Name: Theraman Walkis
Alignment: Lawful Neutral
Class: Therapist Assistant
Mordenkainen's Gait Belt of Walking, +2 Fall Prevention
Bigby's Gloves Against Communicable Disease
2 Copper Pieces
Standard Clothing of the Flanaess
For those of you who are familiar with the Dungeons & Dragons gaming systems, I most enjoyed the original basic red box set as well as the first edition of the AD&D system. I always tried to increase my prime requisite, that is, the main attribute for the character played. As PTs and PTAs, what do we consider a main attribute for our profession? Is it intelligence, manual dexterity, a therapist's charisma when speaking with family members? Perhaps strength is what we want if a patient were to lose his balance and for all those max assist transfers we do.
For us in therapy, our prime attributes allow us to complete tasks and they may change throughout the day. In the morning, we may need the strength to get patients up and going. In the afternoon, we may have to dig deep into our memory for the intelligence and wisdom of years in the field to answer a patient or family member's question. By the afternoon, maybe it's our charisma that gets people up and motivated to come into the therapy gym. Our dexterity allows us to palpate those bony prominences and our constitution keeps us above the 85% productivity range every day.
To improve one of these requisites takes practice and devotion to the art of therapy, as well as an understanding of patient dynamics and abilities. Sure you can be intelligent, but do you have the charisma to talk to the patients and get them to the gym? Or how about if you have the dexterity to feel the psoas musculature but not the strength to assist a patient from supine to sit? The skills we have must come together and allow us to develop our whole character, not just one area of it. We also have to know when to ask for help if a patient becomes too difficult or we become stagnant in our treatment approaches.
I will always be a happy adventurer in the field of therapy as long as I don't have to go into fellow ADVANCE blogger Toni's Temple of Elemental Evil. And a special thanks to E. Gary Gygax (1938-2008), the original Dungeon Master, for those wonderful and frustrating adventures in Greyhawk.
There are some therapists who are born to lead and bring a dynamic quality with them during evals and treatment sessions. Others are hesitant to make decisions and will prefer the "wait and see" method in regard to patient care. I have worked with both types.
Since I don't like to hold a PT's hand when discussing patient care and progression, those who are hesitant to make decisions can be frustrating to work with. I would rather work with a PT who will make a decision based on the most recent data available and then make changes during a reassessment. Those who are hesitant to lead should take leadership courses or improve their clinical decision-making through education. I've often stood by while a PT vacillates between several options. When pressed to make a decision, he doesn't, and I'm treating the patient with no clear goals or objectives from the PT who is my supervisor.
When I have made decisions based on my own clinical judgments and presented these to the PT who doesn't lead, I was met with disdain. Therefore, no hand-holding with the PT when decisions need to be made.
There are a handful of PTs I would follow anywhere because I know they have the patient's best interests in mind during every treatment session. They observe me while I'm treating the patients and will make simple suggestions to improve my outcomes because they know if I do well, they will do better. Like a symbiotic relationship, when one thrives, the department thrives.
Those PTs who are hesitant to lead a PTA to better quality patient care should read up on what it takes to be a leader and direct others. Also, read up on what exactly a PTA can do in your state. PTAs have a lot to offer to improve a department and make a success of every treatment, but since we're not able to make completely independent decisions without the PT's approval, we need skilled guidance to ensure a patient's success.
Since I follow the PT's direction in regard to patient care and treatment, I sometimes make suggestions in regard to modalities to facilitate the patient's recovery. Not every PT likes modalities and I respect that; however, if I see the OT providing treatment on a patient we are also seeing, and the OT is using modalities the PT doesn't agree with, what should I do?
I know OTs have different ideas and clinical reasoning behind what they do and why, just like us. But if we take an example of a heat pack and the OT is applying one every day and PT is not, eventually the patient is going to ask why he only gets heat with the OT. The same could be said of cold packs after a vigorous TKA workout. If the PT hasn't indicated an ice modality is okay to use, then I'm not allowed to place ice on a patient's swollen painful knee even though I know it would be beneficial post-treatment.
I understand we shouldn't overlap modalities with patients, but there are times when a patient would benefit from its use. A moist heat pack on the low back prior to activity can do wonders for some of the patients. And if OT provides it in the morning and PT in the afternoon, the patient would probably perform better. When patients ask whether they can have a hot or cold pack, I defer all questions to the PT and allow him to give a clinical reason why PT doesn't provide any modalities but OT does.
