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PTA Blog Talk

Growing a Program
by Jason Marketti

It's not like you can plant some therapists in a gym and suddenly the department is busy. To adequately have a therapy program develop into the future, the way business is conducted today has to change. When looking at more cuts in reimbursements, hiring another person doesn't seem logical, but it is.

A good PT aide will get patients up and ready and will have the patient in the gym as you walk through the door and clock in for the day. If therapists are scheduled to come in a half hour apart, the PT aide will have the first person ready to work as the next therapist walks in the door.

And each successive patient will be promptly ready to participate while the therapists waste no time in the gym. If all goes according to plan, therapist productivity will increase because they won't have to locate the patient, get multiple refusals, talk to three nurses to medicate each patient, and locate linen and clothing items.

To grow a program, you also have to let some people go. One therapist can deflate the morale of the whole department with negativity. Letting the person go is a difficult decision; however, if a therapist is negative maybe the place he is now is not the best setting for him. By freeing him to explore other options, maybe he can become happier.

If a facility is actively involved with all things therapeutic, there should be no end to referrals from nursing staff. OT and ST referrals should be apparent with dressing, bathing, eating and swallowing pills on a daily basis. Nursing staff should be addressing these issues and asking for orders if a patient has any apparent change in status. For PT, every fall should get a referral. Every patient who has ended up on the floor, whether from a staffing error or an attempted self-transfer, should be seen by the movement specialists, us.

If there hasn't been a referral from nursing in a week, something is wrong. In a SNF there are numerous missed opportunities for therapy to intervene to prevent falls and improve ADLs, thus helping nursing reduce the amount of assistance needed to transfer patients and get them ready for the day. Not every referral will be appropriate but that's why we are paid so well, to make clinical decisions based on a patient's functional limitations.

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Leave of Absence
by Jason Marketti

I have heard nursing staff, therapists and even social services tell patients they are not allowed to leave the facility or they'll lose their benefits for Medicare. Simply not true, and, in fact, Medicare makes it clear facilities should not tell patients that leaving the facility will lead to loss of coverage.

Patients can leave the facility for the purpose of attending a special religious service, eating a holiday meal, family occasions, going on a car ride, or a trial visit home. Patients can also leave for overnight stays without losing their Medicare coverage. The stipulation of an overnight stay is that the patient may be billed for a bed hold at the facility.

Perhaps people get the home health rules mixed up with the SNF rules. Home health rules limit outside activity when a patient's condition keeps him from leaving or it isn't recommended by an MD and leaving the home takes a considerable and taxing effort. These rules do not apply to the SNF. And by definition, a patient could leave the facility every day for a "short leave of absence." The "holiday meal" is awfully vague too when a patient requests to leave for Arbor Day, Valentine's Day, St. Patrick's Day etc. Technically the facility has to allow the patient to leave because of the way Medicare has worded it. And who am I to tell patients they shouldn't celebrate those days with a meal when I have the therapy room decorated for almost every "holiday" on the calendar.

I wasn't able to clarify what exactly a "family occasion" is according to Medicare either. Birthdays, funerals, christenings, third-grade graduations? The rules are not clear. However, if a patient's condition is improving enough to go out of the facility every day, I would assume a push for discharge is in the works. Essentially it would be up to the therapy department (the PT, OT, ST) to decide whether skilled care is still necessary for the patient's condition. And depending on how adamant a facility is about discharging patients who like to enjoy their Medicare benefits for 100 days, this may cause some problems.

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Getting Political
by Jason Marketti

If multiple Presidential administrations can find money for wars and conflicts to participate in, certainly there should be money available to feed, house, clothe and provide basic medical needs to the poor who live in the United States. When America can provide billions of dollars in aid to other countries but lacks basic health services to large groups at home, I scratch my head and wonder where the priorities are. Please look into the shanty towns and tent cities across America and ask yourself whether the people living there need medical, food and housing aid too.

I've read about how hospitals will airlift foreign patients to their native country once they're stable enough to be transported because it would cost the hospitals too much to care for the person. The person's country of origin may not have the medical infrastructure to provide adequate care for the patient, but that doesn't concern the hospitals because they're looking at cost of care. I'm not sure if social services get involved but transporting patients like this does not seem like an ideal "next level of care" situation to me. And this practice of transporting people is legal under our current system of government.

