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Toni Talks about PT Today

How Can This Be a Safe Discharge?
by Toni Patt

This morning I was working on discharge planning with one of our case managers. A doctor was ready to discharge a patient and she had asked me for recommendations. I immediately said SNF. He wasn't able to safely transfer out of bed. I had yet to see him walk due to complaints of back pain. And he lacks insight into his limitations. The case manager agreed with me but said the patient was refusing to go anywhere but home.

Believe me, this is not someone who needs to go home. He can't make it to the bathroom without assist. I don't know how he would function if he were home alone. On top of that he has a 10-step entry into his home. Finally the case manager called the man's wife. After some hemming and hawing, she stated the patient's brother had recently moved in and would be able to assist her with assisting him.

Both the case manager and I know that isn't going to work. His family isn't going to be able to manage him. The case manager informed me his insurance won't pay our facility if we say he needs to go to a SNF and he goes home. The only way we'll be reimbursed is if he follows whatever discharge plan we establish.

I get that is a problem. What I don't understand is when did we stop billing these people? Who decided and when that patients are no longer responsible for medical bills? Maybe the question is when did people stop caring whether medical bills were paid? Once again, we have decisions being made based on reimbursement that aren't in the best interest of the patient.

Both the case manager and I documented our concerns. She added a statement that his wife states she and his brother will be able to adequately care for him 24/7. Both of us know that isn't correct but there's nothing we can do about it. It'll only be a matter of time until he is readmitted, probably worse than he already is. How is this good patient care? How is this good discharge planning?

The saddest part of this is that it's not an isolated case. It goes on every day where I work and in facilities throughout the country. These people are in and out of the same facilities over and over again. Eventually the insurance companies will refuse to pay us because of multiple admissions for the same problem.

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Strategic Meeting
by Toni Patt

As part of my leadership program, I attended the Texas Physical Therapy Association (TPTA) strategic planning meeting last weekend. The idea was to get newer and upcoming leaders to meet and mingle with people in leadership positions. We also got insight into how decisions are made and what is on tap for us in the future.

I loved it. I chose to participate in the professional development subcommittee. I think I have found a new niche. Right away I realized things I've been thinking and saying were parallel with what was going on. I was able to make some suggestions that were added as steps to the overall strategic plan. I want to do more of that.

There's one problem. All of the people involved beside a few leadership fellows hold elected positions. In order to attend further meetings, I need to be elected as either a district chair or to a state-level office. I'm on the nominating committee but am not chair so that doesn't help. I don't think I'd be turned down if I wanted to attend again, but I need to ask in such a way that it's obvious I will be a contributor.

It's been a while since I've done something I've actually enjoyed doing. Other than teaching and keeping up with the stroke literature, there hasn't been much. My eyes have been opened to a new avenue to pursue: leadership. I'm not sure what's out there but I need to investigate.

As a leadership fellow, I'm expected to complete a service project for the TPTA by October of next year. I have until October of this year to select what it will be. I'll be working with a mentor to complete the project. The purpose of the mentor is to problem-solve and keep me from reinventing the wheel. I brought the materials home to study. Ideally I would like to dovetail my project onto this meeting.

I also discovered that a horse show is an acceptable excuse for missing some meetings. Several others mentioned they wouldn't have been there if "blank" was going on. I can't describe how relieved I felt. It was worth it. Allie and I got three firsts but I felt I was missing an obligation. In order to run for higher office I must serve as a delegate. That requires some travel. I'm not sure how that will work out in the future but planning is everything.

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We're Not Going to Pay for That Brace
by Toni Patt

A few weeks ago, a woman was admitted to our facility with a knee injury. She appeared to have ligamentous damage on top of arthritic deformities. She came to us for medical management and antibiotics prior to surgery. Before she was admitted, her orthopedist ordered a KAFO for the involved leg.

I'm not a big believer in KAFOs. In my experience they are bulky and uncomfortable. In this case the woman weighed more than 300 pounds with chronic lower-leg edema, although her skin was intact. This meant the brace required extra reinforcement to be able to support her.

When the brace was finally completed, it cost $2,500. My facility refused to pay for it because that money would come out of their reimbursement. Management stated the brace was ordered before she was admitted and therefore wasn't our responsibility. Furthermore, the brace wouldn't be used until after the surgery, when she would transition to a SNF, so the SNF should pay for it. Naturally the brace company wouldn't release the brace to her without reimbursement.