Maybe I should just weasel my way into the OT's treatment session for a co-treat because I know the patient will perform better after moist heat. Granted, most PTs will see the benefit and weigh the risks involved and decide ice and heat will allow better patient care and function than none at all. But what about the use of TENS for pain control or ultrasound for tissue adhesions?
If OT decides to treat two days a week and PT is treating for six or seven days a week, there are opportunities to complement what OT is doing in regard to any modality usage. Unless you work in one of those places that clearly divides the patient into different body sections, where only the OTs can work on the upper half and PTs on the lower half. And whenever I come across those places I ask, "Where exactly on the patient is the line?"
I moved, again. Every time I find a new place to live, there seems to be several steps to negotiate and this can cause some problems with me. There are days my joints do not want to move as fast as I think I can and I wonder how I will be in 20 years. And woe unto me if I break a leg because I'll have a heck of a time going up and down steps just to answer a door.
In hindsight, I should have listened to what so many patients have advised me over the years, "Move into a ranch-style home." The patients who have one-level homes seem to glide across the floor during home assessments, show no hesitation when opening the front door, and walk from room to room with confidence and at times flash and flare.
I've seen patients who live in multilevel homes with stairs to enter become hesitant once they're at the top of the stairs, wondering how they're going to open the front door without falling backward while holding onto an assistive device. After a rest in their favorite recliner chair, they talk about how the laundry is in the basement and their bedroom is upstairs. When the subject of a home helper comes up, there are quite a few who aren't able to afford it because of their fixed income.
I had one patient who was cleared to do a home assessment and she had five steps to enter her home with a sturdy rail. She put one foot up on the step and told me she couldn't do it. When asked how she would get in the home after being discharged, she said, "The fire department comes out and helps me up the steps."
"Yes. They told me I could call them anytime to get up the steps."
"What if there's a fire and someone needs to be saved and they're busy helping you?"
"They shouldn't have told me to call them anytime to get into my house."
That was the end of the home assessment and it was reported to the PT. The patient went home anyway and probably called the fire department to get into her house. I'm not sure who is at fault, the fire department for encouraging the patient to use their resources or the patient who didn't want to extend herself and work a little harder in therapy to increase her independence.
No one wanted to treat this patient. He was certainly different and at times difficult to understand. His goals often fluctuated based on his mood and he smelled of cigarette smoke and urine. I treated him though and we got along fairly well. His wife wanted him to be able to walk before taking him home and we achieved that goal with an SPC. It took about two months to get that far, then he hit another patient and was transferred somewhere else. Others told me I wasted time with that patient and he should have been discharged earlier because he was so volatile.
Another patient had flatulence everyday in the middle of the gym and it was often frowned on to bring him into the small area. His goal was to get back home and we almost achieved it but his other medical complications prevented him from discharging. Then there was the patient who had a large wad of chew between his cheek and gums. He was from the 101st Airborne with wounds and stories you wouldn't believe. Those who despised tobacco hated to see him with his cup of tobacco juice sitting on a table while he performed his exercises faithfully in the gym. I never mentioned the effects tobacco has on his body. I'm sure he would have told me where to go if I ever did. And who am I to dictate this patient's norms when I don't have a medal and never parachuted into a hostile territory?
We cannot expect patients to conform to our schedules, mandates and social order of things in a healthcare setting. The situation is foreign to them and they may not understand all the nuances involved in healthcare. Yet, we often expect patient to act and react in certain ways. The homeless patients I worked with have a different outlook than the very wealthy residents and each has a different perspective about their health provider. Our personal standards should be shelved as soon as we walk into a room and interact with a new patient. We cannot let our own personal values and social order dictate whether a patient has the ability to succeed or fail.
Patients expect health providers to keep them from falling, injuring themselves and free from harm. This is not a new expectation but one we should be mindful of. There are patients who have been convicted of crimes and require our assistance to improve functional mobility and activity.
I've worked on a patient in a hospital on the surgical floor who had on the striped prison uniform and an armed guard very close by. I've also been in a locked unit with various prisoners, ensuring they were performing their various exercises to improve functional mobility so they could return to prison as soon as possible. Since several of them were handcuffed to their beds, there was little in bed mobility I could accomplish with them.