If the 7 million people who have enrolled in "Obamacare" decided to disenroll tomorrow and not pay the fines imposed, do you think the jails and court systems could handle all the cases? And by enrolling, are Americans accepting and agreeing to the new rules and costs for insurance? If a law says I have to do something that I don't agree with, either the law is flawed or I need to rethink my position. There have been several people throughout history who have instituted social change and brought attention to laws that needed to be updated or were simply wrong laws to begin with. Mahatma Gandhi, Dr. Martin Luther King Jr., and Cesar Chavez come to mind in a non-violent, more peaceful way. They each recognized a situation that needed to be reformed and took action. Are people like this still in existence? Maybe that group Anonymous with the Guy Fawkes masks comes close.

With all this revolutionary talk, someone might think I've been reading books that were once banned or gearing up for a Che Guevara-style attack. I've simply been studying our current health system and recognize there needs to be a change. The first changes would be to eliminate any cap on therapy services and allow more than 20 visits a year for OT, PT, and ST services, which most insurances have as their limitation. I wonder if I could get 7 million followers who agree with me like the government did, although I don't pass laws forcing people to do so.

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One-Trick Pony
by Jason Marketti

While interviewing for jobs years ago, I met a therapist who primarily treated knee patients. He was looking for an experienced PTA to assist in this specialty. I ultimately declined the generous offer so I could explore other interests. I had difficulty understanding how an experienced therapist would only treat one body part. The human body interconnects, and yes, after knee surgery the muscles and structures are weakened but so are other parts of the body.

When I was an outpatient PTA, the policy was to treat one body part at a time. So although a patient might have upper-body weakness from a disability, we could not address that until the patient's back was better. There were exercises the patient was unable to do to mend his back because his UEs were too weak. I could understand that we simply didn't have the time to treat every body part that was weak and achy on every visit, but it seemed ridiculous not to instruct or send some HEPs home with the patient to strengthen the weakened area.

These and other experiences finally led directly or indirectly to where I am now, in a SNF. I have the freedom to treat the "whole person," provided I stick to the plan of care and address the patient's goals set by the PT. If I see the patient has difficulty with certain arm motions that will ultimately allow him to increase function and attain a goal, I can discuss the issue with the OT and PT. I don't have to wait until the patient's surgery site is at maximum improvement to progress the patient and I usually see greater improvement faster.

Most therapists will see patients with a variety of ailments and treat accordingly, but those who specialize in one area are either setting themselves up for a great niche market or limiting themselves professionally. I have yet to determine which.

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To My Dissenters
by Jason Marketti

I have been accused of being ageist, burnt out and one anonymous reader said I should work in a fast food restaurant as a favor to the patients I see. A state licensing investigator even contacted me for something I wrote because a reader or two did not agree with my opinion. Perhaps I should stick with feel-good stories about how the PT and I held hands singing "Kumbaya" while skipping down the hall. Then a cornucopia of brightly lit rainbows appeared as we were treating the patients next to a babbling brook while Strawberry Shortcake and My Little Pony played close by.

My opposing views and questioning of how things are done are not new. If I question the current state of thought in the therapy community and how state licensing boards operate, I'm told I shouldn't be in the profession. Perhaps there are therapists who want complacency and like their little slice of pie that's doled out by the insurance companies. Heaven forbid a therapist questions a decision by an unlicensed, non-medical person from the insurance company who decides how much and when he will get paid.

And we better not question the licensing boards because they can deny a license or investigate you. That hasn't stopped me from investigating them and learning more about them on social media sites than I would ever care to learn. You realize there are therapists on the state licensing board who still believe in the tooth fairy. I would encourage everyone to investigate your state licensing board members on social media and find out what kind of people are deciding who gets a therapy license and who doesn't. Also, ask your state licensing board if they sell or give away your information (address, professional license, employer) to vendors. Should state boards be allowed to do this or is there an "opt out" so your name isn't on the list for everyone to find out where you live?

And if a state licensing investigator is going to investigate me, he should at least contact the five or six supervising therapists I was working with. Apparently, the investigator did not and the licensing board tried to get me to comment on information unrelated to the original complaint against me. By the way, the state board protects people who make a complaint even if that complaint has no merit and wastes money. Perhaps costs related to cases where there isn't a valid complaint should be reimbursed by the person making the complaint. That could reduce the amount of investigations and costs every year. What a novel idea to save money, make sure the person making a complaint has evidence a violation occurred. And don't waste time and money on investigating me regarding an article I wrote as an opinion piece.

I know, I have a different idea about how things should operate and there are those who don't appreciate an opposing view. Maybe we should all think and act the same, but first let's all agree on which treatment choice and approach works better than others when it comes to post-surgical back care. Good luck with that.

I do enjoy the feedback, email me at ptablogtalk@gmail.com.

