I was working with an elderly female on transfer safety. After about 20 minutes, she understood the sequencing involved in standing up from a wheelchair. This was important -- she had fallen multiple times because she had forgotten to lock the brakes on the chair. I was satisfied that she was safe and we proceeded with other aspects of mobility.
The next day we were at square one. She didn't understand the sequencing involved in scooting to the edge of the chair, locking the brakes, pushing up, and the "nose-over-toes" verbal cue. I asked myself whether the 20 minutes was wasted time the day before and if I should spend another 20 minutes that day to do the same treatment. I chose not to spend the time instructing her with sit-to-stand from a wheelchair. We focused on LE strengthening, standing balance in the parallel bars, and a little work on endurance activity.
On the third day, I reviewed the sequencing and safety with sit-to-stand. She didn't get it. I wanted to spend more time on this but realized she may never get it in the time allotted to her. We focused on gait and LE strengthening with the hope that her strength would improve so she could stand up easier. Days four and five were similar, based on the notes I read by other treating therapists. On day six she scooted without cues, placed her hands on the arm rests but was unable to weight-shift effectively to stand up.
By treatment day 15, she had the sequencing down but couldn't stand up without falling backward into her wheelchair. I elevated her chair to no effect; she did sit-to-stands from the mat table with it at various heights. She could talk about why she couldn't stand up without falling back (foot positioning), but wasn't able to put it into practice. So I moved on with her treatment and focused on standing balance and increasing her leg strength.
Treatment day 30 brought no difference in her ability to stand up. She could get the whole sequence perfect except the part that took her from sitting to standing. She pushed with her legs, heels dug into the floor with the toes in dorsiflexion. She wasn't able to get the toes down and the weight shifted forward over her center of gravity. She was stronger with better dynamic standing balance but this may not make much of a difference if she isn't able to stand up from a sitting position. She was discharged home shortly after this because she could walk 300 feet with supervision and her LE strength was 3+/5. Basically, she met the goals for the insurance company so they no longer paid for her care.
I was at the grocery store a few days ago. There was one cashier and a long line of people. One person told the cashier what she already knew, "There's a line going out the door." I stood silent waiting my turn. The guy behind me seemed impatient and was making grunting noises while holding a case of beer. Clearly he had somewhere important to go.
Then it occurred to me, the same people who are so impatient at the grocery store will stand in those long airport lines, saying nothing for fear of being denied access to flight service. They also sit and wait in an MD's office reading a magazine awaiting their turn, sometimes for over an hour. Why are people suddenly impatient when they have to wait for certain services and not for others?
Some of the patients I see get tired of waiting for me to show up for therapy. I explain to them we want to see people at different times of the day to better assess how they move. For instance, if I come in at 7 a.m. and have a patient walk to breakfast, I'm assessing balance and mobility in the morning versus seeing that person at 4 p.m. after he's been up all day. I tell patients that when they get home, they'll need to be able to get up and move any time of the day.
I further explain that it's normal for them to get up out of bed in the morning, get dressed and walk to the kitchen for breakfast. If I see patients in the late afternoon, I explain that we're assessing energy level and mobility to ensure they're safe in their home if they need to get up and move at that time. I go on to tell them if they have an MD appointment in the late afternoon, they'll need to be able to safely navigate out of their house, into a car, to the doctor's office and back home without getting too fatigued.
Perhaps the people who complain about waiting for services should be denied access to them. The airlines and TSA agents can deny access to flight services without warning because there's a perceived threat. Why shouldn't other service providers have that same right when a person becomes angry about slow service? If I complain about the two-hour delay in an emergency room, should they be able to deny me access to their care? If I complain about the same time delay at the airport, I might not be able to fly to my destination.
People who complain are strange. There are other modes of transportation, there are other MDs, and there are certainly other grocery stores they can go to. Yet people will complain about the services, the time wasted, and of course how much everything costs. But, before I forget, there are other therapy providers who'd love to evaluate your patients if your wait time is too long, so try not to let the patients wait because there are other SNFs and outpatient facilities that will get the person seen that same day.