In an outpatient setting, I've worked on ex-cons who have done their time and are trying to improve their lives after several years behind bars. I never discussed details of their crime and conviction because it was none of my business and it didn't interfere with their functional progress in therapy. But in a SNF environment, there are patients who live in close quarters, dine together, share stories of their favorite therapist (me), and complain together about medication, food, and me.
The expectation is that these patients are safe and free from worry while in a SNF. They have so much to worry about as far as recovery and getting back to their prior level of function, they shouldn't have to be concerned about their own personal safety.
This government website can give patients and health professionals that extra security to be sure they are safe from harm. A facility should have already done the checking for all admissions and new hires but just in case we could also do a search. As health providers, we have a responsibility to ensure our patients are well taken care of and in a safe environment while recovering from an injury or illness.
Last week I wasn't feeling well. Between patients, family members and other employees, there's a lot that can be passed between people in a facility. Although I use the alcohol gel and wash my hands, there are instances where a virus will find its way to me and I cannot avoid it. I didn't have a fever or any of the "normal sickness" symptoms, I just didn't feel good and wanted to sleep to get better.
A few days later, my daughter became sick with a high temperature and vomiting. She was better after several days, then it was passed to my son. Soon the rest of the family will become ill and the cycle will have completed itself. So, did I bring home a virus from work that caused my family to become ill? Maybe.
I look back and work is not the only place I went to. I went to several different stores and used a shopping cart, I handled paper money and coins that others have as well, and I used an ATM machine. Since I didn't have access to those handy alcohol wipes that kill 99% of every known virus, I wasn't able to wipe off the handle of the shopping cart or the ATM keypad. I could have picked up a virus almost anywhere -- the gas station, opening a door, touching a handrail while going up stairs etc. There is no escaping contact with those pesky viruses.
I could easily blame any sickness on other healthcare workers who come to work sick and spread it among everyone else. I could also blame all those family members who come in and cough and sneeze in the therapy department, then leave. Maybe I'll emulate Steve Martin and not shake hands with people so I don't spread a virus to anyone else and I won't have to risk picking up one from someone either. When I met new people, I could do the forearm bump like he did when he met President Obama. I could also wash my hands more frequently with soap and water and make sure I thoroughly dry them off before doing another task.
Looking over my yearly employment reviews of the past, I often came across standard phrases that could describe any person. I was surprised no supervisor wrote, "Jason is a patient advocate and will question decisions he deems not in the best interest of the patient."
I suppose if someone actually wrote this, I would not be seen as a team player and therefore labeled a troublemaker who threatens the authority and integrity of a cohesive department. Would it be better to go along with the group decision and not make waves that could disharmonize a therapy structure? How about when I was sent to jury duty? When everyone else voted guilty, guess who questioned the validity of the witnesses. Did I do the right thing by questioning certain information and documents? In my position as a health provider, I do the same thing and can be criticized for it.
Overall my yearly reviews of the past have been positive. Of course, there's always room for improvement and I would be shocked if there wasn't. We should always improve ourselves professionally. Often that can mean taking an unpopular stand and being a devil's advocate for the betterment of the patient. Perhaps there are some who would like me to be more complacent and would love to have a totalitarian rule when it comes to patient care and interaction with other health providers. As long as I continue to provide therapy services for a community, patients will have an advocate by their side who can question decisions but will try to work well with others.
When we are documenting patient care and tracking progression of goals, we'll typically chart assistance levels and whether the patient required verbal cues as well as manual cues to complete a task. What if the assistance levels were eliminated from our documentation? Insurance companies would no longer be able to deny services because the patient wasn't meeting their goals based on our own documentation.
I wrote about how one PT eliminated goals for gait because certain insurance companies were discharging patients based on distances walked and not on function. If assistance levels are not documented, patients could no longer be denied services for lack of progress during therapy. The argument for this may seem illogical but with creative goal-writing, it's possible to keep patients on therapy who need the skilled services but would normally be denied by their insurance carrier because of a perceived lack of progress by a reviewer.
This may open up some departments to a fraud alert, however, there has to be an objective measurement that can be reached by the health providers during therapy. A standardized balance test could be used to justify services or strength testing could be used to track progress objectively. I'm not sure how this will play out in some departments since it seems like a new method to keep patients on therapy for a longer period of time. But so far I haven't heard of any therapists being called before a panel and questioned about its practice in patient care.