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Addendums, Amendments, and Late Entries
by Jason Marketti

Our documentation is being held to a higher standard and scrutinized more frequently by insurance carriers. This can cause some concern among providers to ensure all pertinent information gets conveyed through the electronic health records. I was not able to find a time limit concerning when information can effectively be added to a patient's medical record except that it must be "timely recorded".

Addendums add information to the original record or entry. Amendments clarify health information after the original health record is completed, and late entries are entered after the point of service is completed. Understand though if information is added to a health record, it may be further scrutinized and more questions may be asked than anticipated. As providers of therapy services, we should document during a therapy session. But how can we expertly justify spending 3-5 minutes to document a note when we are not actively engaged in a therapeutic procedure with the patient?

If I have a patient on the mat table doing SAQs and I sit next to him while using my laptop to write a note, thereby not engaging the patient for 3 minutes, does that qualify as therapeutic minutes being spent with the patient? Three minutes can be the difference between a RU and an RV reimbursement rate. Multiply that by eight patients a day and clearly there is some serious money at stake. On the other hand if I wait until the end of the day to do my documentation, do all the notes have to be late entries?

To further darken the waters on documentation, do I have to be in line of sight of the patient or even in the same room for my minutes to count with the patient? What if the patient is getting dressed behind a curtain and I document my therapy session at a table across the room, do those minutes count? And is a curtain considered a separate area (room) from where a therapist is documenting? Or would it be easier for me to put an amendment or addendum attached to the medical record later, clarifying my intent during the therapy session.

In the world of insurance providers and paying for therapy services, a couple of minutes can be the difference between several hundred dollars in reimbursement claims. We should not expect an insurance provider to pay us simply because we are standing in the same room as a patient.

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Falls and Staffing Issues
by Jason Marketti

Reducing falls in a facility is about quick response times to answer call lights and having adequate staffing ratios to ensure the patients' needs are being met. To save money, some facilities will decrease staff to a minimum level and those who are working will have to simply pick up the pace to meet the demands of care.

As reimbursements continue to decrease, limited staffing may now be the norm even though every indicator tells us the quality of care decreases and higher fall incidences occur with fewer staff to attend to patient care. To reduce falls at night, floor lighting of different hues has been used. The soft yellow glow seems to work best, and does not disrupt the circadian rhythm as much in certain patients. But this doesn't resolve the dilemma of staffing issues as a whole.

I'm certain if patients and family members would sue a facility every time a fall occurs, changes in staffing would happen. If family members would then bring a class-action suit against their insurance carrier for being the responsible party directly related to a fall, reimbursements may go back to prior levels where adequate staffing could ensure safety to the high-risk patients. Of course, all this legal maneuvering could be avoided if insurance carriers would stop decreasing reimbursements and facilities would staff appropriately based on the needs of the patients, not the needs of the bottom line. There is finger-pointing about who is responsible every time a patient falls, but little is done to resolve the larger issues.

There have been times when a patient will have a fall and no therapy is recommended. Therapy can play an instrumental role in staffing education and patient safety to reduce the risk of falls, but some facilities underutilize the best resources that are available to ensure patient safety. Front-end staff, the CNAs, should be used at every opportunity to glean ideas from a patient-safety perspective and about how to appropriately staff any given facility. If facilities are concerned enough about patient care, they need to take steps to ensure every resident is safe and has the care required before reducing staffing levels.

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Truth in Treatment
by Jason Marketti

Since therapy has been focused on science-based evidence, I thought I would examine two treatments that are embraced by "leaders" in the therapy community. The first is visceral manipulation. The APTA took a hit for including this in the Section on Women's Health and I wanted to find out why. Jean-Pierre Barral, the French osteopath and PT, states visceral manipulation will assist with functional and structural imbalances. Sounds good enough to me, so I kept reading.

Unfortunately he lost me when the organs stored emotions and needed to be released. And since insurance companies have included this as an experimental treatment, I will pass on learning more for now. To give kudos to Dr. Barral, Time magazine ran a story about him and this alternative treatment.

The second "treatment" is craniosacral therapy. I've written about this before but wanted something more in depth and even though insurance companies find this experimental, I thought I'd once again examine the treatment and see if I believe in it. Like visceral manipulation, the concept sounded alright but when I got to the part of the energy cysts and movement of fused bones, Dr. John Upledger lost me. I won't disagree totally with this but I'll need to see and read more about it. I have to give praise to anyone who steps out of the given line of thought and devises a concept that might otherwise be overlooked and dismissed.

Many other treatments that can restore function to patients are proven, without doubt, and are reproducible in almost any clinic. When physical therapists are on the edge of holistic treatments and theories of ideomotor activity with inconclusive results, I scratch my head. But I don't totally discount any treatment that will help improve a patient's mobility and function. Now all we have to do is get the national organization behind legalizing marijuana because of all the positive effects it has on the body. But wait, there's controversy with this, kind of like endorsing visceral manipulation.

