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PTA Blog Talk

Working with a Disability
by Jason Marketti

There are certain employment criteria that need to be met to become a PT or PTA. However, certain provisions can be altered, provided the therapist is able to maintain safety precautions with the patient and himself while performing the skills required.

Some state licensing provisions may incorporate restrictions in addition to the lifting and positional (standing, sitting, squatting etc.) work-related requirements that a therapist will need to meet to become employed. These barriers can limit therapists in employment opportunities and decisions about where to apply for a position. Is there a discriminatory nature against therapists with a disability or does this become a safety issue when dealing with patient care?

I've spoken out against state boards that ask about mental disabilities because they often ignore other health-related concerns regarding the safety of patients. For instance, if I'm HIV-positive (not every state asks about this, nor do they require a blood test), I could potentially infect patients and other health workers if I'm not careful. State licensing boards don't ask if I'm in a wheelchair either but they are concerned about my mental health. Doesn't the Americans with Disabilities Act protect disabled workers from discrimination? The ADA does make provisions for alcoholics and recovering drug addicts but state boards are apparently not concerned about those disabilities.

What happens if I acquire a disability after I have a license? I can simply check the box "no" that asks if I've ever been convicted of a felony, send in my licensing fee and get a new license to practice and the state is no wiser. Does the state need to know I have a head injury or that I'm now confined to a wheelchair for the rest of my life? No, because they never asked me. And they certainly don't need to know if a therapist has been in a psych unit for two weeks with a new diagnosis of schizoaffective disorder.

What happens when a therapist has a surgery that may limit him in his job performance? Should a PT who had carpal tunnel surgery have to tell the state he had the procedure because it could potentially interfere with how he puts his hands on the patient and adversely affect a manual muscle test? What about a PTA who had a surgical repair of the Achilles tendon? Couldn't that affect patient safety during a transfer? This then opens up a question regarding the correct definition of a disability in relation to patient safety in the physical therapy environment.

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The Kiosk
by Jason Marketti

Imagine getting a sore shoulder from work you had done hanging drywall one weekend. There's a week wait to see the MD and a three-day wait until you can see a PT. The pharmacy down the road has a kiosk you can access and speak with a PT via monitor and a PTA on site who can take you through an exercise program after speaking with the therapist.

The idea of tele-health is not new but the way it can be delivered may change. Currently the kiosk is being developed and can accommodate a pulse oximeter, otoscope, dermascope and blood-pressure cuff, among other devices. There are attendants who will assist for blood-glucose testing and placing a stethoscope if needed. There's no waiting in a long line at the emergency room or waiting for days or weeks to see a health provider. Psychiatrists and dermatologists are just a few of the health providers who may begin using this type of tele-health in the near future.

Would it work for the PT world? Possibly. If a PTA is under the direction of the PT and the telephone is an acceptable form of supervision, why isn't tele-health where a PT can actually see the patient and watch him move through a range of movements? The PT could direct the PTA to palpate, manual muscle-test and perform ROM testing on the patient while watching him move through the activity.

After this, the PT can direct the PTA and patient on which exercises to avoid and which to do. Then the PTA can instruct the patient on proper form and body mechanics while going through the exercises. This will not replace an office visit to a clinic where a more comprehensive eval can be performed and where more equipment is available for a patient's needs. This is where the skill and knowledge of the PT will be most useful, to determine whether the patient can be seen on site or whether the patient should seek further care in a clinic.

I'm not sure why therapists are resistant to this type of care. It's already happening and we may be left behind when this technology is implemented as the new standard of care. If anything, therapists should get behind it and improve the functionality of the kiosk, deciding what equipment will be needed (TENS unit and ultrasound) to make it work to their advantage.

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The Grinch
by Jason Marketti

How am I supposed to see my patients if they keep having holiday celebrations? Every time I turn around, there's a singing group coming in or some other form of entertainment and all of my patients flock to the activity. Okay, I see it now, sitting around listening to a bunch of off-tuned singers is more important than therapy. If that's the case, then maybe I should sing for my patients while they are in the gym. That way they can get both entertainment and therapy done at the same time.

