The patient's SPO2 was 81%, she had shallow rapid breathing and a heart rate of 135. I looked and noted her oxygen tank had run out. After replacement of the oxygen tank and cues for deep breathing, her saturation returned to 94%.
This got me wondering what we could do to help prevent patients from running out of oxygen when using a tank. Especially if the tank is attached to the back of a wheelchair where they're unable to see the dial. I first asked a nurse if we could place a sign that said "Check O2" on the back of the wheelchair. This could be a reminder for staff to check the tanks when walking by. That idea was nixed. Then I thought, "Why not make neon-colored oxygen tank covers so they are highly visible?" Those blue and black covers blend into the chair and are like background noise, barely noticeable.
Since I don't have the time and material to make the covers myself, I'll allow another manufacturer to do it. A warning system would also help, where the tank would issue a beep once the dial reaches the red mark. This would help the patient and staff become more aware of when it's time to change the oxygen tank. But it would also create more noise pollution in some facilities and staff may begin to ignore the beep when it becomes a regular occurrence.
Educating patients to be alert when oxygen is running low works to some extent but if a patient is confused or has memory deficits, education wouldn't work. Maybe a color-coded dot placed next to the patient's room and on his wheelchair could alert staff to become more diligent. One nurse told me, "We can't babysit patients all day to make sure their oxygen tanks are full." I agree that healthcare workers aren't able to stand around and monitor O2 tanks; however, this delves into a patient-safety issue and needs to be addressed. It seems to be a recurring problem at several facilities where I've worked and has yet to be figured out or discussed and addressed in regard to neglecting a patient's medical needs.
I step into the patient's room and immediately my billing clock begins to tick. After introductions and some small talk of who I am and what I would like the patient to do, I have 54 minutes left. We begin with supine LE exercises with instruction on what the exercises are for and which muscles are involved for an increase in functional mobility. I then assist the patient to a sitting position via log-roll technique. She sits there feeling a bit lightheaded while I do some patient education on pursed-lipped breathing. Her saturation is 89% but quickly increases to 93%. I have 42 minutes left.
I instruct the patient to do some seated LE exercises with patient education on the benefits of increased activity and ease of mobility. She stands with no reported dizziness while I give verbal instructions on safety and sequencing using the FWW. Standing LE exercises are next with verbal and tactile cues for center-of-gravity training and compensatory techniques to maintain balance. A little pre-gait activity and the patient requires a sit rest at the edge of the bed. I have 28 minutes until I see my next patient.
We go for a walk out of her room, turning to the right down the hall. I check her saturation and it is 92% during gait activity. I'm giving her verbal cues for heel strike and to increase her step length and width to increase her base of support to reduce her risk of falls. After 100 feet, she needs to sit and rest. I check her saturation again when she is sitting and give verbal instruction on pursed-lipped breathing. Saturation is 90%. When she's ready to stand, I give verbal instruction with sequencing and we walk toward the therapy gym while I occasionally give verbal cues for heel strike. She sits on the mat table and her saturation is 93%. I have 16 minutes left.
After a short rest, I have the patient ascend/descend three steps several times, first using both hand rails and then using only one. As we head back to the mat table, she reports that she is getting fatigued. I again instruct with the breathing technique and check her vital signs. Blood pressure is 128/71, pulse 89, saturation 92%. There are only 10 minutes left.
We begin the trek back to her room and I have her do some balance activity while she's walking so I can assess dynamic mobility. There is one loss of balance but she doesn't report dizziness or lightheadedness. When we get to her room, I assist her to the bathroom. There is no nursing assistant readily available so I wait until she is done (non-billable time here since there is no line of sight of the patient). She pulls the call light indicating she is done and I walk her toward a chair in her room. One last time I check her saturation (92%) and attach the call light to her chair and move the tray table within reach. My time is up so I say goodbye. Then the questions begin.