A recent study of surgeons who had a couple days off work showed an increase in patient mortality rates when they came back to the hospital and performed CABG surgery. This increase may have been from scheduling the sickest patients first, who would not have survived regardless of when the surgery was performed, or from a lack of attention to detail and being out of practice with the surgery team. There was also a noticeable decrease in costs when a surgeon came back to work, which may be attributable to surgeons not ordering tests they normally would after a surgery.
So what would happen after a week or two off in the therapy field? Would we forget details, hand placements, basic exercises? Would we be able to properly educate patients on hip and back precautions or are we so skilled in performing our art that information stays with us forever? After I took a couple of months off in 2004, I struggled with my first few patients. After a week, I was back in full swing like I never left. I did forget some information but that was quickly recovered with a home review of details on the patient's limitations.
I would suspect that time in the field has a lot to do with how we perform after being away for a while. The longer we do an activity, the more innate it would become. Like throwing a baseball or hitting a golf ball. The more we practice and perfect what we do in the chosen profession, the easier it is to remember exactly how to do it and how to respond when we need to adjust and adapt to changes.
When I had surgery and took a three-month leave, I actually did more research into what we do than I had ever done before. I looked at evidence, patient responses to what we do, muscle actions, almost anything that dealt with our profession so I could better understand patient perspectives and what they look for in a therapist. The time off was well spent for me and I didn't miss a beat when I came back to work.
I get tired of reading and hearing about the audit triggers in our profession. It's part of the business we're in and if people don't want to risk an audit, they shouldn't be in our field. It's like an audit from the IRS -- you don't want one, you don't know why you were chosen, but if you can back up all your data and information it shouldn't be a worry.
Multiple design changes have improved our electronic documentation, which better shows the skilled nature of what we do. If auditors really want a job to do, they should go back three to five years and read all the handwritten SOAP notes in clinics and facilities to figure out where the skill was and whether the treatments were justified. That's where the big repayments are for CMS.
Fortunately, for now, some of the audits have stopped (I heard they ran out of budgeting money) so businesses should have a short relief. But even so, if we're able to clinically justify what we do and why we do it, there's no need to be afraid of an audit. Good clinicians should have better data to support treatments and justification of time needed to get the patients back up and moving.
What I see in some facilities is the therapists doing the minimal amount of work and documenting a safe amount so they don't trigger any audits into what they do and why. Therapists may be afraid to try something outside of their comfort level, so the half effort is the safe bet to hide under the radar of scrutiny. If we're not able to clinically define an activity and give a true justification as to why we are or aren't doing a certain procedure, then we shouldn't be doing any therapy on any patient.
Too many therapists will take the safe road so they don't have to explain themselves to anyone in regard to what they're doing. We get paid a lot to do what we do and if we can't, won't or aren't willing to explain and justify our services to those who pay us, maybe an audit is just what we deserve.
When a PT is in the facility, that person becomes the de facto supervisor for me. That means I can make his day very easy or a nightmare. I could easily present him with a long list of issues and clinical concerns that I feel need to be addressed with each of the 10 patients on my list or I could wait until the regular PT comes back and then discuss the issues with him.
Any therapist or health provider who tells me they don't know the patient, yet they are the supervising provider for that patient's care is a danger to patients. If one wishes to be a supervising provider of care to patients, that person should at least become familiar with each resident he is in charge of. If a patient is injured because of negligence, it's usually the supervising provider who has to explain his role and the role of others regarding why and how a patient became injured. A statement of, "I was filling in for the regular supervisor and didn't know the patients" should go over real well with a jury; it seems like a legitimate excuse.
The clinical portion of what I do is to report any changes in condition or relevant data to the supervising PT so he can be aware of any issues that need his skills and attention. If I fail to report data, then I too as a PTA could be directly responsible for a patient injury or death. What a supervisor does with this data is not for me to decide. I report results of testing and the condition of patients but it's up to the PT to interpret that data and make appropriate decisions. Allowing a "fill-in" supervisor to make these decisions doesn't seem right, but ultimately that person is the responsible party for every patient on the therapy list. And some places consider the evaluating therapist the supervisor of that patient, so trying to get another therapist to make a clinical decision regarding care can be difficult.
I'm not sure if there's a way to adequately resolve who is the actual supervisor versus the acting supervisor for patients. Either way, if a person is in charge of patient care, he needs to "therapy up" and make a decision.
