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.
I believe we should all question what we do and why we do it, especially when it comes to patient care. We should be asking ourselves, "Is this the best I can do under the circumstances I have to work with?"
We should also question whether adding more than two pounds on an elderly patient's ankle is the best thing for him. I have seen six- and eight-pound weights added to a patient's ankle and struggles to lift the weight, causing him to be extremely sore the next day. I have read the evidence regarding increasing the weight lifted by the elderly, and it is positive but there are other factors to consider.
If the OT has the same mindset of increasing the weight because she read the same study, the patient will be completely exhausted and will have no energy for the SLP. It's hard to achieve 225 minutes of therapy a day with someone who is too sore and tired to move.
Can we realistically increase a patient's strength a full muscle grade in one month? I guess it depends on the genetic makeup of the person and his activity level prior to an injury or illness. I'm not sure if our patients will want to increase their strength anyway. There are patients who only want to move if it's absolutely necessary.
Should the sedentary lifestyle be considered before we take on a patient who has one ambition and that's to be able to walk from the lift chair to the kitchen and then into the bathroom? Maybe if we showed the patient all the evidence we have amassed over the years, he would come around and agree to a more rigorous training schedule.
And speaking of evidence, if the insurance companies don't recognize a treatment provided, we either don't do it or when we do perform the task, we will not get paid for the skilled service. If we don't get paid the full amount for our skilled care, should we still treat the patient using it? Would your mechanic change your oil for free just because it's good for your car? Would your surgeon reset a broken bone for free because it will improve your mobility when it heals? Unlikely.
Why should we provide care that we don't get reimbursed for? And the evidence we do have for certain treatments may not be field-studied. I mean, when we take the evidence and attempt to apply it to our current system of healthcare, is it applicable and reasonable to be successful? We can do a lot in the lab but try to recreate it in a therapy gym with the noise, interruptions and confusion, and that evidence may not hold up in a real-life scenario.
After negotiating wages for our skilled service, we may run into someone who gets paid more. Or worse, who does less and performs mediocre treatments for the patients we normally see. Maybe having a national standard pay scale could rectify this. I've known therapists who made five dollars more but did less work when progressing patients. I applaud them for their ability to coax that much more out of an employer and their dedication to making the most money with the least amount of work, but I question whether they should be doing what they do with that attitude.
Those who work for a per diem rate generally make more money for the same work full-time employees do. They work for a higher rate and forego benefits and other perks of full-time work. But they still make more per hour for doing the same work as a full-time employee. I have also seen a discrepancy in the per diem rate. Sometimes this will fluctuate by 10 dollars depending on the solvency of the company at the time the therapist signs up for work. Would a reduction in the per diem rate "weed out" those therapists who simply do it for money and not love of the job and patients?
Maybe those who make more money have better credentials, better CEUs for the position, or are simply better negotiators for a higher pay rate. The other factor for an increase in pay rate is supply and demand. If a therapist comes across a position that has been advertised for a long time, he may be able to ask for more money and the company, which is eager to fill the position, will pay the higher-than-normal rate. Is this fair to pay a therapist who is simply out for the money and not for the best interest of the patient? What would happen if our pay rate was nationalized, would we still do it for the patients and not for the financial gain?
Suddenly our facility will receive patients who have had joint replacements. Hips, knees and even back surgeries will flourish in our department. I took several CEU courses specifically for this reason, so I could better treat the patients we see. Then just as suddenly all joint replacements will vanish.
I don't see a pattern with this and the people we do treat always have nice things to say about our therapy department. I have discounted the patients being angry and telling the surgeons we are horrible therapists. Some patients we can foresee coming into therapy based on the time of year, such as when flu season hits. Even when I looked at insurance coverage, there were a few patients who had elective surgeries toward the end of the year but nothing that would increase the census to what it is now.