I wish I could say this was an isolated incident. Maybe the cost is a little more than usual, but it happens all the time. No facility wants to pay for any sort of brace or orthotic. If something off the shelf can't be used, the patient must wait until transferring to the next facility or using Medicare part B if discharged home. Stroke patients do much better with hinged AFOs but they are almost impossible to get.

It almost seems like facilities and insurance companies are practicing medicine. The need is identified. The physician writes the order. Then either the insurance refuses to pay for it or the facility does. Insurances simply say the device wasn't covered. Facilities say the patient can get it at the next level of care, which also won't pay for it. The end result is something deemed medically necessary with a physician's order isn't purchased for the patient.

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My Latest Continuing Education Course
by Toni Patt

Last month I went to an onsite CEU course. Back in the day, I was a CEU junkie. I'd go not just for CEUs but if the topic sounded interesting. More recently I've had to cut back and limit myself to CSM. This year I got burned by the stroke course at CSM. Needless to say, I was a little nervous about this one.

The topic was motor learning. It was taught by someone I'd heard speak previously. He was interesting a few years ago. More importantly I was positive he knew more about the topic than I did. I was correct. It wasn't so much that I learned new information. I learned better application of what I knew and gained some insight into why I see some of what I do.

It was nice to sit in the class for a change. I didn't have to watch the clock. I didn't have to be on for 6 straight hours. I could go to the bathroom whenever I wanted. People attending a class don't realize this. They can get up and run to the bathroom whenever they want. The instructor can only go on the breaks.

I realize the more I know about a topic, the less there is for others to teach me. I'm trying to pick things that are newer or unfamiliar. Having written course descriptions and the like, I'm getting better at reading between the lines.

It was a nice experience to sit back and listen to someone else for a change. Not once did I have to sit on my hands to keep from correcting him. Nor did I have the urge to cite literature contradicting what was being said. More importantly, I actually received useful treatment suggestions for application in the clinical setting. I didn't agree with everything he said, but he supported what he said with research so I understood how he drew those conclusions.

When I attend courses, I try to be considerate. I keep quiet if I disagree or have evidence otherwise. If I want to discuss something, I wait until the break. It was nice to actually get more than my money's worth this time.

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The Change Cup
by Toni Patt

The facility I work in isn't very large. We have a cafeteria that's only open a few hours at time. For lunch we have two entrees, soup or the grill. Just like everywhere else I've worked, we all complain how expensive it is. When you check out, there's a small cup for pennies. The cup rarely holds just pennies. There are usually a few dimes, nickels and even a quarter. It's never empty.

At first I would drop in the pennies I got in change. Then I started adding more. I'm afraid I'll be short one day when buying lunch. I put more in so I won't feel guilty if I have to rely on it to make up the difference. Now I probably put in anywhere from 50 cents to a dollar each week.

A few days ago I was behind someone who was 20 cents short. The woman was going to run back to her purse and get the difference. The cashier grabbed the difference from the change cup and told her not to worry. When I checked out a few minutes later, I added the difference to the cup from my change and told her not to worry.

Since that time, I've seen the same thing happen three times. Now I know why the change cup is always full. We're all putting in extra change to cover everyone else.

Wouldn't it be nice if we could do that on a larger scale?

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Sometimes It's Hard to Feel Sorry for Patients
by Toni Patt

Last weekend I was describing a difficult patient I had worked with earlier in the month. It was someone with several chronic and out-of-control problems, obesity and medical noncompliance. I summarized my statement with, "I don't feel sorry for him. He created his situation."

I was immediately taken to task by someone who overheard some of what I said. I was told I shouldn't be working at that facility, much less in the profession if I don't feel sorry for my patients. This was someone who never works directly with patient care. She also only eavesdropped on part of the conversation because the statement made more sense in its entirety.

My eavesdropper apparently has equated good, quality care with feeling sorry for a patient. I don't feel very sorry for people who bring it upon themselves by neglecting diets, skipping medicines and becoming obese. That doesn't mean I won't provide the best care I can for them. Nor does it mean I don't want them to improve. I don't have to feel sorry for you to treat you to the best of my ability.

The sad truth is much of what we do involves working with people who don't want to do therapy. Or who don't want to get better. Or who don't want to take responsibility for anything. They would rather have a PT lay hands on and heal them. Once they leave the facility, it's only a matter time before they return with exactly the same diagnosis and deficits.

One such patient was an obese gentleman who came to us with an infection and chronic back pain. He didn't want to walk because it was painful. He couldn't move enough to make exercises effective. The only thing that was going to significantly help his pain was weight loss. He didn't think weight loss would work because he'd always been big-boned. That was not someone who was easy to help.

