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Toni Talks about PT Today

My Patients Are Sicker Than Ever
by Toni Patt

We're all well aware of the fattening of our patients. Years ago facilities rented bariatric equipment. Now they own it. Obesity compounds other medical problems as well as interfering with mobilization, and the trend continues. I've noticed another trend that doesn't seem to be getting attention. Our patients are sicker than they've ever been.

My facility has always been known for accepting critically ill patients. But the ones we get now are more dead than alive. It isn't that they're acutely ill. Acuity doesn't always correlate with severity of illness. Some of them have been chronically ill for years. The severity of how ill they are has changed.

Even our "better" patients are in bad shape. Our liaisons aren't going out of their way to find these patients. This is what is in our hospitals. This is what is being discharged. The less severely ill are being sent home.

Nursing homes are also feeling it. I've heard several complaints on the weekends of how the admissions aren't as good as they used to be. Trach patients are much more common.

We can blame our reimbursement structure for some of this problem. In an LTAC, the sicker the patient is, the higher the reimbursement for care we receive. The same is true of DRGs. On the flip side, payers limit the length of stay so the less sick are sent home to be cared for by home health.

The other piece of this puzzle is that patients are living longer and developing more chronic diseases. Combinations of DM, HTN, renal failure and CHF pack quite a wallop, especially if they're not well controlled. I can't remember the last evaluation I did that didn't list something in the past medical history as out of control.

It isn't going to get better. It is the way things are now.

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The Patient Is Always Right No Matter What
by Toni Patt

My facility has instituted a new policy: Keep the patient happy no matter what. Staff has been instructed to think of patients and their families as clients. Happy clients tell friends about their experiences. We want those friends to choose our facility if they ever need long-term care. That way we can maintain our financial goals.

Nothing is more important than achieving that goal. Patients and families who complain are termed priority patients and must be kept happy. For example, a Spanish-speaking family complained that not everyone caring for their mother spoke Spanish. As a result, we now have a contract with a telephone translation service, with the number posted in every room. A formal letter of apology was given to the family.

Our liaisons are telling outright lies to potential admissions. They have been told to promise anything. It will be provided once the patient is admitted. Needless to say, staff isn't very happy about this. It falls to us to meet these outrageous demands and keep the unhappy happy.

So far, rehab has escaped the worst of this. Administration has already decided to remake all departments in the image of nursing. Thus all departments will be expected to respond to demands in the manner of nursing. It won't work but until it fails horribly, the expectation will be there.

What administration fails to understand is there are some people who will never be happy. The more they accommodate, the more those people will demand. Staff will be the ones caught in the middle. I wonder how many good workers are going to leave as a result. Meanwhile those people will still be unhappy.

There are so many other things that could be stressed that would have a positive impact on the facility. Keeping staff happy should the priority. They are the ones who do the work. All I can do is watch this play out.

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When a Patient Refuses a Bedside Commode
by Toni Patt

"I'm not sitting on that."

This week I have a patient who refuses to use a bedside commode. He refuses to allow us to position the BSC over the toilet to increase the height. He refuses to do anything but use the toilet in his room. Many people feel the same way, although the BSC is considered an improvement over a bedpan.

There is just one problem. The patient in question has an incomplete spinal cord injury and has been chronically ill the past few months. The only way he can use the toilet is if someone lifts him on and off of it. He can walk to the bathroom. He can do a pivot. What he can't do is the sit-stand from the toilet. Between his spinal cord injury and multiple orthopedic injuries, he lacks adequate flexion in the necessary joints.

The simple solution is to put the BSC over the toilet, which would compensate for the ROM restrictions. He won't let us do it. He wants to use the toilet and expects someone to be available as a human lifting service. Worse, he complains if the person isn't available on demand because he doesn't want to have to wait.

Bedside commodes aren't known for comfort. They're designed to allow people with weakness and joint restrictions, just as this gentleman, to use a toilet with minimal assist. All I can do is shake my head. Because he requires assist to get on and off the toilet, he ends up sitting there waiting for the one person who can perform the transfer.