Maybe the influx is due to people being out more in the summertime, so injuries are more likely to happen. Maybe the surgeons think our therapy department is the best and they send every surgery they do to us, but this is unlikely because there are great therapists in facilities around us. In about a month, the joint replacements will stop coming, the patients will be replaced with new ones who have completely different diagnoses and my CEUs will not be as effective.
So this got me thinking about the new changes in healthcare and the ACOs (accountable care organizations). If an ACO knows a skilled nursing facility has good outcomes with joint replacements, it will send all joint surgeries to that particular SNF. This makes sense because the facility can decrease healthcare costs and rehab the patient in a shorter amount of time.
The same would be true if a facility has excellent outcomes with CVA patients, provided it has opted into the ACO. What happens when there are no joint surgeries or a decrease in CVA patients coming from the hospital to the SNF? Do those PTs and PTAs stay home because another facility has all the COPD patients? I guess I shouldn't get too much involved in the antitrust aspect of this because there's a voluntary review process for the ACOs.
The value of our service seems to be declining. I base this statement on several observations, beginning with how many times we're interrupted during a therapy session. As I'm working with a patient, the lab will come in and need a blood draw. So I stop what I'm doing and allow them to do the procedure. When I continue to treat the patient, a nurse will come in and need to do vitals, then the X-ray person will need the patient; it never ends. I wonder what those other professionals would do if I decided to work with the patient when they are in the middle of a treatment or procedure?
Our value can also be measured by what we are reimbursed for our service. Like our pay rate, we are worth something to an employer. What would happen if our employer paid in full our first hour of treatment, then cut our pay by 20% every hour after that? This is similar to what Medicare Part B does but on a larger scale.
Facilities value therapy but equate us to dollar signs and reimbursements. In some facilities, we're not allowed to take a patient to the therapy gym if he's already engaged in another activity, such as a bingo game. We are expected to see the patient, but not to inconvenience the other departments in the facility. When the patient is not seen for therapy or the patient misses a RUG level, we become the target of wrath because the facility missed out on some money. How are we supposed to see the patient if he's in activities all day?
There is a disorder in the therapy system. It begins with how we're treated in a facility and ends with how we're reimbursed for a skilled service. I only have this to say about it all and I quote Chuck D from the rap group Public Enemy, "Fight the power."
In a skilled nursing facility, the focus is often on function to get the patient back to his home environment. We work on gait safety, fall prevention and strengthening activity to achieve the patient's goal of going home. Shouldn't we be more focused on the patients function so he can perform ADLs and mobility with less risk of falls?
For a joint replacement, I understand the need to go through the exercises and assist with restoration of mobility and initiation of muscle activity. However, those patients who come in related to weakness, confusion or multiple falls in the home would seem to benefit more from something they can actually take with them when they leave -- besides a three-foot-long yellow exercise band and a faded copy of leg exercises.
If I have a patient doing supine leg exercises, I can justify my time with the patient and explain how each exercise directly relates to gait, transfers and increased performance when the patient is mobile. But when put into practice, doing 10 short arc quads is not necessarily going to make my patient any safer at home on the way to the bathroom when it's 2 a.m.
Wouldn't it be wise for therapy to assess a patient's gait when he is most vulnerable to falls? I'm proposing a 24-hour physical therapy department. Three eight-hour shifts, and the focus of the therapy is all about safety and function to ensure the patient safely returns home. Don't MDs and nurses work the night shift? Why should it be any different for the other allied health professionals? If we see the patients when they have the most energy (during the day) and are alert, how are we supposed to truly assess their functional deficits?
We could have the nurses alert us when one of the patients requires assist to use the bathroom, for example. What better way to assess transfers and gait than when the patient is half asleep and more apt to fall, especially in an unfamiliar environment?
There are patients who fall in the hospital and SNF settings because skilled professionals aren't available to assist them with safe mobility. I'm sure a therapist's presence could reduce the number of night falls in a healthcare setting, plus our time is reimbursable. We could specialize in units that care for patients who don't recognize the difference between day and night. I have not seen any rules that say therapy can't be done on an 11 p.m. to 7 a.m. schedule.