Disagreeing with someone is not something new for me. I will freely voice my opinion (usually supported with data and anecdotes) to anyone who will listen and objectively discuss an issue with me.
In the case of discharging a patient from therapy, the decision is ideally the PT's; however, as a patient advocate I have the responsibility to ensure patients receive the best care to maximize their potential. No health provider has a crystal ball to determine whether a patient will advance any further from his current functional status. There have been too many incidences where patients do progress and eventually go home when most providers had given up hope.
All clinical decisions should be based on educated evidence (and supported by data), not on whether a patient and family is liked or disliked. A decision to discharge a patient isn't necessarily about whether the patient will make progress in the future. It's about whether he is making progress today with therapy intervention and if that intervention so skilled, only a therapist is able to provide the care. If one wishes to debate a discharge, I'll be happy to quote CMS and state regulations and if a therapist doesn't like the rules, then he shouldn't play the game.
The phrase, "I'm the PT and I make the clinical decisions regarding patient care," means absolutely nothing to me when I'm the advocate and make a couple of calls to the ombudsman, state therapy board, and Office of Inspector General. I'll allow the experts to determine whether discharging a patient is equivalent to abandonment of care and I would love to see the data a therapist presents while trying to defend this.
When United Parcel Service (UPS) began to collect data on drivers and their trucks, there were some improvements. These included no more key locks in doors because they slowed the drivers down and use of a computer clipboard that also held data on how the truck was loaded and the best routes to take to deliver the packages. Productivity went from 90 package deliveries a day to 120. The sensors in the truck also monitored how often drivers were backing up and at what speeds they were going. These changes increased their productivity, enabling them to deliver packages and complete their jobs efficiently throughout the day.
In the hospital and SNF setting we often backtrack because a patient isn't ready, get delayed by nursing because medication was not given, or have to leave a treatment because family has arrived and the patient asks (demands) we end so they can visit. These things kill our normal productivity levels, so maybe we can learn from UPS.
Putting sensors on a therapist seems feasible to track movements throughout a facility to see how many times we try to see patients. The sensors could monitor when we are in contact with a patient and exactly how long we spent treating the person. This information could be relayed to a number cruncher, who could then set up our schedules and let us know the best times to see patients and quickest routes to get to each room. Our productivity should improve based on this model.
Except we are dealing with humans who are ill and there are too many variables to contend with. But it might be worth an attempt to have the sensors placed to prove we are on the move all day looking for patients to work with. When the number crunchers see that we are moving all day, maybe the productivity demands now in place will go away. Then we can concentrate on our treatments and not how long we're in the facility doing our job.
It's not like you can plant some therapists in a gym and suddenly the department is busy. To adequately have a therapy program develop into the future, the way business is conducted today has to change. When looking at more cuts in reimbursements, hiring another person doesn't seem logical, but it is.
A good PT aide will get patients up and ready and will have the patient in the gym as you walk through the door and clock in for the day. If therapists are scheduled to come in a half hour apart, the PT aide will have the first person ready to work as the next therapist walks in the door.
And each successive patient will be promptly ready to participate while the therapists waste no time in the gym. If all goes according to plan, therapist productivity will increase because they won't have to locate the patient, get multiple refusals, talk to three nurses to medicate each patient, and locate linen and clothing items.
To grow a program, you also have to let some people go. One therapist can deflate the morale of the whole department with negativity. Letting the person go is a difficult decision; however, if a therapist is negative maybe the place he is now is not the best setting for him. By freeing him to explore other options, maybe he can become happier.
If a facility is actively involved with all things therapeutic, there should be no end to referrals from nursing staff. OT and ST referrals should be apparent with dressing, bathing, eating and swallowing pills on a daily basis. Nursing staff should be addressing these issues and asking for orders if a patient has any apparent change in status. For PT, every fall should get a referral. Every patient who has ended up on the floor, whether from a staffing error or an attempted self-transfer, should be seen by the movement specialists, us.
If there hasn't been a referral from nursing in a week, something is wrong. In a SNF there are numerous missed opportunities for therapy to intervene to prevent falls and improve ADLs, thus helping nursing reduce the amount of assistance needed to transfer patients and get them ready for the day. Not every referral will be appropriate but that's why we are paid so well, to make clinical decisions based on a patient's functional limitations.