Sitting that long on a toilet can't be any more comfortable than sitting on a BSC for any length of time. I don't understand the logic. Is it that important to say, "I was able to use the toilet, not a bedside commode," to go through all this?

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Treating a Difficult Patient
by Toni Patt

"I'm paying to be here and be taken care of. You will do what I tell you."

It's bad enough we struggle for respect from physicians and occasionally other disciplines. I would say the majority of the population doesn't know what we do or the amount of education required to be a therapist. Usually if we work hard and prove ourselves, the respect follows. Or we generate recognition that what we do requires skill and training.

That wasn't true of a woman I attempted to work with last weekend. She had just arrived to the SNF and wanted to go to the bathroom. When I arrived, she was still on the gurney demanding a RW be given to her so she could walk to the bathroom. When I told her I wouldn't do that, I got the response quoted above. She seemed to think I was a servant, not a trained and skilled therapist.

At that point, I knew nothing about her because I'd been called to the room without explanation of what was needed. The only information in the old chart was her diagnosis of THR and ambulation of 15 feet with moderate assist. That's not a lot of information, certainly not enough for me to plop a RW in front of her and let her be off to the bathroom.

I tried to explain the process to her. This resulted in being told I was rude by both her and her son. Her son pulled me into the hall and threatened to have me fired on the spot as well as have my license removed. He actually behaved worse than that. Meanwhile his mother was still demanding to go to the bathroom very loudly. They both believed I should just deliver the RW and let her be.

The EMT person made things worse by saying the patient did it at the hospital. Yes, but did she do it correctly? The EMT had no way of knowing.

I was the bad guy because I wouldn't simply put the RW in front of the patient, but actually wanted to do an assessment and make sure everything was done safely and properly. The patient, her family, the EMT and nursing didn't seem to think any of that was necessary. The woman said she could do it. That was enough for them.

No one seemed to understand that PT is a skilled service. A PT can't just deliver a RW because the patient wants one; much less leave it in the room without assessing the patient. I made everyone angry because I wanted to do things the right way. The patient's demand was more important than using clinical judgment and making sure everything was safe.

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APTA Membership: Cost vs. Benefit
by Toni Patt

I've been reading the responses to my various blogs over the past few weeks. The responses seem to be echoing what I've been saying. Hardly anyone has had anything to say in support of the APTA. Many explain why they don't belong.

The general consensus is the APTA doesn't represent the majority of PTs and PTAs. No one wrote in support of its current focus on direct access. While no one specifically said it, there continue to be negative feelings about moving to a DPT. Concerns were voiced about cost, additional years of school and stagnant salaries that aren't enough to pay back school loans.

Many writers had other suggestions for the APTA on where to direct its attention and money. I can think of only two people I know who contribute to the APTA and TPTA. I've contributed to the TPTA but will not give the APTA anything. No one is going to donate money toward something they don't believe in. I wonder if it has occurred to anyone at the APTA that this might be a reason for the difficulty in raising funds.

The only positive comments I read were for the chapters and sections. Several people would join at the state level. In order to address the cost issue of membership, the APTA has developed some payment options. But I don't think cost of membership is the problem so much as the belief there is no benefit to membership. What are we really getting for that money? The majority of work is done by volunteers. If you're an elected official of the APTA or a section, you get some money toward expenses to attend CSM. Where does the rest go?

I make the same amount of money now that I did four years ago. That doesn't seem to concern the APTA. I've heard nothing from them addressing PT salaries. APTA membership is very low on the priority list for expenses. Of course that also goes back to the perceived value of membership.

I'm not encouraging anyone to belong. The sad truth is unless you work in outpatient, you don't seem to matter. That seems to be the image the APTA is creating for us. But then look at our leaders, who are either outpatient orthopedic, private practice or both. It shouldn't really surprise us. Even if someone with a different agenda made it to elected office, I doubt it would do much good. They would be one vote against everyone else.

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Remaking PT in the Image of Nursing
by Toni Patt

We've had a changing of the guard where I work. A couple of months ago upper management reorganized. Last month the previous rehab manager was asked to step down. A new manager was appointed with the mandate to clean up the department. Changes have been coming ever since.