People don't always make the best choices. Just because I don't feel sorry for you for making bad choices doesn't mean I won't help you try to get better.

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Gerichairs Are Not Recliners
by Toni Patt
This is something I've never experienced. The facility I work for uses therapy gerichairs as recliners for patient family members. For some reason, the facility has yet to invest in recliners that can be put in patients' rooms.  When a family member or patient requests a recliner, someone is dispatched to the rehab department to retrieve a chair.

This creates many problems. Once the chair goes into a room, I'm not allowed to remove it. This decreases my already limited supply of chairs for patients. I'm not allowed to remove the chair to keep the patient or family happy. Currently I know of two chairs being used as recliners in rooms where the patient isn't on caseload.

If I point out I need the chairs for patient comfort, I'm told to make do with what I have, but make sure the patient is happy. Usually this means rotating the chairs between several patients so everyone gets out of bed but for a limited time. 

To make matters worse, whenever a chair is commandeered it's always one of the newest ones. Family members sit in the newer chairs. Patients sit in the older, less comfortable ones. I'm already forever searching for wheelchairs that have been commandeered to transport family members, then left in the room so the visitors have some place to sit. Now I have this.

When I brought the problem to administration, everyone agreed it was a problem. Everyone agreed the patients needed the chairs. Currently there is no money in the budget to buy recliners, or any other chair for visitors. It wasn't budgeted for. That's interesting. This problem has existed for years and no one has thought to budget for even one chair.

This is another one of those battles I cannot win. More chairs are not the answer. I got more chairs this year. I can't keep them in the department.

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New Grad Readiness Survey
by Toni Patt

Last week I completed an electronic survey asking if new graduate DPTs were ready to enter the clinic. Then it asked about specific areas of education and characteristics of new graduates and how they related to the first answer. It's about time someone looked at this. In my experience, no new graduate is completely ready to be thrust into a caseload but recent graduates seem less prepared than in previous years.

Every new graduate faces an adjustment period from student to clinician. Some transition easily, others take time. In previous years, the students had a fundamental understanding of what to do and why to do it. I'm not seeing that now. This is a common lunch topic when I teach. Many other therapists are saying the same thing.

The schools try to address things such as professionalism, punctuality, readiness to learn and patient-centered therapy. They don't seem to be spending as much time on fundamental knowledge. Or, maybe it isn't soaking in as much as it used to. Students vary in ability and knowledge but I hear this across the nation. We can't all be getting weaker students.

I don't think teaching methodology has changed that much. The problem lies elsewhere. I've had more than one person tell me new grads don't know anything but how to be called doctor. Obviously something is missing in the education because they should know many things.

Not that long ago I worked with a new grad who thought he knew everything. The material he knew, he knew well. He either didn't know there was more knowledge out there or didn't think it was necessary. As a result, all of his patients did the same things all of the time. There was no telling him anything because he didn't listen.

I hope this survey helps someone quantify what the rest of us are describing.

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Let's All Be on the Same Page
by Toni Patt

Last week as I was preparing to do an evaluation, I overheard one of our case managers talking to a family member of one of my patients. Nearly everything the case manager said started with, "Rehab will take care of that." They were discussing gait training and preparing the patient for discharge home. That would have been wonderful except for one small problem.

The patient's chart was talking about end-of-life issues. The patient was not expected to survive long enough to be discharged and if she did, it would be to another care facility due to vent dependence and dialysis. There was a palliative care consult in the chart. Everything I read implied the patient wasn't going home.

Now, I can understand the family asking those questions. Patients and families always believe they will be the one out of a million who gets better. What I don't understand is why the case manager, who should have also read the chart, wasn't redirecting the conversation somewhere else. At least she could have prefaced her responses with, "If the patient improves" or "If the patient goes home." Give them hope but try to be realistic.

Now I, meaning therapy, will be the bad guy here. I'm not going to be doing what the family expects because the patient won't tolerate it. Someone with a resting heart rate over 120 isn't going to jump out of bed and walk to the bathroom. She didn't even tolerate transitioning to sitting.

It isn't that I don't want to progress the patient. Walking to the bathroom would be great. It just isn't going to happen any time soon, if at all. However, since the case manager talked about therapy walking the patient to the bathroom, the family probably thinks it is possible. Sooner or later, I'm going to be explaining why I'm not doing something with a patient who couldn't do it in the first place, because someone thinks it should be done.

I wish the case manager would have limited what she said to, "If that happens" or included a timeline to keep the expectations in line with reality.

