What Is the Definition of Skilled Therapy?
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.