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Is 'ASPT' the Answer?
by Jason Marketti

‘ASPT' should be the new designation for PTAs who have an associate's degree in physical therapy. The PTAs who have successfully challenged the testing and don't have a degree as a PTA should not be allowed to use this. These new letters will denote we have an associate's degree in physical therapy and will practice and be licensed as a physical therapist assistant.

This new degree designation may combat some insurances that have stipulations preventing PTAs from seeing their patients. If a degree in physical therapy is required to treat a patient, the ASPT will fill that role so PTAs may qualify. This new designation wouldn't change anything in regard to a state's practice act or interfere with supervision levels required.

Some may argue that a PTA's degree is physical therapy assist, or is it physical therapist assist? But that makes no sense. This would mean I'll tell people I have an associate's of applied science degree in physical therapist assistant. Or is my degree in physical therapy assisting? Maybe I should get my degree out of storage and take a peek. My wallet license says physical therapist assistant but that doesn't mean that is the degree earned.

We should look at the PT degree designations. There was a certificate as a PT, then a BSPT, an MPT, a MSPT, a DPT, a PhD PT etc. All of those denote the degree level earned, which makes them eligible to practice and become licensed as physical therapists. As a consumer of healthcare, all the levels of degrees for a physical therapist seem confusing. Maybe PT schools should add the habilitation degree and the higher doctorate degree for physical therapists too just to have some fun with the public.

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PTA Justification
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If you've been working in therapy for a while, you'll know there are some patients who are more appropriate for a PT to see than a PTA. It's usually the PT who determines this based on the clinical and medical needs of the patient. But why even use a PTA or any assistive personnel if there's a question about acuity levels in patient care? What's the reasoning behind using supportive staff to treat patients in any setting?

The PTs will be able to answer this question better than anyone else. And there should be a clinical and medical reason behind it. If the reasoning is to see more patients in the clinic or to grow the department, that's not valid for using any assistive or supportive personnel. Cost and because state laws allow it are not clinically valid reasons either.

If PTAs and other supportive workers weren't used, patients wouldn't get seen and wait times would be greater than what they are now. But this isn't a medical or clinical reason to have a PTA treat a patient, it's a consumer convenience to have them seen for treatment as soon as possible. A stipulation on the number of patients seen in a therapy setting would keep PTs from over-utilizing PTAs and aides and allow more one-on-one time between the patient and PT. But this would severely impact a clinic financially that depends on vast numbers of patients rotating through the place. And it still won't answer the bigger question of why use a PTA if there's no clinical or medical need to?

At this point, am I talking myself out of a job? Not really. The supply and demand for services are still in our favor and according to the BLS handbook, they will be for some time. But I would like to hear from PTs on why they use PTAs or supportive staff even if there isn't a justifiably appropriate reason to do so.

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EMS and Home Assessments
by Jason Marketti

National Public Radio recently did a story on Dr. Kevin Munjal, who is in charge of EMS at Mt. Sinai hospital in New York. His idea to put the EMS system in the forefront of preventative medicine is interesting. Rather than the EMTs and paramedics simply picking up or dropping the patients off, they should inspect the home for loose wiring, throw rugs, grab bars etc. and look at the safety of the home to prevent and possibly decrease the need for EMS. And looking longer-term, to allow EMS to choose the best place to bring the patient after an acute event rather than the ER.

Right off the bat, I'll pose a question to the PT community. Does EMS have the knowledge and experience to do home assessments and make a determination on whether the patient is safe to return there?

I doubt many PTs and PTAs are home-assessment certified so what makes us any more expert at home assessments than any other provider of patient care? Not a whole lot, to tell you the truth. If EMS has a checklist like me when I enter a home, they can simply check off whether the patient does or does not have rugs, grab bars, smoke detectors etc. and then recommend the patient makes changes before returning home.

The big difference is whether the patient is able to maneuver around the home safely. This is where our therapy expertise and knowledge come in. The initial assessment would come from EMS, who would refer to therapy if a follow-up is required based on the environment and mobility of the patient. Yes, this could potentially be another referral resource for home health agencies who desire to expand their business.

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My Responsibility
by Jason Marketti

As a provider of physical therapy services, I'm often asked about information not related to my position. Questions regarding insurance coverage, co-pays, length of stay etc. are all technically outside my expertise as a PTA. I could answer these questions, and more, but often choose not to and defer them to another department or to a supervisor.