Eight minutes later I walk out of the room in search of the nurse and the social worker regarding the patient's concerns. It takes a total of 6 minutes to locate both and briefly explain what the patient's concerns are. I have gone over my 60-minute allotted time by 8 minutes. Those six minutes searching for people are not billable. Multiply this by the eight people I see a day and there are 48 minutes of unaccounted, non-billable time and 64 minutes of extra billable time per day. My 8-hour workday just turned into almost 10 hours. Multiply this by five days a week and I'm in overtime by Friday morning.
Documentation is extremely important regarding patient care and services delivered. We should be able to justify our services in writing based on the plan of care established. When a patient has a complaint regarding pain, a new injury, or other symptom, writing "nursing notified" in a hospital or SNF setting may not absolve us from complete patient care responsibility.
If notes are reviewed, a question may arise regarding what the therapy department has done to address this, and specifically, the evaluating or supervising PT's reaction to the new symptom the patient has experienced. If the patient's reported symptoms are documented, were they addressed in a care plan meeting or discussed prior to a discharge from the hospital? And what is the end result after the meeting regarding the health of the patient?
Perhaps we did document and discuss an issue regarding a change in status of the patient with the nurse on the floor but that nurse didn't document the conversation in her notes or contact the physician regarding the patient. Now, which health discipline do you think will be believed when the chart is reviewed during litigation?
I've seen nursing notes indicate a patient has "no c/o pain," but during therapy the patient rates pain at 8/10. I'm sure when the nurse documented this the patient was supine, not moving, and had previously been medicated. As soon as the patient begins to move, the pain starts and that's where our documentation should clarify a patient's pain in relation to activity level to alleviate this discrepancy.
The same can be true when a nurse approaches us about a patient's pain level or movement anomaly. If she documents that she has discussed the issue with the therapist but we don't address the issue in our notes, we could find ourselves opposite a Perry Mason-type lawyer who will ask the appropriate questions regarding a therapist's responsibility while caring for a patient.
Let's suppose a surgeon defines a technique that allows total joint replacements to leave the hospital sooner than three days. The patient will not qualify for Medicare Part A coverage in a SNF, so the patient is sent home. Home health nurses and therapists will suddenly be overextended, as will outpatient facilities. The SNF units will see a significant decrease in residents and loss of revenue while therapists will leave that sector of healthcare and go where the patients are.
One proposal I have read about is to eliminate the CMS rule of the three-day qualifying stay to be eligible for Medicare Part A coverage in a SNF. It has been tried before, but according to CMS there wasn't a significant savings and at the time there were not enough patients using Medicare Part A. Now there are, so maybe a rule change would be a good idea. It could take years before it would go into effect though.
Ultimately it is the MDs who dictate when patients go home from a hospital setting and as more MDs become hospital employees, there may be a push for patients to leave before they could qualify for the three-day stay. This would be a business decision by the hospitals so they would not be penalized for readmissions. But the hospitals already have a way around the penalty, it is called "observation beds." Patients are not re-admitted to the hospital, just observed there. And since the patients are not formally admitted, there would be no decrease in payment for services. There is talk to get rid of the observation bed loophole too.
If a patient has a total knee surgery, stays two days in the hospital and is then discharged to an observation bed for another 48 hours, then discharged to home health, would the hospital be in compliance with the Office of Inspector General? The patient would not qualify for Medicare Part A and would still be assessed appropriately by medical personnel. I wonder if that would be legal under the rules CMS has laid out for us. The hospitals could ultimately open their own transitional care units and keep the profits CMS doles out for therapy services. Either way, hospitals will want to be profitable and will adapt to any rules so they can ensure their doors will remain open. By the way, happy PT Month.
The patient I went to see was agreeable to do therapy but wanted to take some things along to the therapy room. "No problem," I replied, "we can take whatever you want." As the patient handed me a tissue box, I assured her there was tissue available in the therapy room. A blanket came next and once again I told her they were available in the therapy room. A cup of water, a jacket, another blanket, and even a cushion followed.
