Study finds gaps in home rehab after joint replacement

Every year, hundreds of thousands of older Americans recover from hip and knee replacement surgery at home. For many, that recovery depends on timely access to physical or occupational therapy after leaving the hospital.

Under the Centers for Medicare & Medicaid Services’ home health quality measures, home health care is expected to begin within 48 hours of hospital discharge. This study focused specifically on whether patients began home physical or occupational therapy within two days. But a new national study led by University of Utah researchers suggests many older adults do not receive rehabilitation within that recommended window.

The study, published in the Journal of the American Medical Directors Association (JAMDA), analyzed 18,998 Medicare beneficiaries age 65 and older who received home health care after hip or knee replacement surgery. Researchers found that 17% - nearly one in six - experienced delays in starting home physical or occupational therapy. Those delays were associated with poorer mobility recovery.

The biggest gaps were seen among rural Medicare beneficiaries and older adults enrolled in both Medicare and Medicaid. Rural patients were less likely to receive timely rehabilitation and less likely to regain mobility. Dual-eligible patients - those covered by both Medicare and Medicaid - faced even larger gaps in access and recovery.

Joint replacement is intended to help people regain mobility and independence, but that recovery depends on timely rehabilitation. So ideally it doesn’t matter where you live- in rural areas or urban areas, you should get timely home health care.”

Amit Kumar, MPH, Ph.D., Associate Professor, Department of Physical Therapy and Athletic Training and Department of Population Health Sciences, University of Utah

Why timing matters

Home health rehabilitation can play a critical role after joint replacement. Physical and occupational therapists help patients rebuild strength, improve mobility, manage pain and safely return to daily activities.

The study found that delays in rehabilitation were not just an access issue. Patients who started therapy later were less likely to experience meaningful mobility improvement during home health care.

That finding is especially important for older adults recovering at home, where gaps in care can affect independence, safety and quality of life.

Rural patients face additional barriers

For patients in rural communities, timely home rehabilitation can be harder to access. Long travel distances, workforce shortages and fewer home health agencies may make it more difficult for providers to reach patients quickly.

The researchers found that rural Medicare beneficiaries had lower odds of receiving timely home health rehabilitation and lower odds of achieving higher mobility improvement, even after accounting for patient, provider and community factors.

The findings are especially relevant in states like Utah, where many residents live in rural or frontier communities and may have limited access to post-acute care services.

A closer look at Medicare and Medicaid patients 

The study also found significant disparities among dual-eligible beneficiaries, or patients enrolled in both Medicare and Medicaid. Dual eligibility is often used as a marker of lower income or greater social and medical vulnerability.

Compared with Medicare patients who were not dual eligible, these patients were less likely to receive timely home rehabilitation and less likely to experience substantial mobility improvement.

The findings suggest that economic disadvantage may shape not only access to care after surgery, but also recovery outcomes.

A changing Medicare landscape

The study comes as Medicare continues to roll out value-based payment models that increasingly hold hospitals and health systems accountable for what happens after patients leave the hospital.

That shift raises an important question: Can the current home health system deliver timely, equitable care for older adults in rural and underserved communities?

Because home health care has been shown to improve patient outcomes and continuity of care, the study suggests that starting home rehabilitation earlier could help reduce gaps in care and recovery between urban and rural patients.

The researchers say the findings point to a need for targeted quality improvement efforts, stronger care coordination and policies that support timely access to home health rehabilitation for patients most at risk of delays.

“I would recommend patients and their caregivers should ask for the comprehensive home health rehabilitation plan and discuss this with the discharge planning process, before they go home,” Kumar said. "In addition, it is also the responsibility of the hospital to improve the care coordination after discharge from the hospital." 

Looking ahead

As more older adults recover from surgery at home, the first few days after discharge may be especially important.

For patients recovering from hip or knee replacement, timely rehabilitation can help restore mobility and independence. For health systems and policymakers, the study highlights a clear opportunity: improving access to home health rehabilitation may be one way to reduce disparities in recovery for rural and low-income older adults.

“Home health care is a key part of the recovery process after joint replacement,” Kumar said. “Ensuring that patients receive those services quickly could make a meaningful difference in how well they recover.”