variety of practice settings over the course of my 14-year career as a physical therapist (PT)—in acute care, at a physician's office, at skilled nursing facility, and now in home health. One challenge in home health, as in other settings, is working with commercial insurers. We're allotted a certain number of visits with patients, but we must justify and lobby for care provision beyond that limit. This can be quite frustrating, as we often see ways in which patients would benefit from our continued services. Another challenge involves previous level of function (PLOF). Commercial insurers want PTs to return patients to their PLOF. But the parameters for PLOF often are a gray area. If, for example, an individual was walking 3 years ago, had a stroke, and has been in a wheelchair ever since, it clearly cannot be the responsibility of the PT to return that person to walking in the manner in which he or she did before the stroke occurred. With those issues noted, here's the story I'd like to tell. I had a patient who lived in a hotel room with her husband. She was 56 years old, had morbid obesity, and had been limited to her bed for more than 9 months. Her husband was using a lift device to transfer her from bed to a chair. Her insurance company had allotted me just 6 visits. My immediate reaction was, "Six visits! I could simply limit my focus to preventing bed sores and leading her through leg-strengthening exercises, but, holy cow, she's just a year and a half older than I am! If I were her, I wouldn't want to spend the rest of my life lying in bed or only sitting up in a chair." So, at the end of my first visit, I explained to her husband the challenges that her insurance situation presented. I wanted to prepare him for what I was going to say next. "We'll get her into the chair on my next visit, and then I'll quickly be able to determine if walking is a reasonable goal for her," I said. "I'll keep her safe—don't worry about that. But I need to determine what her physical capabilities are, so that I can help her maximize them. Provided we make progress, I'll document that to the insurance company. Then they'll authorize more visits. That will give us an opportunity to really enhance your wife's quality of life." On the second visit, I leveraged proper body mechanics and asked the patient to try to use her legs to stand. With only minimal assistance from me she stood for about 15 seconds. That told me what I needed to know. After I sat her down, I announced, "You're going to walk again. I'll make sure your insurance company gives me the visits we'll need for us to get that done." Over our next few sessions, we worked on both standing and sitting exercises, and I gave her a home exercise program. As I'd forecast, we made enough progress that insurance authorization was extended beyond the 6 initial visits. Before long, she could perform standing balance activities, placing one foot in front of the other to strengthen her hip muscles in more of a static walking stance. She soon progressed to being able to take a few steps with a walker and only contact guard assistance from me. One of her legs was notably weaker than the other, however, and she was dragging it. To help correct that problem, on my next visit I had her stay in bed, and I used my own body as resistance during leg presses. I progressively used more of my body weight to help strengthen her weight-bearing tolerance. Lo and behold, when we tried walking again during the next visit, she no longer dragged the leg! She was extremely excited that she now could walk with the walker for about 20 feet before getting too tired to continue. The next challenge was the height of her bed. As it happened, I was friendly with the owner of the hotel. I explained the situation, and the bed was replaced with one that sits closer to the floor. That allowed my patient's husband to help lift her in and out of bed without needing the lifting device. The insurance payments stopped eventually, but by that time my patient's life had been transformed in ways that neither she nor her husband had foreseen when I first met them. The bottom line was, I'd seen in her not a person with a hopelessly disabling condition, but a contemporary who was in danger of being unnecessarily forced to spend the rest of her life in bed. I'd seen an opportunity to do for that woman what I would want someone to do for me, were I in that situation. I'd want to walk again. I'd want to stop being so dependent on someone else. In short, I'd want my life back. As I watched her guide her walker those 20 feet the first time, I felt almost as excited as she was. "If you 2 ever decide to renew your vows," I told the happy couple, "I'd be more than honored to walk you down the aisle." They thanked me and laughed. Talk about renewal! My patient's success made me feel renewed and revitalized in my own profession.