None of our new upper management team has any experience with rehab. They are recreating our department in the image of nursing. Every change is accompanied with the statement, "That is how nursing does it." When one of us raises an objection, we are told that isn't how nursing does it.

Yes, there were problems in our department. Most resulted from bad decisions made by the previous manager. Upper management has every right to correct those mistakes, but not to take it out on the remaining staff. We might be grumbling but we are going along with the changes. Threatening us with write-ups and suspensions is not necessary but that is on the table.

Nursing is different from therapy. The nursing model does not lend itself to rehab. They might as well force a round peg into a square hole. We are professionals. We can think for ourselves, or at least we could think for ourselves before. Apparently nursing procedures are universal and do not vary from facility to facility. Nor do they require the ability to make clinical decisions, because that is how our department must now function.

To say this is a disaster in the making is an understatement. Rehab should follow the same facility rules as everyone else when it comes to attendance, tardiness, time off etc. At the same time, a huge difference exists between how the two disciplines provide care to patients. The question isn't whether this experiment will fail. The question is how much damage will be done in the process.

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It's Time to Renew My APTA Membership
by Toni Patt

It's that time of year again. I just opened my mail and found my APTA renewal notice. For a mere $585, I can continue to receive all the benefits of membership. This amount includes APTA membership, Texas chapter membership and membership in three sections. The only one of those I have any interest in maintaining is section membership.

My last several blogs have been critical of the APTA and the direction it is taking the profession. My biggest complaint is the lack of attention to what the average PT and PTA are saying. We are voicing reasonable concerns. No one seems to be listening. As a result, I've been trying to find a way to communicate with our leaders.

The best I can do is contact the APTA headquarters in Alexandria, Va. Although I would address the communication to the elected officers, I'm not sure they would even see the communication. No matter who sees it, I doubt I would receive any meaningful response. I would like to sit down with someone and ask these questions. I don't see that happening.

Now I have to decide whether I want to spend the money to renew. It isn't about the total cost. It isn't about payment methods. The issue is that I'm not getting value equal to the expense. I have trouble with spending money and getting nothing in return.

Nonetheless I will go ahead and pay the money. It gives me access to current literature. I get a discount on the Combined Sections Meeting when I go. Membership in the sections is well worth the money. I'm not encouraging others to join, renew or not renew. That is an individual decision. But I can see why many will choose against membership.

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Who Is Going to Pay for This?
by Toni Patt

As I've read the responses my latest blogs have generated, I've noticed a few common threads. Everyone seems to be in agreement on the problems. We might not prioritize them in the same order but all agree they exist. We also agree the APTA is either unaware of these issues or is unwilling to address them.

Last week, I was in Minnesota teaching. During lunch we were discussing our profession. One of the attendees told me there is direct access in Minnesota, but it doesn't matter because none of the insurance companies or Medicare will reimburse them unless there is a doctor's order for therapy. I so wanted to laugh.

Everyone knows the APTA believes direct access to be the end-all, do-all for PT. Its supporters talk about resistance from physicians. They encourage us to call legislators in support. They ask us for money to continue the fight. I can't think of one instance when I've heard someone talk about getting financial reimbursement for those services once the goal is achieved.

Direct access is meaningless unless payers are going to reimburse for the service. Requiring a physician's order to receive reimbursement negates the whole point of direct access. You would think there is a push on payers to recognize direct access and reimburse accordingly.

I can only speak for Texas. As far as I know, the only communication with payers is to prevent further decreases in reimbursement under our current system and impingement on our billing codes by other care providers. In essence, payers don't recognize those services as unique to physical therapy. They recognize those services as skilled, but apparently those skills aren't exclusive to PT.

I actually find this amusing. Somebody needs to take a giant step backward and reassess priorities. Direct access is moot if no one is going to reimburse for it. On top of that, there is the little problem of the general public lacking awareness of what PTs do and the perception that chiropractors are the practitioner of choice for back and neck pain.