Throughout my career, I've kept a mental list of things I should not or will not do anymore. Last week, I learned a new one about never getting stuck in the corner of a patient's room without an escape route. I thought this list might help some people so they won't make the same mistakes I have. And feel free to add your own.
1. Never volunteer weekends unless that's the schedule you want to keep.
2. Never stand behind a patient when he's transferring onto a commode chair. This is especially true in the hospital and if the patient has been given docusate. Trust me on this.
3. Never give out an elastic band without inspecting it first. One band broke while a patient was pulling it. He was standing and ended up on the floor with a sprained ankle. There were either small defects in the material or the elastic was old.
4. Never lend your favorite pen to an MD.
5. Never sit in a wheelchair without looking at the cushion first. Is it wet; are there food particles in there that will attach to your pants?
6. Never put a gait belt around a patient before you inspect for open wounds, colostomy bag etc.
7. Never offer to fix equipment. You will be the "go-to" person if anything breaks.
8. Never offer to work per diem if you have no intention of keeping that agreement.
9. Never argue/disagree with a coworker in front of patients.
10. Never try to hide your favorite walker; someone will find it.
I walked into a room and positioned myself toward the head of the bed while the patient sat up. I was reviewing seated LE exercises and safety with the patient when his spouse walked in. She stood by the foot of the bed and began to question both myself and the patient in regard to being discharged. According to our therapy department, the patient was safe to go home and had achieved 90% of his goals. We were working toward achieving the last 10% of the goals when the spouse didn't think a discharge was a good idea.
The patient and wife began a slight disagreement about whether he was safe to go home. I tried to blend into the wall as best I could and even tried to make a small joke about the situation that failed miserably. My only escape was to either crawl across the patient's bed or push past the patient's wife while she was getting more and more upset with her husband. From experience, I know you do not try to walk away when a patient's spouse is in loud disagreement with a decision.
I was mentally preparing myself for the tuck and roll across the bed, figuring I could land on my feet and make a dash for the door before anyone knew what was happening. Fortunately the patient recognized my dilemma and stood up to guide his wife across the room while she was berating his decision to leave. He was a very brave man.
As I left the room, they were still arguing so I closed the door slightly so the noise would not carry out into the hallway. I walked toward the therapy gym and realized I am not a good mediator when couples have disagreements about whether to go home or stay longer. I can offer information about the patient's progression in therapy but the ultimate decision to go home lands in the patient's court provided he can make that decision with clarity. I often educate patients in regard to the reality of going home but they have to decide on their own based on information given to them. I did learn a very valuable lesson during the argument between the patient and his spouse; never get stuck in the corner of a patient's room without an escape route to the door.
The patients I see in a SNF don't always understand how therapy works. If I see a patient in the morning and assist with ADLs, transfers, gait to the bathroom, and instruct her in safety with all the above, it may take up her whole therapy time. But she might ask later in the day if she's going to be doing more.
"Sorry Mrs. Patient, we can't do more because therapy will not be reimbursed for any more of my services to you. You have been assessed and deemed to only get a certain amount of therapy per day. Medicare has forced therapists to limit how much therapy you get because Medicare won't pay anything extra after you have reached 720 minutes of therapy in a reference period.
I know you have five steps in your home, have a 2+/5 strength in your involved lower extremity, and don't fully understand and follow your hip precautions and weight-bearing status. However if you contact your elected officials, perhaps they can persuade Medicare to pay for more therapy so you don't fall again and can regain your strength and stability when you are up.
Perhaps you can call or email congress and ask why therapy is a time-based service for reimbursement in healthcare, while surgeons and nurses are not. Perhaps you can ask why physical therapy services have been scrutinized and criticized in the last couple of years by our elected officials in Washington, DC, despite all the good we've done to get people up and moving and back home.
And please ask congress to explain why car insurance will pay a mechanic to fix your automobile (without time limits), yet you are limited in how much therapy you can receive by your health insurance company to get back up and moving safely. Aren't you more valuable than a car?"
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.