The patient was in bed, hardly able to move. I was told by the nurses he couldn't move his legs and required max assist of two with all mobility. The PT and I got together and formulated a plan to increase his tolerance for being upright. We started slow with sitting at the edge of the mat table and then progressed to the standing frame. We were using a slide board initially, then gradually progressed to stand-pivot transfers with max assist of one.
This patient had a good support system with family but was viewed negatively by the nurses because he wasn't able to perform bed mobility and transfers the way they wanted him to. Our therapy team continued to work toward the patient's goal of going home within a three-month timeframe. He was hopeful we could work some sort of magic on him to get him moving again. And we did.
As his tolerance in the standing frame increased, he was progressed to the parallel bars with max assist of one and began pre-gait activity. The PT had to continually change goals because the patient's determination to progress was phenomenal. About a month before going home, he was walking short distances inside and outside with a FWW and CGA. He still required minimum assist with bed mobility and sit to stand. That was easily corrected within a week or two with progressive activity and strengthening.
When he was discharged to home, he was walking with an SPC about 50 feet with CGA and a FWW, going 100 feet with CGA-SBA. This was a man the nursing staff had almost dismissed as being in long-term care for life. By his determination and hard work, we achieved what he initially set out to do -- go home.
The man came to see me three months later and said he was still walking at home with a FWW but got fatigued easily so he used a wheelchair for longer distances. About a year later, he came to see me again. He walked up the sloping sidewalk with a family member and sat down carefully. I almost didn't recognize him. He had regained some of the weight he had lost, carried no assistive device and required no assistance with transfers. At that moment, I once again realized why I do what I do.
As a side note, the nursing staff didn't change their ideas about what therapy can accomplish. If anything, the patient's progression and eventual discharge from the facility seemed to irritate some of the nurses, who openly hoped our team of dedicated therapists would fail. I told the nurses we can't fail unless we try to get people home and even with that, we can at least make the patients stronger so transfers and mobility are easier for them.
From the moment we set foot in a facility, we're on the move. We're expected to be productive throughout our day by billing patients for our services. We make it rain for the facility but aren't always recognized for it. When I see every other department in a healthcare setting, they usually take up space and use resources that cost the facility money.
Housekeepers use chemicals to clean a facility, nurses use syringes and bandages, the kitchen staff uses up food products. They don't directly contribute to the financial viability of a facility. I'm not saying they're not needed, they are. Without housekeepers, the facility will become dirty; without the kitchen, the patients wouldn't eat a balanced meal; and without nurses, the patients wouldn't receive their medications. But none of them contribute to reimbursement of care for the people who stay there. Well, nurses can, but the reimbursement is minimal when compared to what therapy is able to contribute.
Now let's take a look at what therapists can do. They can bill for Medicare reimbursement at the ultra-high level, which pays very well. Some facilities encourage this and even insist on the PT making every patient an ultra-high rehab candidate. The PT can comply and bring in even more money to the facility. The facility is happy because now there's an abundance of reimbursement money coming from Medicare.
Medicare will eventually get wind of this and do a little investigating. The facilities are essentially blameless because they don't have a PT license. Even if the facility encouraged the higher reimbursements, it's the PT who made the recommendation of care for the patient. And since the PTAs are under the PT's direction of care guess, who gets stuck taking the blame for any investigation of potential fraud? That's right, the PTs.
So while you're hard at work and making money for the facility because the other departments don't, make sure you're giving the patient the appropriate RUG category based on evidence you have on hand and not for financial gain.
Years ago, I began working at a large nursing facility that also had an assistive living complex attached to it. The place was immaculate in every detail (except one), had a large library and two fancy dining rooms. There were multiple levels with stairs and elevators located at the end of the halls. To get to the therapy room with patients we had to take them in a wheelchair to the elevator and descend into a subterranean level. I felt like a level-three cleric from the game "Dungeon and Dragons." I wanted to cast a light spell to illuminate the whole area.
The therapy room was very hot in the summer with poor air circulation available. To achieve privacy, we put up portable dividers around the patients and tried not to talk too loud because of the faint echo emanating from the chamber. On my first day there, I was locked out and no one seemed to have a key, including the nursing staff, because nobody else went down to that level except the therapists. One lone housekeeper who spoke very little English gestured for me to follow her to the stairwell. Hidden behind a step was the key to unlock the therapy gym. The walls were bare, the ceiling low and the ugly berber carpet didn't add to the décor.