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HIPAA Violations Can Be Overheard Too
by Toni Patt

The other day, I was sitting at a nursing station and overheard a conversation between a patient and a physician. I wasn't trying to eavesdrop. The patient was very hard of hearing and the doctor had to yell to be heard. The patient was yelling back. I realized I was overhearing a major HIPAA violation. Between the two of them, they were broadcasting protected information down the hall.

First of all, the doctor should have closed the door. I still might have been able to hear but wouldn't have understood what was being said. A nurse walking by did almost immediately after the conversation started.

With the onset of electronic charting, facilities have been stressing precautions to protect the data. I think everyone knows to limit exposure to printed information and throw it in the shred box when finished. Passwords must be changed every few months. We go out of our way to not say patient names in hallways, elevators and the like.

What about the patients who can't hear us unless we yell? I can talk loud enough that even those with the poorest hearing can understand me. I have to remember to close doors and have conversations is relative privacy. It just dawned on me how much protected information I've been given at full volume.

Doctors seem to be the worst. They have conversations in the hall. They see people in the rehab gym doing therapy. One had a conversation with a patient in the bathroom. I know this because I was in the bathroom with the patient. That was seriously wrong. He should have asked the patient's permission for me to be present. It wasn't anything I didn't already know, but that isn't the point.

Patients forget this a lot. Many of them yell information into the phone. Either they speak loudly, the other person can't hear or both. I've noticed there is no privacy during phone conversations. They'll share everything.

There isn't too much we can do about patients with loud voices but we can be aware of what we're doing. We can also close the door when the doctor forgets.

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She Loves Her Job
by Toni Patt

I always enjoy talking to the therapists who come to my course. Last week I met a PT I'll call Dottie. I don't want to use her real name, but she reminds me of someone named Dottie. Dottie has been a therapist since back in the day. She graduated years before I even thought about PT school and is still going strong.

Dottie is a home health therapist and has been for many years. She beams when she talks about her work and patients. She prides herself on always doing the most she can for them. Currently every patient on her caseload is someone who she'd seen previously and specifically asked for Dottie to be the treating therapist.

The thing that struck me most about her was how happy she was. She loves talking about her work. A friend accompanied her to my course because he sometimes translates for her. He wanted to know what she was learning so he could be more help to her. I found out later he also teaches boxing to handicapped children in his spare time.

Both of them are of an age where they don't have to be doing anything. Yet here they are. I've never done home health but I can't imagine it would be easy. Unlike most settings, the home health therapist has limited access to things we take for granted in the clinic. Plus, that seminar was in Los Angeles. The traffic was terrible. Dottie drives in it every time she goes to work.

It was refreshing to see someone who loves what she does. I hope I'm the same way when I reach that point in my career.

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Just Do What the Family Wants
by Toni Patt

Earlier today I had a conflict with a demented, agitated patient's wife. She wanted me to get the man out of bed with a gait belt and hoist him over into the chair. I declined, stating I didn't feel comfortable doing that and it wasn't very therapeutic. She insisted. I apologized and told her I would assign the patient to someone else tomorrow who was strong enough to complete the transfer. She was still upset.

I spent the rest of the morning defending why I didn't want to "fling" a patient into a chair who didn't want to go there. He might have been confused but he knew he didn't want to get out of bed. Somewhere along the line, one of my OT coworkers told me I need to learn better customer service. Just do what the family wanted to keep them happy. I was too proud and pride comes before the fall.

There is nothing therapeutic or safe about flinging a person into a chair. Sitting up in a chair might have been therapeutic except for the fall risk from his restlessness. I used my clinical judgment and decided getting him into a chair wasn't a great idea. Being told to do it anyway is wrong on so many levels. Being told to do something simply because the family wants it without consideration of therapeutic value or skill is ridiculous.

We are supposed to be providing skilled therapies. There was nothing skilled about flinging someone into a chair. Charging a service as skilled when it isn't is a form of fraud. Doing something contraindicated because the wife wants it is not only unsafe but wrong. It also eliminates any chance of transfer training, neuromuscular reeducation and motor learning.

When did keeping the family happy become more important than providing therapy? More and more, PTs are being asked to bypass the skills we worked so hard to master and become lifting services. There's so much more to what we do. In this case, standing up for myself and my profession made me the bad guy.

There's more to good customer service than simply doing whatever the family demands. All that does is encourage them to become more demanding. Not only will those people never be happy, but all the other patients who aren't seen will also be unhappy. How does that help patient satisfaction?