I was supposed to carry these things to the therapy room for her while ensuring she was safe during gait. A suggestion of using a 4WW to carry all of this met with disdain. When I put some of the items in her wheelchair, she asked where she would sit if she needed to sit down suddenly.
I wanted to get my hobo stick out and have her tie everything in a neat bundle at the end and carry it herself but I kept my cool and put her cushion in the chair with the blanket draped over the back. I carried the cup of water in one hand and pulled the wheelchair behind me with the other hand. I kept a close eye on her to ensure she was safe with gait using her personal FWW.
Our chairs have cushions in them but she wanted her own wherever she sat down. Our blankets are on the linen cart just outside the rehab gym and we have cold water for anyone who wants to partake.
The facilities I've been in all have an endless supply of tissue boxes scattered throughout the department so I couldn't understand why this lady would want to bring all these items with her every therapy visit. Maybe doing so was a security blanket for her but it could also be unsafe if she were to suddenly lose her balance during mobility.
Maybe I should have stood my ground and told her, "No, we're not bringing all of that." She is the customer of therapy services but it made me wonder if prior to going into surgery, she'd ask the surgeon to hold her water, the anesthesiologist to carry her blanket and the nurse to carry and position the cushion under her.
Apparently a mechanical lift is not a skilled source of treatment. Maybe that's why there are therapists out there who have no idea how some of the lifts work. If they did, they would realize there is a skilled component to ensure the patient is safe, not to mention the patient, family and caregiver training involved.
I guess the argument against a lift being part of skilled treatment is that anyone with minimal training can do it and the patient isn't actively moving, kind of like supine passive range of motion lower-extremity exercises. But wait, we bill for PROM exercises, don't we? So that's not a good example. What about a tilt table? No, we bill for that too and the patient is lying supine, not actively involved in the process. Maybe the skilled portion of the tilt table is taking the patient's blood pressure, but don't CNAs do that and not bill insurance companies for their time?
Using a lift requires skill, professional judgment of the patient's response to the lift and most of all, technique for a safe transfer. There's positioning involved in the sling as well as in a chair as the lift descends into it. If all straps aren't adequately secured, the patient could get injured. This is something home care givers and family could easily miss if they're not instructed in safe and secure transfer techniques.
Aren't patient, family and caregiver education and safety with transfers part of a skilled session of therapy? How has it been determined that a mechanical lift doesn't fit that scenario but other forms of passive activity do? Can someone explain this to me please?
I was reading about how the Native Americans are going to be affected by the Affordable Care Act. Apparently there's still confusion about the federally recognized tribes who will be covered and some may have to prove their ancestry again. Then there are the Amish, who have opted out of the ACA without much difficulty. I guess the government picks and chooses who they want to impose a fine on and who they'll ignore. Weren't we all told that everyone is required to have health insurance? I guess the wording on the barn can change as we go about our day. (An "Animal Farm" reference).
I'm trying to understand how all of this will directly affect me professionally as well as personally. As I understand it, reimbursements keep decreasing for the same care we're providing in order to save money, and hospitals will be directing which facilities receive funds from Medicare as well as how much. Contain costs, force workers to work harder with less. I get it, no problem; I'll keep pulling with my head down.
Personally, however, I have issues with the medical system. As a consumer of health services across the spectrum, I'm disappointed by it all. There's no consistency when asking for specific information and finding a specialist in the healthcare community to treat my child is like mining for a bitcoin. We're on several waiting lists for potentially life-threatening situations and I can't always afford the emergency room visits when things are real bad. If insurance didn't pay for both my daughters' medication, we'd have to decide on their well-being or buying food for a family of five every week; the medications they take are that expensive.
If any of that changes, I am doomed. As I tried to get more information last week regarding changes to the health system regarding both my daughters' medical status, I was unable to because of the government's inability to compromise on issues. It has not been a good week to be a consumer in the healthcare market. Even some websites were down when I went searching for information.