Later in the morning, I went to another facility that was straight out of the early 1960s. It didn't have a gym. The therapy space was the hallway or if I needed the parallel bars, I had to unhinge them from the wall in the dining area. Next to the parallel bars was one of those big steel wheel things attached to the wall for shoulder ROM. I had never seen one up close before and I stared in awe of it for a brief moment. I felt like I was part of history when I touched it and heard it creak. The housekeepers weren't always there before me so I often had to step over spills and food items. When I forgot to attach the parallel bars back to the wall, I heard about it from everyone in the facility. I was thoughtless and thankless to leave the area such a mess for others to clean. Big sigh with rolling eyes as I wandered away.
Physical therapy services can bring in money to a facility to improve structures, hire more staff and fix items that require attention. Every once in a while, the therapy staff will require equipment to be able to serve the clients better. There should be no haggling about therapy equipment since we sometimes work in conditions that are no better than a shanty town.
I've spoken to patients from many countries and places around the globe. Sometimes it's like watching the movie Billy Elliot or trying to understand the lyrics of South African rap-rave crew Die Antwoord. I'm aghast, did they just curse? I wouldn't know because they speak so fast my mind can't keep up. It sounded like a curse word but there was an "O" sound instead of a "U."
That's how it can be when we're explaining details or a procedure to patients. Do they really grasp the concepts I've just explained or are they simply nodding their head in agreement? Pictures can help and sometimes I'll draw to better explain details. This is more for the family's benefit when I realize the patient is unable to follow what I'm talking about. Gesticulating is an art and if you watch enough Charlie Chaplin movies like me, you can get your point across without saying a word.
Talking slowly with appropriate pauses is usually the best way for me to communicate with patients. Since they've had so many changes in their life in such a short period of time, they may not be completely focused on me and what we're doing. If the gym is busy, patients can easily become distracted by other conversations going on around them. When this occurs, I'll have the patient get up and walk outside the gym in the hallway or even outside the building away from the distractions.
Keeping concepts simple for THA patients with phrases like, "Don't bend, twist or cross your hip," instead of the more detailed explanation that's on their handout can more readily be understood by them, especially if they have a memory deficit. Long details of what we do and why can often be placed aside as well, so we don't confuse the patient during the session. How about you, what is the best way for you to communicate with the patients you see?
Where is the objective data regarding gait distances in hospitals, rehab centers and SNFs? What I mean is, when we write down a patient used a FWW and walked 100 feet, where is the data to prove the distance was exactly 100 feet? Did someone measure the distance and quantify the data and calibrate the measuring device to ensure its accuracy? Maybe the distance put in charts are guesstimates from therapists and there's no data to back up the claim about how far a patient actually walked.
I think this may qualify as part of the evidence-based practice that has been in the therapy news lately. What evidence do we have that the distance across the gym or to and from the bathroom is what we've written down? This is similar to having a new grad and a seasoned therapist measure a knee joint using a goniometer. The range is close but not exact and shouldn't we, as therapists, be exact in the data we put in a medical chart? If the gait distances we've been writing in the charts are wrong, wouldn't that be against the law?
Therapists have used a variety of ways to measure how far their patients have walked. Some use the tiles on the ceiling and floor, while others use their own step lengths, but none of this is exact. If a patient stops three-quarters of the way through a floor tile, do we round up the distance walked? If we do, we are falsifying data in a medical record. I'm not sure how using your own step length would work outside on uneven surfaces. Step length can also vary significantly between two therapists, so this type of measuring is totally inaccurate. Please, someone tell me there's more than one place that has measured its hallways for exact distances.
We often see patients three to five days post-operatively in a SNF. The ortho docs, who send the patients to the facility, expect certain outcomes while the insurance companies have outcomes and agendas of their own. This creates some difficulty in managing the patient from a therapy standpoint.
Most surgeons are somewhat familiar with what we do and some even send their protocols with the patient after surgery with the expectation we follow them closely. Insurance companies want to know when we're going to discharge the patient within days of arrival just as the "Phase Two" protocol is beginning. If we discharge too soon, the surgeon will be upset and if we keep the patient on caseload, the insurance company will put pressure on us to do as it wants.