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Doesn't the APTA See It?
by Toni Patt

For the past few weeks, I've been writing about problems facing the physical therapy profession. These include tunnel vision focused on direct access and practice without referral. Another is the public perception of who we are and what we do. Still another is poor membership in the APTA and why most PTs don't see the benefit of being a member.

Based on the comments I've been receiving, I'm clearly not the only one seeing these things. I'm not the only one who feels these are serious problems facing our profession. Usually I receive both positive and negative comments. Lately most comments have supported what I'm writing.

I know from teaching in various parts of the country these problems are nationwide. I see it. Others see it. What I want to know is why the leaders of the APTA don't see it. And if they do, why don't they address it, even if to redirect focus onto their issues.

I've yet to read anything from the APTA addressing these issues. The closest thing talks about rebranding the profession as movement professionals. They might be working on that but I'm not seeing it in mass media. Nor am I hearing it from our leaders.

Why is this not happening? Why aren't these issues important enough to address? Every year the Foundation for Physical Therapy has an auction as a fundraiser. One of the things you can bid on is lunch with the president of the APTA. I wish I could afford to bid on that. I would love to ask these questions. Granted, afterward I might be stripped of my membership and barred from further participation in APTA activities. It would be worth it.

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The Things I Hear at Horse Shows
by Toni Patt

Last weekend was another horse show. During the downtime, I was involved in two conversations that illustrate some of the points I frequently make. The first occurred between two women who didn't know I'm a PT. The second occurred with a high school senior who did know.

The two ladies were discussing a recent hospitalization following an orthopedic procedure. The woman who'd been in the hospital wasn't happy with her doctor. He told her he couldn't predict the outcome. When he asked her if she wanted therapy she said no. It wasn't anything she couldn't do at home by herself. He agreed with her and told her to save her money.

The high school senior told me she had been considering becoming a PT but changed her mind. She had specific reasons. There aren't enough jobs. It's too expensive compared to the salary earned. It takes too long to finish. And my personal favorite, the title doctor is misleading.

I didn't bother to say anything to the ladies. It would have gone over their heads. I did talk to the senior. She made valid points. Her perception is that other senior students feel the same way about the profession.

I think the APTA has some work to do. They don't seem to be improving public perception of the profession. Direct access isn't going to do anyone any good if patients don't think they need the therapy and don't want to pay the co-pay. Who is going to provide that care in the future if students continue to perceive PT as they do now?

There was one other conversation I should mention. One of the parents was complaining about back pain. He said he needed to get home to his chiropractor. He didn't want to go to the doctor. That would just waste time. He didn't want a massage. That wouldn't help. He thought he hurt it at the gym so was laying off exercise. But one trip to the chiropractor and he'd be as good as new.

Yes, I did ask him why he didn't ask for physical therapy. He didn't realize we treat back pain. Besides he'd already been to his chiropractor and gotten therapy before. He didn't see a need to change.

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The Perception About PT
by Toni Patt

Last weekend I had dinner with some friends. One of my newer acquaintances knew what a physical therapist does. First he wanted to know what clinic I worked at. When I told him I work in a hospital, he wanted to know how I liked working with shoulders and knees after surgery.

I finally had to explain in detail what I do each day. This included an explanation of the difference between orthopedic patients and neurological patients, and my preference for the latter over the former. I don't know which he had more trouble believing: that I actually do what I do or that I wasn't searching frantically for something orthopedic.

Given some of my comments about lack of brand identification for the profession, you might think I would be happy he knew what a PT is. His knowledge didn't make me all that happy. His concept of PT was so narrow it excluded the majority of what we do and where we do it. At least he didn't ask for a massage.

This is an example of another divide in our profession. The divide of how we are described. The information that is out there focuses on outpatient, orthopedic therapy. To the uninformed that is the impression being issued. With the exception of pediatrics, I have yet to see anything that shows PTs doing anything that isn't orthopedic.

The ads for local PT schools feature orthopedic settings. Whenever PT is discussed as a career, the accompanying picture is some kind of outpatient setting. I don't think I've ever seen a picture in a catalog depicting anyone with any visible impairment. Everyone looks like they're at a clinic receiving therapy.

