Supervision and Delegation

1. Supervision and Delegation Alyssa Trotsky, DPT Natalia Fernandez, BPT, MSc, MS, CCS University of Michigan Health System May 23rd, 2013

2. Learning Objectives By the end of the lecture, students will be able to: • Describe the educational background and responsibilities of a physical therapy assistant (PTA) and physical therapy aide. • Distinguish the levels of supervision. • Explain how PTAs should be utilized under Medicare. • Verbalize state rules and considerations that the PT should account for when delegating tasks to a PTA or PT aide. • Describe responsibilities performed exclusively by a PT.

3. PTA Background Education: • Associate degree • Course work includes classes in therapeutic exercise, modalities, and communication. • Students have clinical experiences in a variety of settings. Licensure: • Required to have a license or certification. • Needs to be renewed regularly with some states requiring continuing education to renew.

4. PTA Background Continued Description: • Work under the direction and supervision of a physical therapist • Perform components of a physical therapy plan of care developed by a supervising PT. Minimum Entry-Level Skills: • Chart review and understand contraindications. • Notify PT of any changes in patient medical status or if the patient complexity if outside of their knowledge. • Perform, modify, and objectively assess interventions. • Communicate with other health care professionals. • Perform accurate documentation of treatment sessions.

5. Use Of PTA Under Medicare Home Health Agencies • Physical therapy services must be provided safely/ effectively only under the general supervision of a skilled therapist. Inpatient Hospital Services • PT services must be those services that can be safely and effectively performed only by or under the supervision of a qualified PT. • The provider must defer to PT state act as the regulations do not specifically delineate the type of direction required.

6. Use Of PTA Under Medicare Continued Outpatient Hospital Services: • PT services must be those services that can be safely and effectively performed only by or under the supervision of a qualified PT. • The provider must defer to the PT state act as the regulations do not specifically delineate the type of direction required. Skilled Nursing Facility: • Skilled rehabilitation services must be provided directly or under the general supervision of skilled rehabilitation personnel.

7. Levels Of Supervision • The American Physical Therapy Association (APTA) recognizes the following levels of supervision: • General Supervision: the PT is not required to be on-site for direction and supervision, but must be available at least by telecommunications. • Direct Supervision: the PT is physically present and immediately available for direction and supervision. • Direct Personal Supervision: the PT, or where allowable by law, the PTA, is physically present and immediately available to direct and supervise tasks that are related to patient/client management.

8. Direction And Supervision Of The PTA • Direction and supervision are essential in the provision of quality PT services. • In determining the appropriate extent of assistance from the PTA, the PT should consider: • PTA’s education, training, experience, and skill level • Responsibilities of parties involved • Organizational structure in which PT services are provided • Patient client criticality, acuity, stability, and complexity • The setting in which care is delivered • Federal and state statuses • Liability and risk management concerns • The mission of PT services for the setting • The needed frequency of reexamination

9. Supervising PTA In Off-Site Setting • When supervising the PTA in an off-site setting, the following requirements should be observed: • The PT must be accessible via phone while the PTA is treating patients. • Have regularly scheduled and documented conferences with the PTA. Should be determined by needs of patient and needs of PTA. • Supervisory visits • Re-examiantion of patient • Review plan of care • Evaluation of need for utilization of outside resources

10. Supervision And Delegation Of PTA In Michigan • Services must be provided safely/effectively under the general supervision of a skilled therapist. - General Supervision: the PT is not required to be on-site for direction and supervision, but must be available at least by telecommunications. • Verify the qualifications of the PTA • Examine and evaluate the patient before delegating interventions • Provide predetermined procedures and protocols for all delegated tasks. • Maintain a record of the names of the PTAs to whom tasks have been delegated to. • Meet regularly and in person with PTA to evaluate performance, review record, and educate on delegated tasks. • PT should not supervise for than 4 PTAs at one time.

11. PT Aide Background • Unlicensed individual with educational requirements set by the supervising PT. • Should have great communication and interpersonal skills. • Can work in a variety of settings and require direct supervision of a physical therapist • On the job training is specific to each employer.

12. Direction And Supervision Of The PT Aide In Michigan • Services must be provided safely/effectively only under the direct supervision of a skilled therapist. - Direct Supervision: the physical therapist is physically present and immediately available for direction and supervision. • PT should have regular meetings with aide to evaluate the individual’s performance, review records, and educate on the tasks that have been delegated. • Maintain a record of the names of all the unlicensed individuals in which tasks have been delegated to. • Provide predetermined procedures and protocols for all delegated tasks. • Examine and evaluate the patient before delegating task. • PT must have contact with patient upon each visit.

13. Responsibilities Performed Exclusively By PT • Regardless of the setting, the following responsibilities should only be carried by a PT: • Interpretation of referrals • Initial examination, evaluation, diagnosis, and prognosis • Determine the most appropriate utilization of a PTA that provides for the delivery of service that is safe, effective, and efficient. • Re-examination of the patient/client in light of their goals and revise the plan of care accordingly. • Establish discharge plan and documentation of discharge summary/status. • Oversee all documentation for services rendered to each patient/client. • Procedures that require immediate and continuous examination and evaluation throughout the intervention are performed exclusively by the PT. • Spinal and peripheral joint mobilization/manipulation (manual therapy) • Selective sharp debridement (wound management)