Since I haven't read the ACA, I cannot say if it will be good or bad for us in the therapy profession. And since the government keeps adding addendums, I doubt I'll ever be able to finish reading it in my lifetime. I want to say we'll be alright but as reimbursements decrease, companies may begin to hire more assistants to reduce costs. It is a business, find cheaper labor to deliver the product. Don't blame the PTAs for this, talk to the representative you voted for (or the one in office) and see if you can fight the system. As a consumer of healthcare and an advocate for my daughters against the conglomerates who own the health system, I am tired of fighting, but I never give up.
The billing clock stops ticking when the patient is no longer in front of me, but this doesn't stop family, nurses and other colleagues from talking to me about the patient when the patient isn't present.
If I see six patients a day and the nurse and I want to discuss medication management for pain reduction to accurately progress the patients, each small visit could take 10 to 15 minutes. This adds an hour or more to my day. If family members have questions regarding their loved one, this can add another hour to my day. When there's a care conference and the patient isn't present, I'm unable to bill for my professional presentation of how the patient is progressing with his care. So add another half hour to my day for each conference.
Where does all this unbillable professional service go? The employer eats the cost of it and that's not right. Basically we give our services away for free when we consult with family, nurses and other caregivers while the patient isn't present. To combat this, we could talk about patients while they're always present; however, there are some things family may not want to express in front of their mom or dad. We could pull the nurse into the patient's room and discuss the medication, but this diverts the nurse from completing her tasks.
If I were to see eight patients a day and have two care conferences, discuss case management with the supervising PT and pain medication management with the nurse while the patient isn't present, my productivity can easily dip to the mid-70s while I complete work in a nine-and-a-half-hour day. Maybe the answer is to decrease the caseload per day and definitely not to rate a therapist's skill and performance of a job based solely on productivity scores.
We all know that money and politics go hand in hand. With the money, there are lobbying expenditures that can influence decision-making. So I went on a search regarding how much our beloved national therapy organization spent in regard to certain issues. As I found out, not a whole lot when they are compared to other healthcare sectors. What most surprised me was how little they spent in 1999 and 2000 when there was a large impact on the therapy profession.
Maybe the level of money spent for lobbying is directly related to how many PTs/PTAs are members. This then begs the question of how to increase membership to increase money for lobbying efforts for the therapy profession. Allow me to offer some advice to increase membership so the PACs, lobbying efforts and 527s can have a positive effect on the profession.
First, full membership, voting etc. for all members. Second, lower the membership dues. Third, create a special section for PTAs to join for an additional fee like the neuro and ortho sections. Fourth, get rid of the language that puts the PTAs in the same league as supportive staff.
Ideally this should increase membership initially. A dues increase implemented over a five-year span is easily accommodated, but do not increase it by more than what is feasible. And because I do care about the therapy profession, I could be a lobbyist (for a moderate fee) to help implement these changes.
Normally I welcome family members with open arms to therapy so they can watch and learn what we do. But when family begins to speak for the patients or tries to assist too much with their care, I want to draw the line. If families become intrusive and disrupt the normal progression of care, they need to be told to back off on their approach. When families get too involved, I often wonder if they were in the operating room with the surgeon, asking questions and trying to assist with surgery.
There are some family members who will sleep on a fold-away bed and rotate days with other family members so there is someone present 24 hours a day. Why? I doubt it has anything to do with trusting the care provided.
I made the mistake of seeing a patient when her family wasn't around early one morning. I wanted to assess how the patient did when she wasn't under the influence of family. I was grilled by a group of family members later that day who were trained investigators. I had to recite SPO2, blood pressure, pulse, response to treatment etc. Finally, the family asked what time I would see their mom the next day. When I told them that I vary my times to see people to better assess how they respond to treatment, they weren't happy.
I completely understand when family wants to be part of the complicated maze of healthcare and try to actively participate in every aspect of treatment. But when they don't go home, it's time to cut the apron strings and allow their loved one some time alone. Having too many family members involved can also complicate decision-making regarding end-of-life issues. Not every family member gets along or wants to be part of the process, but they are sometimes forced into it by their siblings.