Just the other day, there was a holiday lunch for the patients. It began around 11:30 in the morning and didn't end until after 1 p.m. So I had to wait for my patients while my productivity was taking a nose dive. I'd love to explain that to the bean counters when they ask why. "Oh, I'm sorry if my productivity was in the 70s. You see there's some sort of holiday coming up, I think it's called Christmas or something like that. And well, people like to celebrate it with family, so our facility had a luncheon and entertainment prepared and I didn't think it would have been polite to interrupt."

So, how do I get the patients to participate when there are so many other festivities going on? I can't. It's as simple as that. I'm not able to approach patients when they are in an activity. If a patient chooses to participate in the festivities, he's unavailable for therapy and that's about how I document it in the chart. I could work until 8 or 9 at night when the patients are not so busy, but by that time they're tired and don't want to do therapy.

Frankly, this time of year is difficult to get patients to work. There are family members in and out of their rooms, children roaming the halls handing out holiday cards, and a lot of noise I could do without. How many singing groups have to be heard in one week to say, "Enough!" They all sing the same songs; it's like my stereo is on repeat with no auto-tune. Maybe therapy should take off from December 15 to January 5. By then the holiday spirit will have waned and we can get back to the important business of getting people well without so many interruptions.

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Employment Testing
by Jason Marketti

I have been employed in the therapy sector since 1996. I've worked in hospitals, nursing homes, outpatient buildings, pediatrics, school districts, home health and wound care. I have several certificates related to different clinical and business aspects of care. But all of this doesn't make me an expert at what I do. It simply means I have a lot of experience and require only a short orientation to a new facility before I can be shown a list of patients to see.

However, experience can't always prepare me for everything. Let's say I decide to change directions and go back to acute care, specifically ICU. I would need more in-depth training on acceptable levels of when to treat and when to hold the session as well as clinical information to back up the reason why I'd withhold a treatment for a patient in ICU. This would take some time for me to gather and study the information and accurately apply it to a scenario.

Maybe an employment test of skills, knowledge, and a practical exam would be beneficial for anyone who decides to change employment settings after a couple of years. This would allow the therapist as well as the employer to decide if it would be a good fit in the new environment. But would this demean what we know and do? Haven't we been through enough testing and training to become licensed? Why should therapists have to dance around a facility and put on a puppet show for a new employer to prove they are good at what they do?

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Therapists Unite
by Jason Marketti

I can tell you what's wrong with the healthcare system and even some ways to fix the problems. I can explain why our current system is flawed and why being a therapist is not all glory and fame even when patients succeed and are released back to home. And I will try one more time to provide therapists with a different point of view about how much authority they really have within the healthcare sector.

If a facility holds productivity over our heads to stay employed, then therapists should not work for that company, ever. When a company realizes the therapy community could essentially shut the place down if no therapists show up for work, they will back off. Therapists essentially hold within their grasp thousands of dollars a day for the patients they see. When unscrupulous companies understand the power therapists have in making money for a facility and that we should be worshipped every day we come into work, then we'll get the results we want from the company. Imagine if all the therapists in a company decide not to get the ultra-high RUG level in a week, imagine the power we have, imagine the changes we can demand, imagine if we actually did it.

If a company asks you to do anything you perceive to be unethical, they need to be turned in and the authorities can sort it out. If an employer tries to bribe you to work longer than you want, they need to be turned in to human resources without question. Then a strategic call to the Office of Inspector General for good measure to show them we don't play around with our professional licenses. A quick note to the Better Business Bureau can also get results and if enough people complain, changes will occur.