This misconception isn't doing us any good. The promotion of PT should be all of PT, not just a special interest group or featuring generic pictures that could have been taken anywhere. I lay this problem at the feet of the APTA as well. They are so driven toward direct access and practice without referral, the rest of what we do seems to have been forgotten.

At the end of the evening, I asked my new friend about his PT experience. As I suspected, he'd been to an outpatient clinic for back pain. But he only went one time. The co-pay was too expensive. He went to a chiropractor instead and feels much better.

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Offering a Therapist Recommendation
by Toni Patt

"I need therapy. Refer me to someone who knows what they're doing."

This was an actual request to me last week. One of our CNAs has an Achilles tendon injury. She has been wearing a moon boot for a few weeks. Last week her physician ordered physical therapy for her.

I wasn't much help for the request. I'm not in the loop of people who would have information like that. The other PT at my facility is very strong orthopedically. I told her to ask him. He couldn't help either. It is very hit-and-miss in a clinic. It all depends on who works with you. He named a clinic in her area that has a good reputation but couldn't promise she would work with someone good.

This is sad. Obviously skill level will vary by practitioner but you would assume everyone has a basic knowledge level. Apparently this is not the case. I could treat someone with an Achilles tendon injury. I wouldn't be the best at it but I believe I would be adequate. I hate to think a PT working in an outpatient clinic has no better knowledge than someone who hasn't treated orthopedic patients in years.

True or not, that is the perception of our CNA. It is also the impression of my coworker. What is happening in these clinics to make people think this way? I've had other people tell me they went for therapy but it didn't help. Those same people will later report improvement following a chiropractic visit or getting a massage.

What is the problem? Some of it may be inappropriate referrals in the first place. Sometimes patients are sent to therapy because the physician doesn't know what else to do with them. Some of it may be passive patients who want things done to them rather than doing it themselves. Is it a lack of education on the part of the PT?

I really have no idea. But it must be addressed. This reflects poorly on the profession as a whole. There is a segment of the general population who believes not every PT is good at what they do.

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Whose Profession Is It?
by Toni Patt

Two weeks ago I attended a Texas Physical Therapy Association meeting. The speaker was Mike Conners, president of the TPTA. Last week I discussed my belief the APTA is too focused on issues, such as direct access, that do not affect the majority of PTs and PTAs. Mike made another point that needs to be considered.

We all know that physician's orders are required for PTs to treat patients. Mike pointed out that none of the other disciplines competing for the same patients have that restriction. Anyone can be seen by a massage therapist, an athletic trainer or a personal trainer without having to see a physician first. None of these have the education we have but all practice without restriction.

In Texas, as in other states, there is stiff resistance from the physicians to remove the physician referral from the equation. They have described PTs as skilled technicians who require the direction of a physician to know what to do. Obviously some of this is financially driven. If they control the therapy, they control the money.

In the hospital setting, I need the physician to tell me the patient is medically stable enough to begin mobilization. This isn't true in skilled nursing. The majority of those patients are stable. In the school setting, it is easy to recognize those children who require intervention.

This problem is larger than the conflict between therapists and physicians over referrals. It is a mindset problem. There is a large scale belief that physical therapists are incapable of treating patients without first having the approval of someone else. Part of that belief arises from lack of understanding about what physical therapists do.

Once again we circle back to the APTA. Educating the public about who we are and what we do falls under their umbrella. I don't see anything out there on a large scale. Individuals and small groups are doing this but we need a large-scale, national educational push over a long period of time.

For example, the elder former President Bush is known to have Parkinson's disease and other chronic health problems. Somewhere along the line he received physical therapy. An ex-president would be a wonderful spokesperson. What about Gabrielle Giffords, the ex-congresswoman who was shot? She received inpatient rehab at a facility in Houston. She could speak firsthand as to the difference therapy made in her life. Somebody missed the boat.

Here's the problem. Neither received therapy for orthopedic problems, which is what drives the push for direct access. I hope there were other reasons not to approach those people rather than tunnel vision as to what physical therapy is and does.