In the SNF, we often focus on functional activity that will make the patient more independent in a home environment. But not every facility has access to the equipment it needs to adequately progress the patient according to the protocols established. Foam pads, pillows and corrugated cardboard tubes often replace balance machines and bolsters. If the patient has several 8-inch steps at home, we don't always have time to progress from 2-inch to 4-inch to 6-inch steps over a 16-week period of time. Insurance companies and MDs want results but their timeframes represent two different worlds.
This is my suggestion. All the insurance companies and MDs need to have coffee and discuss what type of equipment each rehab facility and SNF needs to have for their patients to achieve success during therapy. The initial cost would be high but the cost savings would be enormous because the patients would have access to every conceivable piece of equipment to handle any type of restriction they may encounter.
As of right now, there are "rich" facilities and "poor" ones. I wonder if the facilities with all the fancy equipment have better outcomes than the ones that must reuse the elastic band on every patient and have those tiny metal balls come out of the 2.5-pound weights with each short arc quad. I've worked for both types of facilities, as well as some in between, and found that therapists as a general rule can adapt to almost any therapy gym, whether it's an old maintenance closet or half the dining room, which is shared with the activity department.
I just wish the insurance companies and surgeons were as flexible as us. Maybe they should do their jobs in some of the environments we do ours in; they wouldn't last a week.
The patient I was supposed to see was in a RUG level that paid very well. He had some complications that prevented him from participating to get the full minutes for several days. On the patient's assessment day, I spoke to the nurse in charge of his care and she advised me not to see him that day due to a change in status, with a decline in health and inability to participate in functional and meaningful activity, i.e. ADL care.
Because I know this nurse and her assessment of patients is very good, I decided not to see the person that day based on this information. Then I heard someone say, "The nurse can't do that; she can't make that determination." I was puzzled. When is a nurse not allowed to make an assessment of a patient based on a change in status? After all, the nurse is in charge of the patient and his care while on duty and there are times a nurse can and will interrupt therapy to make a professional determination whether the patient is able to participate in any activity. Countless times after taking blood pressure, pulse and SpO2, the nurse will advise me to leave the patient alone for a while.
When people who make the financial decisions decide to RUG everyone at the ultra-mega-big reimbursement level, the expectation is patients will be able to tolerate that level by any means necessary. The decision-makers become upset if the patient isn't able to tolerate the activity and their anger and frustration is directed toward the PT or PTA who didn't get the minutes. In the case above, the anger was directed toward a professional assessment the nurse made based on the patient's overall decline in functional status.
Are professional assessments and determination of care being slowly eroded by those who make financial decisions? I don't know, but if a nurse advises me to hold patient care, who am I to disagree with her professional assessment? She certainly doesn't make a determination on safety with assistive devices, exercise tolerance and gait deviations -- that's our area of expertise.
I worked in a clinic that reused TENS pads. Cross-contamination anyone? I understood the financial aspect of it; the pads were expensive. But to jeopardize patients and expose them unnecessarily to a potential infection didn't seem worth it. Didn't a dentist recently get in trouble for not completely sterilizing equipment? I wonder what microorganisms lived under the pads after multiple patients had them against their skin.
I often wonder about the blood pressure cuff and the finger pulse oximeter too. How often are they cleaned? Only when visibly dirty? Microbes are small and we can't see them with the naked eye; are the nosocomial infections directly related to these types of vectors? Perhaps infections are directly related to the use of our gait belts. How many patients have they been around? When was the last time they were washed?
Plastic belts would be easier to clean between patients. It seems the cloth belts would more easily pick up food particles, fecal material, and how many times have patients stuffed their used tissue into the gait belt because they had no pockets or long sleeves? And please do not get me started on the use of hand putty. You can visibly see the color change when a patient is rolling that around on a dirty table. I hope clinics aren't reusing it on multiple patients; think of the liability issues you could have if a patient becomes ill.
We could pass the cost on to the patient. If they want new TENS and interferential pads, charge them for it. If they want a new gait belt, put it on their bill. And putty should be cut and placed in a small container with the patient's name clearly marked on it. I just think of the airport screener tubs. How many shoes have been placed in those tubs? And then I see people place their phones, jackets, baby toys into the same tubs, yuck. I have yet to see the TSA clean them out. The tubs probably have to be visibly dirty before they get cleaned. I feel like "Monk" sometimes, please pass me a wipe.
