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Toni Talks about PT Today

What Is the Definition of Skilled Therapy?

Published February 19, 2013 1:28 PM by Toni Patt

I've been noticing a disturbing trend lately. More and more facilities are considering the need for supervision as a need for skilled therapy. Back in the day, patients referred to SNFs and outpatient had an obvious need. They had trouble walking. They couldn't transfer. They'd recently undergone total joint replacement. The knowledge and skill of a therapist were needed to treat the impairment.

Last weekend, I worked at a different SNF than usual. I had nine people on my caseload. Six of those were ambulatory with supervision. They didn't need help to transfer. They didn't need help to walk. They weren't falling all over the place. They all had a diagnosis of dementia and required supervision for safety. For two of them, dementia was the admitting diagnosis. I'm not talking about facility residents who've declined in function. I'm talking about people admitted because they can't be left alone.

Physical therapy addresses physical problems. Impaired cognition that prevents the learning and retaining of new information isn't going to respond to physical therapy. No amount of safety training is going to make someone who can't form new memories remember to lock a wheelchair or rolling walker. Admitting someone with the expectation that a PT can improve cognition is ridiculous.

It doesn't require skill to walk with someone like that. Anyone can do that with minimal training. These are people admitted because they can't go home for some reason. They don't need PT, or at least not very much. They need to have someone with them at all times for safety. Training the caregivers would be skilled therapy. Caregivers might come to visit but rarely attend therapy sessions. They have to work.

I don't have a problem with admitting those people. They do qualify to be in the facility, just not on therapy caseload. Medicare A only pays for the stay if there are skilled needs, which usually means therapies. And therein lies the crux of the situation. This is a common situation with TBI patients. Their mobility improves but they can't be left unsupervised. We refer to them as walking wounded. I think that definition needs to be broadened.

The APTA is characterizing us as movement specialists. We are the muscle experts. So please tell me how an elderly walking wounded fits into that description. I don't see it.

10 comments

Dementia patient's may not always have balance or strength/ROM deficits but still can warrant PT. Cognitive deficits can still manifest physical problems with safety. For example, in a SNF, or ALF a patient can be safe with a walker, but constantly forgets it. The treatment can be strategies of rearranging furniture, positioning the walker in the direction of points of interest such as the bathroom. Also, training the staff to consistently ambulate the patient with the walker (no hand hold assist or use of wheelchair) to instill "familiarity" to the patient and the walker use can become routine to the patient. PT visits can be without any specific exercises. I've had visits where I ambulate an ALF patient who forgets his or her walker - to the bathroom, the dining area, to the bed, to the chair, to the activity room, to repetitively transfer and ambulate to rehearse acquiring the walker.

Keith Bisesi February 22, 2013 9:55 PM

To Kate, the PTA. It is an easier job for you to challenge what you are questioning. You can look at the evaluating PT's goals. Do they make sense? Are they measurable and reasonable for that patient?

Keith Bisesi February 22, 2013 9:42 PM

I find the same problem in home care.  We are keeping patients for a year or more who have no real therapy needs except supervision. It is very frustrating and it seems to be on the cusp of Medicare fraud.  We go to an assisted living facility and walk with a patient around the halls with or without a walker or cane.  The patients cannot or will not participate in ther ex. There are aides on staff who could do this once or twice a day but "are too busy."  So PT is brought in.  It doesn't seem right.  I've had to see patients who initially had a hip fx. They had 3 months in a nursing home, and return to the ALF and PT is ordered.  We then continue to see them for 1-2 yrs all the while knowing the family and the facility do not want the pt to ambulate at all.  They want to keep them in a wheelchair for safety.  What's the point?  I've tried to talk to the PT and the administrator of our agency but, it's all about the money.

Kate, , PTA Homecare February 20, 2013 6:03 PM
MI

Karen, a quick search revealed that spaced retrieval is an interesting approach. It appears to be primarily used by SLP professionals, but I did find some supporting documentation around PT usage. What I did not find though, was clinical evidence of its efficacy, such as a RCT. Could you direct me and the other readers?

Dean

Dean Metz February 20, 2013 12:26 PM

Karen,

Actually, the evidence does not support that physical therapy interventions for falls in care facilities has a significant impact. I am not familiar with spaced retrieval but look forward to learning more about it. In the meantime, here is the latest evidence regarding falls and fall prevention for inpatient facilities.

Dean Metz February 20, 2013 12:10 PM

Toni,

Spaced Retrieval does work and it is provided to patients (similar to yours) by therapists.  Have you done a Tinetti or Berg on them?  How about the AM-PAC?  Where is your objective data to "prove" they do NOT need therapy?  I bet there is a therapist out there that can justify skilled care based on objective measurements and data.  

Were the patients and family questioned about a fall history?  There are too many variables that can justify skilled care.  What is your justification of not treating a patient if you do not have the data to back you up.

Karen February 19, 2013 11:33 PM

Have you heard of the Allen cognitive approach? OT's are a great resource when it comes to establishing a baseline and developing a supportive and needed program to help these unfortunate patients. We are in a very scary time. Alzheimer's disease is on the rise and not going away! We, as PT's need to understand the needs of our long term residents-refer as needed or educate ourselves if we are puzzled. I see a future where our services contribute to the higher function and dignity of patients who cannot help themselves. I can only hope that in this future my family or myself will benefit from caring and well trained professionals.

Jennifer Perry, PT - DOR February 19, 2013 9:52 PM
Gainesville FL

As the owner of a rehab consulting firm, I hope you provide better advice to your customers than you presented here. If not, they can certainly expect future denials on reimbursement claims.

While it is true that physical activity may improve memory, this does not require the skilled services of a licensed physical therapist.  This is better left to the Activities Department. The other interventions you mentioned were to delay onset of conditions. CMS is quite clear that to be considered "skilled services," there must be reasonable expectation for improvement in the condition within a reasonable period of time.  Delaying onset of any condition is not skilled therapy.

Chris, PT February 19, 2013 4:04 PM
Jackson MS

In response to the comment from "Folarin".  I appreciate the benefit and need for regular exercise and indeed you are correct that studies have shown delay in deterioration in those who receive regular exercise. However, and Dr Patt will correct me if I'm misinterpreting her point, regular exercise is not the same thing as skilled therapy. A CNA can administer a maintenance walking program or simple exercise program. Walking with a patient who requires supervision for safety doesn't require the time or expense of a skilled therapist and asking third party payors to reimburse for these activities appears inappropriate.

Dean Metz February 19, 2013 3:53 PM

Your article is quite interesting but as an owner of a rehabilitation consulting firm. I have to disagree with you. Studies have shown that physical therapists can provide physical activity which can improve memory. Regular exercise may delay the onset of dementia and Alzheimer disease. Also, regular exercise may delay the decline in ability to perform activities of daily living in people who have Alzheimer disease.

Dont write someone off because you think the care you provide doesn't help. Medical facilities dont turn away patients even if they think nothing can be done. You owe the patient to keep working! Exhausting all options. We ALL owe the patient that. I included this link for more information http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=48d29ec1-3159-45d3-bf6e-ea31ab7c978a

Folarin, CEO February 19, 2013 3:30 PM
Rego Park NY

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