Unfortunately there are therapists out there who will do anything for a buck. They have no ethical dilemma about seeing a comatose patient for 90 minutes a day, six days a week. I've seen therapists kowtow to large corporations that couldn't care less about them as individuals but cared a whole lot about how much money their licenses could make for the company. Maybe it's time for a change; however, I doubt enough therapists are willing to stand up and be sufficiently vocal to make change happen, voicing their opposition to corrupt businesses that take advantage of them at every level. Fortunately, I'm pleased with who I work with (not for) and would recommend them over the competition in any region.

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Clothes for Patients
by Jason Marketti

I've worked in many facilities and for both large corporations and small independent businesses. One of the reoccurring problems I've seen is finding adequate clothing for the patients. Family should provide some clothing to the patient but if the facilities don't explain this to the family members, the patient ends up wearing whatever is available.

One patient, a distinguished male veteran, was dressed in green female-size sweat pants that were obviously too short for him and a plaid button-down shirt. This man stormed the beach and survived enemy gunfire at Normandy and someone assisted him with dressing like this? What were the aides thinking?

When I went to the laundry room, I found his clothes and helped him look more presentable when he interacted with other patients and staff. I then went to the director of nursing and asked what could be done about the clothes situation, specifically putting female clothes on male patients. "It is a dignity issue," I said.

I saw heads nodding in agreement about the issue but I didn't see any significant change in the facility's enforcement of a dress code for patients. Some blamed the laundry department for not returning the clothes in a timely fashion, others blamed the nursing aides for their laissez-faire attitude about getting people dressed.

The aides, in their defense, had limited time to get people dressed and would usually grab what's clean in a patient's closet or go to a linen cart to find something for him. In some facilities, the aides would raid closets for clothes to dress another patient. Then there's the issue of having the patient's name written on the waistband of the clothes. If there's no name, the clothing sits in laundry until claimed by family or it is placed in another patient's room, hopefully of the same gender.

If the therapy department has to hunt for appropriate attire for patients to make them more presentable, it interferes with our productivity. If we do nothing about what the patients wear, stripes and plaids go together and we need to accept this. Personally I would rather have my patients look presentable than worry about productivity. When family members show up and the patient is dressed like a rodeo clown, don't you think they will question why their dad is up and working with therapy dressed like that?

Not only is it a dignity issue, but also a professional judgment issue about what's appropriate for a patient to wear when working in the gym with other patients around. Maybe the therapists who allow this to happen should be dressed by the same aides who dress their patients.

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Relationships with Lawyers
by Jason Marketti

As the therapy profession moves forward, maybe another avenue to explore and receive referrals from is lawyers. When there are accidents, the parties involved may consult with a lawyer and that lawyer could refer to your clinic first rather than a chiropractor or MD. After the initial evaluation, a determination could be made on whether to send the patient to have further X-rays and testing or to continue to treat within the time limit allowed before an MD is required to see the patient.

This would free up the MD offices to allow PT clinics to see patients with minor injuries first and could decrease costs with overall treatment time. All that needs to be done is to convince insurance companies this course of action could save them money (in settlement claims) and they will be on board right away. Then all a clinic has to do is ensure their documentation is up to a court's scrutiny and that the treatment provided was appropriate for the injury involved.

The first time a patient comes in the therapy clinic without an MD referral and a hairline fracture of C1 is missed, either the PT profession will be asking for X-ray privileges (like chiropractors) or realize having a buffer between diagnosis and treatment is worth it. The first patient to get injured in your clinic because no X-ray or CT scan was done won't be the only one trying to call Saul Goodman (of "Breaking Bad" fame) to represent them.

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Checking Oxygen
by Jason Marketti

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.

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60 Minutes of Activity
by Jason Marketti

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.

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Nursing Notified
by Jason Marketti

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.

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A New Scenario
by Jason Marketti

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.

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I Need a Backpack
by Jason Marketti

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.

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Skilled Mechanical Lifts
by Jason Marketti

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?

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Medical Industrial Complex
by Jason Marketti

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.

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Wisely Spent Time
by Jason Marketti

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.

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    Jason J. Marketti
    Occupation: Physical Therapist Assistant
    Setting: San Jacinto, CA
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