PT Techs

I am a traveling OTR and am in a contract in a SNF in CA.  In the 10 years I have been an OTR, this is the first time I have encountered a facility that gives a rehab tech their own caseload treating sub acute patients not within line of sight of me.  I am apalled and cannot stomach this on so many levels.  I complained to the regional rehab director, who reinterates that it is okay and he will find a way to make it so that the tech is in line of sight of me.  However, when I am given 20 patients a day, 10 of which are assigned to the rehab tech, it does not matter if they are in line of sight or not, this is ilegal and medicare fraud.   This has me billing at 200% productivity which is also fraudelent without a group.  I have only seen this happening in CA so far.This  company continues to say they are legal in their practices.  How do I go about finding out the definitive truth and/or reporting this facility?

I have been a rehab tech for almost 4 years. Until reading this blog, I did not know that techs are even allowed to treat/have a caseload in some states?! I myself, think it is absolutly wrong. Not only do techs not have a degree, they lack the the knowledge that you really learn from either going to school for a Physical or Occupational Therapist. Where I work, I am not allowed to treat patients.  My day consists of-transporting patients to/from therapy,endless filing of paperwork,making the patient schedule at the end of the day for the following day, daily cleaning of the gym,wheelchair follows when a therapist is walking with a patient..and...I do assist the therapists in doing things like balance or group activities but there is ALWAYS a therapist present and instructing me on what they want me to help with.  Also, on a side note...for anyone that has ever worked with a decent rehab tech...from time to time don't forget to thank your tech...we are underpaid for the amount of work we do, and it's nice to hear a thank you once in a while.  

Let me begin by stating that I have worked with some awesome tech.'s in the past.

A P.T. tech should be utilized as a "helper" they lack the knowledge, skills and abilities (KSA) of a therapist whether it be a P.T.A. or a R.P.T. The question was posed whether ultrasound and hot packs were "skilled". Although CMS has determined that hot packs do not require the KSA's of a therapist, I even disagree with that. Just ask the patient who had an aide place a hot pack on them without sufficient padding causing a burn. Ultrasound is a skilled service because it requires the KSA's of a therapist to determine wattage, intensity and duration. Ultrasound also requires the knowledge of  how to use the ultrasound head effectively utlizing the appropraite timing of swipes. Other questions arise about gait and therex. If a patient does not need a therapist to provide proper cueing, progression and supervision; Is the service still skilled? The question we need to ask ourselves is this : If I feel comfortable delegating this task to an aide, is the patient still appropriate for SKILLED therapy or is it time to d/c the patient to less qualified personnel or a home program?

By delegating skilled tasks to an aide we are reinforcing the perception that as a profession we are not needed. If the KSA's of a therapist are not needed, why not just add modalities and exercise to the nursing  curriculums around the country? We hurt ourselves by not utlizing ancillary personell appropriately. Do aides have a function in the therapy clinic? Yes. But their function is to assist the treating therapist in performing tasks. Not to perform the tasks independantly.

I think there's a two fold reason for the tech issue: 1) relying on word of mouth and not really knowing the guidelines for how a therapy aide should be used, on the otherhand 2) the absence of specific medicare guidelines on use of rehab techs.

the way i see it is that the PTs and PTAs should be responsible enough to know the limits of the their tech. i think the word skilled service is a good way to start. altho we provide skilled service to our patients, we can break the tx that we provide into smaller activities that may require unskilled or less skilled tasks. like for example: i would tell my tech to put this much ankle weight, or set up a patient on an ergo, or get a moist heat pack for this individual (i would even instruct the tech how to prepare the hot pack), and the list goes on. but in all cases, i would decide on what to do. of course after working with the same tech and with the same patient after a while, your instructions become less to your tech unless something needs to be changed. i would not leave a tech to work with a patient from start to finish without me knowing what's going on. every tx session should be a special session that requires a PT/PTAs complete attention and not just one of those days that a tech can just "go through the motions" completing a generic tx plan. so i believe it should be "line of sight" and not "on sight".

but when a "blow by blow" assessment is needed while doing the tx activity, a tech should not be doing it. as an example, i would not have a tech ambulate a patient if it is part of my treatment because the skilled part with what i am going to do won't be there. if the patient can ambulate with nothing left for the therapist to work on really, which means a tech can do it, then that is not part of the tx. the list can go a long way, but the simple discretion, responsibility and sound judgement of a PT or PTA should be enough for us to tell us what a tech can and cannot do.

the system is partly to blame for the techs overuse/misuse. SNFs for example want skyrocketing caseload more than a normal PT/PTA staff can handle. techs are the cheapest answer. that means more revenue for lesser overhead. therapists are forced to delegate (or surrender) most of their role trying to keep up with seeing patients and catching up with their documentation. Sometimes the therapists themselves trade dignity over income, seeing a smorgasbord of patients (using their techs) so that they can rake in the most hours in the least possible time and spend less hours at work. all we have to do is to look at ourselves and we know what is wrong.