I have debated putting a sign on the therapy door that says, "Therapy In Session, Do Not Disturb," and explain to family that therapy is a closed-room activity and we don't allow family members to come in. I don't know what kind of response some families would have to this and I don't know if I'm willing to risk the backlash of it either.
I was reading about a facility that promises one-on-one hourly sessions of physical therapy with a DPT. My first thought was, "How can that facility financially support so many DPTs and see seven to eight patients a day per therapist?" The reimbursement isn't there to make this an effective use of a DPT's skills and training. And if a patient cancels, there will be a large hole in the therapist's day.
I would think a better way is to have several PTAs seeing patients and one DPT could advise, direct and consult with the patients as they are progressing under the supervision of a PTA. The facility would effectively stay in business with reduced reimbursements and the cost per full-time employee would be less. Some may argue the financial gain is not worth it, but it is. When the reduction of reimbursements is finalized, there may be some associates who will need to be let go because the cost to retain them outweighs what insurances will pay for their skilled care. This should have no reflection on their knowledge and patient care abilities; it's a financial decision to keep a company afloat in a volatile healthcare market.
If every facility in the country was to develop a plan to have one-on-one sessions with only PTs, treatments would be delayed, missed or never done at all, and this is not in the best interest of the public. We could advise patients that all therapeutic treatments will be provided by individuals who are licensed to provide physical therapy services and their care will be directed by a physical therapist. But this would not jibe with the APTA's RC 4-11 and would certainly not help the case for RC 7-11.
Federal age discrimination laws state that an employer may not discriminate on basis of age for those who are 40 years old and older (provided your employer has more than 20 employees). I am over 40 years old so this affects me personally. Last week, I posted a blog asking why there is no mandatory retirement age for "old" therapists. I didn't anticipate there would be so many therapists who thought of themselves as "old."
Some have accused me of being discriminatory based on retirement age but those therapists ignore the U.S. Army, which has a mandatory retirement age of 62 and an age limit to enlist. Airline pilots have a mandatory retirement age of 65, yet I don't see therapists rallying to their aid to change this nor do I see therapists petitioning the government to change the mandatory retirement and enlistment ages of those in the armed forces. And where were those therapists when school bus drivers were fighting the mandatory retirement age of 65?
If a job is dangerous or requires a high level of physical and mental skill, there's a probability the position will come with a mandatory retirement age. Is our job dangerous? Yes, we are faced with potential blood-borne pathogens and infectious diseases with every patient we touch. Does our job require a high level of physical and mental skill? Yes, this goes without saying. Therapists have the luxury of treating patients and working while others are forced into retirement even if they are physically and mentally able to perform the job.
There is no governing board or group of physicians who look into our health and mental status before we're issued a license to practice. If I suggest this should be changed to protect the public from therapy license holders, how is this age discrimination? A therapist could have early-onset dementia (or Parkinson's) and still practice while potentially putting the public at risk. But at the mere mention of a therapist possibly having significant balance and memory impairments, I'm called ageist and discriminatory.
Maybe those therapists who called me discriminatory could petition the state boards to eliminate any wording regarding the mental health status of PTs and PTAs in the rules and regulations. A mental illness is a chronic disease and shouldn't have to be disclosed when applying for licensure. Those same therapists who want to protect the public from the mentally ill and deny licensure to them, will probably see nothing wrong with allowing licensure to a therapist who scored poorly on a balance test or memory exam.
Please email me with your thoughts: firstname.lastname@example.org
To drive an automobile, you must pass several tests before you're issued a license. There is the eye test, the written test, and then the practical driving test. In some states, young drivers are encouraged to take a driving course while in high school to get a learner's permit. As one ages, states may require an older driver to take another eye exam and sometimes a practical exam to maintain licensure, and a doctor can recommend that an elderly driver not be issued a license.