I've read about social security running out of money, reduced reimbursement rates, a decrease in the number of qualified providers, quicker discharges and supposedly better recovery after surgery. Where does this leave everyone?
Social security has to be there to provide care for the blind and disabled; a reduction in reimbursements will always strain the health care system but will not put it out of business, there will be ways around the reduction. I can see a decrease in the number of qualified providers because there are more lucrative ways to make a living than doing therapy and certainly more opportunities out there to graduate with less debt. Patients will always be discharged before they and we want them to be, but that's life. Recovery rates are faster as technology improves in surgical techniques. How many remember that a THA stayed in the hospital for two or more weeks?
What I want to know is when will insurance companies start paying for replicated organs and tissues? There is technology that can replicate organs but I've yet to see any insurance company pay for the new technology; they probably consider it experimental like they do with taping a joint, despite any evidence provided. Maybe we could replicate me so I can stir up twice as many people with my ideas. I could irritate twice as many organizations and have twice as many complaints against me. And in regard to any complaints against me, I'll paraphrase rapper Chief Keef, "That's that stuff I don't like."
As for the future of healthcare, that's still an unknown. I see changes that are slowly eroding how we do business and I see that eventually we'll comply with how the rest of the world performs healthcare. Imagine how easy it is for an insurance company to deny payment just because you're injured and out of the country. Why do our current healthcare policies stop at the US border? The insurance industry would probably accept my check drawn from a foreign bank but may not reimburse for care provided in a foreign country.
I currently pay more than $600 a month for medical insurance for a family of five. I also have co-payments with every visit. The bills are unending sometimes. It would be nice to not have a medical bill and still have the care my children require. I can see this coming but very slowly and maybe not in my lifetime. I can still dream the dreams that no mortals ever dared to dream before.
We're all aware of the patient's bill of rights regarding treatment in a healthcare setting. They have the absolute right to refuse treatment and I think we should encourage them to invoke that right but with some consequences attached. First, we should provide a menu-type selection of which RUG level they'd like in regard to therapy. They could choose between 150 minutes and 720 minutes of therapy in a seven-day period beginning on the day of admission. This will allow patients to decide how much therapy they want. If a patient isn't able to decide, then a person of authority can decide for him.
The second thing we need to do is educate the patient, based on the current index of evidence-based practice, about the benefits of physical therapy. The patient could then make a very informed decision about how much therapy he actually wants and needs. This will take the stress off PTs and PTAs in regard to encouraging patients to participate in therapy.
And thirdly, if a patient is not compliant with his own decision, we need to discharge him immediately. Why should we keep a patient on caseload for a week or more and keep getting refusals? The patient can go home and refuse treatment rather than being in a facility and refuse care. This will free up a bed for a person who wants therapy.
These ideas may not be popular but they allow the patient to make the decisions rather than the PT in regard to RUG levels and care needed. If an MD prescribes a course of treatment and the patient is non-compliant, the MD will educate the patient on the reasons why it's needed and then the person decides if the treatment is worth the risks. Oncologists do this frequently.
Prior to admission into a SNF, the hospital can provide information to the patient and family members so they can decide on a proper course of treatment. If a person decides to go home rather than to a SNF, care can be provided but with an understanding that any equipment needed (elastic band, weights, gait belt etc.) will need to be purchased by the family and patient. This will allow a patient to recover in the comfort of his own home but with limited resources available.
We can agree that patients should make decisions about their care, and we can agree that patients can refuse treatment anytime they want. I'm advocating that we encourage their decision-making based on information provided that will help them and their families find the best course of treatment for themselves. Every decision has a consequence and the consequences don't always have to be negative.
According to Medicare, I'm able to work under the direction of an MD. Imagine what that could do to the outpatient market in some areas. As a PTA, I could set up a clinic, hire an MD and begin to provide care based on the MD's plan of treatment. Of course the state rules would try to prevent this but I'm pretty sure federal law trumps state law any day of the week.