In this case, I think the man is deteriorating mentally and physically and his wife is refusing to see it. She isn't going to be happy unless he does whatever he was doing before he was hospitalized and that isn't going to happen. I was wrong because I put safety first. I was wrong because I stood up for my profession.

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Selection for Recognition
by Toni Patt

Driving home from work today, I was listening to a podcast of a morning radio show. They were making fun of a man who had been given some awards because he had been contributing regularly to the organizations. Because it's a local show, I knew who they were talking about. I had to agree there was no reason other than money that the man was being recognized.

That got me thinking about all the people I know who should be recognized but aren't. One of the greatest unsung heroines I know works as a palliative care nurse for the "evil empire." Everyone knows how great she is, but she has never been formally recognized. I doubt she has ever been nominated.

There is nothing spectacular about doing a good job or being good at your job. You know who I mean. They never call in sick. They do whatever is asked of them. They manage impossible caseloads of complex patients. They don't talk about it, they do it. I've been at my current job for almost a year. I've yet to hear a thank you or a job well done from anyone.

True, you must be nominated to win. From what I can tell, there are two reasons people get awards. The process has become a popularity contest or there's a political reason. Why else would doctors who never set foot in the building win employee of the year? I worked with a male OT who was the only male in the department. He regularly won recognition awards because his was the only name anyone could remember.

There's no correlation between likeability and job skill. Yet job recognition awards count toward promotions, raises and other perks. At the evil empire, it counted on the annual evaluation. Friendly employees got bigger raises.

I don't think there is a PT out there doing this simply to win an award. I do think there are lots of PTs out there who should be recognized for the hard work they do. I suppose getting your name on a plaque is nice. I'd be happy with being told I did a good job.

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Blatant Rudeness
by Toni Patt

Usually when I go on a teaching trip, I have wonderful students. For the most part they pay attention. I get good questions. Some have fallen asleep because they drove three hours to get there. Others are obviously there for the CEUs. Last week I had someone who disrupted the class.

I encourage questions and discussion with attendees. This time I got something different. We were talking about pushers. She didn't agree with what I said. Instead of a discussion, she tried to argue with me. It was more of a, "I'm right, you're wrong," exchange instead of mutual agreement both options could work. I changed the topic as quickly as possible so the class could move forward.

Wouldn't you know that on my course reviews I got comments about not being open to discussion with the class. What bothered me most was up until that exchange, she seemed more interested in the crossword from the newspaper than what I was saying. I guess she didn't think I could see what she was doing.

I don't mind if someone doesn't pay attention. I try my best but still get paid whether someone pays attention or sleeps the entire time. Maybe she was already familiar with what I was saying. I'm sure there are others just as skilled as I am with stroke patients. God knows I've sat through classes in utter boredom for that reason. That just happened at CSM during the stroke course. Instead of being rude and argumentative, I kept quiet and tried to appear to be paying attention even when my mind was drifting.

I never said she was wrong. Instead I said I had tried what she suggested and it didn't work. But that didn't mean it wouldn't work for someone else. I only have so much time and a lot of information to cover. If she felt that strongly, she should have come to me at lunch or on a break.

Yes, I probably could have handled that better. Maybe if she hadn't been so interested in the crossword, I might have taken her more seriously.

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Why I Became a PT
by Toni Patt

I was asked this question on Sunday by someone who doesn't know me very well. I had to stop and think a minute before replying. The answer is I don't remember. I remember applying to PT school. I remember PT school. I remember deciding I liked acute care the best. Yet I don't remember why I made a decision that has shaped my life for many years.

Now I'm wondering if I would give the same answer if asked today why I am a PT. I don't think so because so much as changed over the years. I'm no longer idealistic nor do I believe I can help everyone. There are some people I would avoid having as patients at all costs. I also realize there are limits to what can be accomplished.

If I had to choose all over again today, I don't think I would choose physical therapy school. This is partially due to how difficult it has become to get into and how onerous the education has become. If I base the choice on my experiences, I would consider neurology. If I base the choice on horses, it would be nursing because there are many more opportunities for a nurse than a physical therapist.

That's one of the big problems with our field. Where do the older PTs go if they aren't ready to retire? A few go into teaching. I know a few who started working in schools. I can see where some would choose outpatient. What about the rest of us? I have no idea what I'm going to do when I can't keep up physically.

The older I get, the more I think about that. I joke that I'll be working as long as I want to own a horse. That's true. But I don't know what I'll be working as. I thought I would teach, which meant a PhD. I've since discovered if you want a PhD, it has to be the only thing you want. And you must want it badly. I want horses more.

I need to remember why I became a PT. Maybe that will help me decide what I want to do next.

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