As a therapist ages, there is no mandated eye exam, written or practical testing and mental capacity exam to maintain licensure. All a therapist has to do to keep his license current is take the mandatory CEUs every year dictated by the state and he could theoretically practice until he dies. Why don't state boards have a retirement age for "old" therapists? Police officers and those in the armed services have a retirement cut-off and for some positions a person isn't eligible to apply if he's more than 35 years of age. Technically, a person who is 75 years old could become a new grad PT or PTA.
As we get older, we may not recognize the limitations we have, whether they are mental or physical. A 98-year-old therapist may not be the best person to treat a heavily involved CVA patient but since he has a license to practice, he can legally provide care for that patient even if that treatment would put the patient in harm's way. And who am I to tell the elderly therapist not to see certain patients since the state board is who issued the license to practice therapy in the first place?
I won't get into the legal complications state boards will have to justify issuing licenses to therapists who score less on a Tinetti and Berg than their patients and get the Mini Mental exam completely wrong. But all it would take is one good lawsuit and an internal investigation to ask pertinent questions like, "Why did the state issue a therapy license to a therapist who has dementia?" and "Who allowed a therapist to treat patients when he is barely functional trying to instruct others in ADLs and safety?"
Since there's no current oversight on when a therapist has to retire and no doctor can recommend that our therapy license be suspended, we could treat patients forever and ever. Imagine if your loved one is safer, more limber, and has a better gait pattern than your therapist while in the nursing home -- maybe then changes will occur.
Group physical therapy was a way to have patients come together and participate in activities where they could encourage one another and watch each other progress. Since the decline in reimbursements for this type of activity, it's no longer economically feasible for facilities and therapists to do this. In some instances, the group coding may have been abused and overused. With the old system, two therapists could have seen eight patients in an hour and billed accordingly and someone made big bucks when this type of group billing was the norm.
Getting away from groups was not the brightest thing to do though. Yes, the one-therapist-to-four-patients ratio was probably overly abused by some companies but when patients have some sort of workout partner their accountability to participate in their own care should increase. We read and are told to walk or hike with a buddy, work out with a friend, have a running or lifting partner etc. Where are the patients' workout buddies?
I instruct patients in the proper technique of the exercises but I don't perform all the exercises along with them. Another patient with the same or a similar diagnosis would. Two knee patients could compare stories, discuss surgeons, do range-of-motion comparisons, and encourage one another with their exercises and gait.
But I'm sure there would be some therapist who still messes this up for the rest of us and has two comatose patients trying to play volleyball or barely gripping a weight, while they talk about what they did over the weekend to another care provider for an hour.
Finding the right PT or PTA for the right position can be difficult for any employer. There's a culture in the workplace and employers want to ensure their therapists are successful and fit into the group. Below are examples of some therapists I've come across in the field.
Therapist #1 will not question a RUG level no matter how absurd and will get the minutes assigned by any means necessary. He will come in early, stay late and often clocks out at the end of the day to complete notes so he doesn't generate overtime for the facility. He may work 40-plus hours a week, if asked, and be on call for the weekends. He will have excellent productivity and a good work record, he is passive and will agree to almost anything for the good of the department.
Therapist #2 will often question the RUG levels and appropriateness of seeing patients for 75 minutes. She will come in on time and stay clocked in for every minute she's at work even if she goes into overtime. Outside of work is her priority and the job is secondary to everything else. She won't volunteer but will assist when asked to see more patients. She has fluctuating productivity and her work record is good.
Therapist #3 will not be able to achieve the minutes assigned to him, which means other therapists have to see more patients to get the minutes. He will clock into work early to walk around holding a coffee mug and talk to everyone in the facility before settling down to get his list of patients. Suddenly he remembers he has an appointment and has to leave early on certain days, usually pay day. This therapist will complain that he's not getting enough hours during the week but doesn't want to work overtime when asked and refuses to work any weekends. Work record is good because everyone likes him in the facility but his productivity is below the facility's standard.
Most likely the therapists we work with will be a mixture of the three but we've all met the others, especially the last one.