I didn't see any particular rules in regard to having an MD "in the room" when I'd provide care to a patient; maybe that's only useful if I'm under the direction of a PT. I'll have to do some more research before my hypothetical clinic opens and the doc and I put you out of business.
The MD would be the one to initially see the patient and then I could perform all the treatments while the doc looks in occasionally to make sure we are making bank. With a reduction in reimbursement, the doc could see the patient, then immediately send him back for some TENs, massage, biofeedback (this pays a lot in a clinic) and exercises. All I'd need initially is enough room for a universal gym, a combo laser/e-stim/ultrasound machine and maybe a treatment table. Cost would be minimal and my proverbial doc and I would be in business.
If I give up my license as a PTA, there wouldn't be much a state board could do. And if I hire a retired MD who wants to sit around an office for six to eight hours a day doing paperwork and assessing patients, this could be quite lucrative for both me and the doc. The rules of supervision would no longer apply and I'm pretty sure I could expand my imaginative business into the realm of home health with little difficulty.
Just imagine a PTA with an MD as a supervisor; the outpatient clinics will fear me and with the doc's connections in the community, patients would flock to the clinic. Who wouldn't want to be assessed by an MD and treated under his direction? An outpatient clinic with an MD on staff overseeing the treatment -- yeah I think the patients would come, and there wouldn't be a whole lot anyone could say about it.
We were treating a patient for several weeks and making some progress toward her discharge. There was a family conference and it was decided, with the patient's input, that she'd go back to her apartment. For the next couple of days, she seemed not to care where she went to live despite our encouragement.
When a family member cornered me, we spoke about the patient's progress and the decision about having her go back to her own apartment. Then the family member said, "Off the record, how do you think she is really doing?"
I've been in therapy long enough to know there is no such thing as "off the record" when it comes to family and what we say to them. So I played diplomat and said very little regarding what I thought. I stuck to the objective data of how the patient was doing with therapy and the decision about going back home. I could have told this family member to leave the patient where she was for another month to get stronger but I thought the patient may have wanted to go home and money was an issue. I suspected the patient was withdrawing so she didn't have to make the tough decisions about whether to go home or to stay. She probably would have accepted either decision as long as she didn't have to make it.
There's also the detail of what the patient tells me versus what she tells the family. Sometimes it's two completely different things. When this happens, I turn it over to the people in charge and allow them to haggle over the details of where the patient wants to go. My job is to do therapy and see that the patient gets stronger to function more independently.
What do families expect from us? Should we tell them their mom is a pain to work with and please take her home immediately because everyone is sick of her? No. We present our data as objectively as possible and based on this input, the families can make the final decision. There should be no "off-the-record" patient progress; everything we do in therapy should reflect how well the patient is doing functionally and how much assistance the person needs to attain the independence she's striving for.
As I was perusing the various state board websites, I noticed several states offered licenses to PTs but required the PTA to have a certificate to practice and provide therapy care. I've been awarded certificates in achievement, performance and even have one as a geriatric wellness specialist. My children come home from school with certificates in the spelling bee, math, science etc. But state boards that give a certificate to the PTA and a license to the PT need to do some research about licensing and certification of professionals. Even a certified nursing assistant needs a license to provide care and these state boards seem to be saying that because I'm a PTA, I'm not worthy of becoming licensed in their state. Instead, I get a certificate or credential (of achievement or something like that) so I can provide care to patients.
This is part of the inconsistency when it comes to licensing the profession of therapy. Do the state licensing boards talk to one another and ask what each one is doing? Apparently not. I can access each state's rules and regulations via the Internet and point out their flaws and sometimes outdated regulations. Maybe I should be the U.S. therapy licensing czar and set these people straight on keeping things consistent with regard to the profession. Even the reassessments by the PT change depending on which state you live in. Some states require a PT to see the patient once a week, some every 10th visit and others every 5th visit. As a consumer of healthcare, this can be confusing.
If every PT and PTA in the country called their state board and governor to ask why there are inconsistencies in each state regarding licensing, visit requirements and professional regulations, maybe there would be some changes. Especially for PTs and PTAs who are licensed in multiple states, wouldn't it be nice to not worry about whether a patient was seen four times versus nine before a reassessment is required?