This brings me into a gray area regarding participation with therapy services. Who is responsible to educate and ensure the patient will actively work with therapy? My argument is that I provide the service but do not coerce or beg the patient to work with me. I might educate the patient on the benefits of therapy but cannot force the patient to work despite needing another 30 minutes to reach the RU level of reimbursement. The MDS provider may not agree, but therapy, like any other prescription, can be refused by the patient at any time.

Patient participation is not necessarily my problem or responsibility. It is a facility's problem when a patient doesn't want to do therapy. What does the facility do when a patient refuses his medication? Does the facility run to the manufacturer of the medication and demand they get the patient to take it? No, they simply write an "R" for "refused" in the medication chart and move on. But with therapy, a facility will quietly demand we get the minutes or there will be heck to pay for weeks and months to come. This is insane.

Soon the facilities will be demanding that therapy collect co-pays and give us a coin purse to carry around because they're having a hard time with collections. When will we step back and stand up and allow another person's difficulty to become his problem and not ours? If a facility wants RUs on patients, it can be more selective with admissions. The admission clerk can also educate the patient regarding therapy and the need to participate every day. I have yet to hear an MDS nurse or an admissions clerk educate a patient regarding RUG levels and reimbursement rates in relation to therapy participation. When that happens, I'll make the facility's problems my responsibility.

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Jimmo v. Sebelius
by Jason Marketti

By January 23, 2014, CMS will have completed the manual revisions and educational campaign regarding this case. Frankly I haven't seen much about the educational aspect of the case and I had to look up the revisions they made on various websites to get a better overview and understanding of the information involved.

The goal of the settlement was to make sure claims are adjudicated in accordance with Medicare policies so beneficiaries receive the full coverage to which they are entitled. Medicare has never supported an "Improvement Standard" in determining whether skilled care is appropriate. A patient's lack of potential to recover should not serve as a basis for denying coverage, but a determination on whether skilled care is required is the determining factor. (42 CFR 409.32(c))

Essentially, a PT has to make the assessment and determine whether the skills and knowledge of a therapist will be needed to see a patient who doesn't have the potential to recover from his illness, accident or disease. Terminal cancer patients and heavily involved CVA patients come to mind. Some therapy department may discharge a patient if there's no progress in a month or two but now this case should shed light on the coverage Medicare beneficiaries are eligible to receive.

A couple of provisions stipulate that only a "qualified physical therapist" be allowed to perform the skilled service. Heat, ultrasound, paraffin baths and whirlpools are among those services only a PT can do. Therapeutic exercises and activities should be done by or under the supervision of a PT or OT. (43 CFR 409.33)

As I've been told, expect every document you write in to be reviewed and adjudicated somewhere. To establish coverage, documentation should be relevant in identifying markers and clinical information to effectively support skilled services is needed. No more of the vague and insufficient explanations of how the patient "tolerated the treatment well."

This ruling should also open doors for patients and family members alike. We should expect more appeals from beneficiaries when PT services are discontinued. We can then allow CMS, the reviewers, family, patients, and the facility to hash out whether a patient's care is, by definition, "services which qualify as skilled rehabilitation services."

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Just in Time
by Jason Marketti

"Oh, you're just in time," the lady said when I walked into her room. "I was trying to dial a phone number, can you do it for me?"

I'm in the facility to provide a needed service to these patients; I get paid to provide that service. I'm under productivity scrutiny every time I step into a facility. I'm not here to dial phone numbers, get extra pillows and blankets and water and tuck people under the covers. The patients are in the SNF environment to get stronger to go home and I'm a facilitator of that process. My employer doesn't pay me to run around the facility answering call lights and making sure all the patients have what they need to be comfortable. I'm paid to deliver a service in the spectrum of care called physical therapy.

With that said, I did dial the number for the patient and went to see another patient who was willing to work immediately. Realistically, I don't have the time to play fetch with patients. They have a call light and can ring nursing staff anytime. Why does a patient choose to ask me for items when I walk into her room? Lack of professional respect for the therapy profession? Possibly. Some patients have told me they don't like to disturb the nursing staff because they're so busy. And I have all the free time to be their valet.

I remind patients to ring for the nursing staff if they need anything. But patients have short memories at times. "Can you take me to the laundry room to help me find my socks?" a patient asks. "Oh yes, because I have nothing better to do than serve you, my liege," I say under my breath. I get the patient up and we walk to the laundry room, focusing on balance and stability the whole way. Since the patient was so focused on finding her little bootie socks, we weren't able to utilize the gym, thus depriving the patient of a full therapy experience. Perhaps in the next session we'll have more time, unless the patient gives me a shopping list.

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