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What About the Rest of Us?
by Toni Patt

Last week, I went to a meeting of the Texas Physical Therapy Association Southeast District. Mike Conners, the TPTA president, was speaking. His topic was the future of physical therapy and increasing awareness of legislative action in the Texas congress.

He touched on all the usual topics: direct access, reimbursement for outpatient services, the therapy cap, concussion management and defining the brand of physical therapy. The APTA wants us to be known as movement specialists. He cited examples of other disciplines trying to infringe on our area of expertise.

Those are important issues. But as I sat there, I realized they have little direct effect on me. With the exception of the therapy cap, every issue Mr. Conners touched on concerns outpatient therapists. I say except the therapy cap because that contributes to limitations my patients face after discharge. Had a non-therapy person been in attendance, that person would never suspect PTs do anything but outpatient therapy.

I work in a hospital with sick patients. I need physician input as to whether my patients are ready and able to tolerate therapy. The same is true for PTs who work in SNFs, AFLs and the school system. I lack adequate medical knowledge to make that decision.

Restructuring the reimbursement system for outpatient treatment also means little to me. It is a problem. So are flat salaries, increasing therapist-to-patient ratios in facilities and shorter lengths of stay. Reimbursement for what I do comes out of a chunk payment the facility receives.

Everyone agrees our healthcare system is broken. Nowhere is it more evident than in hospitals and long-term care facilities. Reimbursement cuts have taken their toll on every aspect of patient care and care-providing. I'm not going to get a raise this year. I'm just happy my pay isn't going to be cut. I always have more patients on my caseload than I can treat if I spend just 30 minutes with each one.

Where are the APTA and TPTA on those issues? Why aren't they lobbying legislators to fix the broken healthcare system? They spend hundreds of thousands of dollars lobbying for things that affect only a fraction of our practitioners.

If those laws ever come to pass, therapists who work in outpatient settings will benefit. What about the rest of us? Salaries aren't keeping up with the cost of education. Adequate staffing has long been a thing of the past. I could continue. The list is long. One of the reasons given for not being an APTA member is not getting anything out of membership. Maybe this is one of the reasons why people feel that way.

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No Lifting Rules
by Toni Patt

I have a new thing to be upset about, mechanical lifts. Yes, they've been around awhile. Yes, we've all used them. It's pretty much a given that any transfer performed with one is not a functional transfer. Still, as therapists we managed to avoid their use and perform functional transfers.

No lifting rules require a device of some kind. More and more this is becoming some version of a standing lift. They are easier to use and can be performed by one person. They also allow patients to be placed on the toilet, something that could never have been accomplished using a hydraulic lift. There are pluses. There is also one huge minus.

Transfers using a mechanical lift are not functional transfers. By definition the patient is a passive participant. There is no opportunity to practice transferring. They also put the patient into a non-functional position. I can't think of any functional activity that is performed in the stand-lean required by those lifts.

Facilities like them because they are cost-efficient. They don't particularly speed up patient care but they do prevent injuries and loss of work due to injuries. For the cost of a $3000 or $4000 device, they cut down on employee injuries and associated costs. To management that is a winning combination. I just returned from teaching in California, which is a no-lift state. It is state law such a lift must be used by everyone.

I pulled the literature on these lifts. The articles are to the point. All find a reduction in injuries and associated costs. All also state the transfers are not therapeutic or functional. A few looked at patient outcomes and found no significant difference. None specifically looked at transfer skill as an outcome measure.

I have a simple question. If we're using those lifts, when are our patients practicing transfers? They aren't. Sure we get bariatric patients who can't be moved any other way. And we get train-wreck patients in the same situation. I've had stroke patients who could only sit in a neuro or cardio chair. But the end goal has always been improving transfer skills.

No one wants to get hurt moving a patient. At the same time, we want to help our patients become more independent and gain important skills. I hate the things. The only thing I hate more is the electric scooter. We want to promote independence and the ability to care for oneself. These lifts do the opposite.

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