I Myself have been a Therapy Tech/ Aid for some time now while going for my associates for PTA. As far as treating, the only things I have really done on my own with a patient while in the observation of a PT or PTA were just simple leg exercises or mat exercises or taking the patient for a walk.

There have been a few times where I have walked with a patient outside of the therapy area toward the lobby and back by myself but the patient was distant supervision with no device.

To me its a legality issue but also a question of trust. A Tech is still a part of the therapy team and should be used in a way that helps the team with out having it be a question of right or wrong.

as far as a Tech having his/her own caseload, Thats a little extreme.

I ran into this as a traveling PT.  When I arrived in a small Maryland hospital, I was the only PT with two aides.  The aides would leave the department and go see patients bedside--independently.  They carried their own caseload.  Convincing them we needed line of sight supervision to bill for treatments was a tough sell...an even tougher sell to the orthopedic surgeon who was over the department.  

It took about two weeks to go in and assess all of the patients (in patients and outpatients), discharge those who no longer needed our services, and assign appropriate treatment frequencies to those left on caseload.  Then we began a waiting list...something the hospital had never heard of.  Even though the doctor and aides were on board by this point, they were sure that the patients would rebel.  But when we explained that it was necessary to ensure they received quality care, they were appreciative.  

I had to make some of the changes slowly...and very respectfully.  The aides had been running the show, and doing a good job...just not an ethical job, but that was through no fault of their own.  Once the situation was explained to them, they were glad to adjust and thankful someone was looking out for them instead of using them.

I learned a lot from the aides...they were phenomenal.  Just because a PTA or a PT has more schooling doesn't mean an aide has no education to offer.  I was an attentive learner and showed my appreciation.  When a person feels respected, there isn't much they won't do for you.  

As far as skilled treatment, the golden rule we learned was if the treatment requires the knowledge of a PT, then it is skilled.  So as far as a hot pack, though the actual physical application is not skilled, the determination of its use and prequalification to rule out contraindications is skilled.  A hotpack can be applied by an aide under the direction of a PT who determines where it is placed and for how long it remains and at what point during the treatment it is used.  

In the case of ambulation, many people (aides, family, ancillary personnel) can be taught to safely walk with a patient.  That teaching is skilled, but the walking from that point on is not skilled.  But if the therapist is administering intervention during the walking, then it is skilled.  The therapist may apply manual techniques during ambulation.  Or the therapist may observe while someone else is walking the patient...in this case you would have unskilled walking (by an aide) occuring simultaneously with skilled intervention (the therapist assessing the gait pattern to determine skilled intervention for improvement).    

unfortunately, I have observed licensed therapist providing an unskilled level of service; the reason I point this out is a degree and a license do not guarantee skill; board exams are the best available tool to determine skill, the application of skill is dictated by integrity and a standard of excellence. As far as a PT and PTA billing at a different rate this is Not the case with medicare ie a unit of ther ex bills at the same rate for eigther. I do realize that it is common for contract companies to bill different rates for PT's and PTA's. As far as DPT; Most DPT's I know say it was basically a waste of time and money; they do NOT generate more income and there is no reason to believe reimbursement is going to increase proportionate to the cost of education so if their salary increases it has to decrease someone elses cut of the pie.

Aides do treat in some areas.  Line of site is required or should be done by a P.T.  In some places they are overused but with staffing shortages in areas it is wise to use to the staff available provided they are properly trained.

Defining skilled treatments is difficult.  For instance is a MHP and US skilled?  What about PROM (not bed positioning) to a comatose patient? Is walking someone skilled and what about massage?  Is there a list of what we in therapy define as a skilled therapeutic session?

It becomes a business decision and allowing the aide to treat gets the patients up and moving so they get better.  

A certification may be the way to go or have aides with an AAS and PTA's with a BS and the DPT's.  Kind of like the LPN, RN, BSN,and NP

Jason,

  This is NOT legal and no state practice act would support that stance. If this is the environment you are employed in, it is time at the least to find work elsewhere. What needs  really to  be done  for this practice environmemt is for it to be exposed and stopped. If you continue working there, then you become a part of that and you are actually condoning it. Contact your state's APTA chapter for help/ advice. Good luck.

Yes, aides treating.  

I have worked in several states and in each one aides have treated.  In fact in some states the aides even had their own case load with the blessing of the DOR and Regional Director.

When questioned, the P.T. gives a vauge reference about it being legal and the state practice acts are ambiguous in definitions on the role of support personell.  

I may examine this further.

Aides/tecnicians "treating"????