Utilization of the Physical Therapist Assistant

1. Utilization of the Physical Therapist Assistant • A Mentoring Relationship • Lindsay Pugmire MSPT, CCI • Amelia Partridge PTA, CCI

2. Objectives – first hour • Identify the main areas of the Utah PT Practice act that pertain to the PTA • Understand the role of the PT, PTA and aide • Define Physical Therapist, Physical Therapist Assistant and physical therapy aide • Define General Supervision and On-Site Supervision and how they pertain to the PTA • Identify those items specifically mentioned by the practice act which are outside the scope of practice of a PTA • Identify the Authority of the PTA • Understand Medicare policies regarding supervision of the PTA

3. Objectives – second hour • Identify skills Physical Therapists feel are most lacking in the PTA. • Identify qualities that Physical Therapists expect in a PTA regarding effective teamwork. • Identify leadership skills Physical Therapist Assistants feel are lacking in Physical Therapists. • Identify qualities that Physical Therapist Assistants expect in a Physical Therapist regarding effective teamwork. • Describe current practice patterns when utilizing a Physical Therapist Assistant in the state of Utah. • Define mentoring and foster a greater understanding of effective mentoring/collaboration in the PT/PTA relationship.

4. Utah Physical Therapy Practice Act Title 58, Chapter 24b Utah Code Annotated 1953 As Enacted by Session Laws of Utah 2009 Issued July 1, 2009 Physical Therapy Practice Act Rule R156-24b Utah Administrative Code Issued December 9, 2010 http://dopl.utah.gov/licensing/physical_therapy.html

5. Utah Practice Act Definitions General Supervision Supervision and oversight of a person by a licensed physical therapist when the licensed physical therapist is immediately available in person, by telephone, or by electronic communication. On Site Supervision Supervision and oversight of a person by a licensed physical therapist or a licensed physical therapist assistant when the licensed physical therapist or licensed physical therapist assistant is; a) continuously present at the facility where the person is providing services b) immediately available to assist the person; and c) regularly involved in the services being provided by the person Licensed Physical Therapist A person licensed under this chapter to engage in the practice of physical therapy.

6. Licensed Physical Therapist Assistant A person licensed under this chapter to engage in the practice of physical therapy, subject to the provisions of subsection 58-24b-401(2) (a) 58-24b-401 A licensed physical therapist assistant: (a) is authorized to practice physical therapy; (i) under the on-site supervision or general supervision of a licensed physical therapist; and (ii) within the scope of practice of a licensed physical therapist assistant, as described in this chapter and by rule; (b) shall adhere to the standards of ethics described in: (i) the American Physical Therapy Association's Code of Ethics and Guide for Professional Conduct; and (ii) rule; and (c) may not be supervised by any person other than a licensed physical therapist.

7. 58-24b-402 In practicing physical therapy, a licensed physical therapist shall: (a) manage all aspects of the physical therapy of a patient under the licensed physical therapist's care; (b) perform the initial evaluation and documentation for each patient; (c) perform periodic reevaluation and documentation for each patient; (d) perform physical therapy interventions that require immediate and continuous examination and evaluation throughout the intervention; (e) perform all therapeutic intervention on a patient that is outside of the standard scope of practice of a licensed physical therapist assistant or a physical therapy aide; (f) determine the therapeutic intervention to be performed by a licensed physical therapist assistant under the on-site supervision or general supervision of the licensed physical therapist to ensure that the therapeutic intervention is safe, effective, efficient, and within the scope of practice of the licensed physical therapist assistant; (g) conduct the discharge of each patient and document for each patient, at the time of discharge, the patient's response to therapeutic intervention; and (h) provide accurate documentation of the billing and services provided.

8. Under Utah State Practice Act, Both PTs/PTAs “shall adhere to standards of ethics described in the American Physical Therapy Association’s Code of Ethics and Guide to Professional Conduct Code of Ethics for the Physical Therapist Standards of Ethical Conduct for the Physical Therapist Assistant Ethics Documents Both Documents revised 2010

9. Code of Ethics for the Physical Therapist Principle #5: Physical therapists shall fulfill their legal and professional obligations. (Core Values: Professional Duty, Accountability) 5B. Physical therapists shall have primary responsibility for supervision of physical therapist assistants and support personnel. Principle #3: Physical therapists shall be accountable for making sound professional judgments. (Core Values: Excellence, Integrity) 3E. Physical therapists shall provide appropriate direction of and communication with physical therapist assistants and support personnel. Standards of Ethical Conduct for the Physical Therapist Assistant Standard #5: Physical therapist assistants shall fulfill their legal and ethical obligations. 5B. Physical therapist assistants shall support the supervisory role of the physical therapist to ensure quality care and promote patient/client safety.

10. Although the Practice Act delineates specific interventions that a PTA “may not” perform this is NOT the only defining limitation to PTA interventions. • The Physical Therapist determines the appropriate interventions delegated to the PTA. • 58-24b-402 • In practicing physical therapy, a licensed physical therapist shall: • (a) manage all aspects of the physical therapy of a patient under the • licensed physical therapist's care; • (d) perform physical therapy interventions that require immediate and • continuous examination and evaluation throughout the intervention; • (f) determine the therapeutic intervention to be performed by a licensed • physical therapist assistant under the on-site supervision or general • supervision of the licensed physical therapist to ensure that the • therapeutic intervention is safe, effective, efficient, and within the • scope of practice of the licensed physical therapist assistant

11. Physical Therapy Aide a person who is trained, on the job, by a licensed physical therapist; and provides routine assistance to a licensed physical therapist or physical therapist assistant while the licensed physical therapist or licensed physical therapist assistant practices physical therapy within the scope of the licensed physical therapist’s or licensed physical therapist assistant’s license. PTA/ Aide may not: A physical therapist assistant or a physical therapy aide may not: (a) perform a physical therapy evaluation or assessment; (b) identify or label a physical impairment or injury; (c) design a plan of care for a patient; (d) perform the joint mobilization component of manual therapy; or (e) perform the sharp selective debridement component of wound management.

12. Authority and Ethical Standards A licensed physical therapist assistant: (a) is authorized to practice physical therapy; (i) under the on-site supervision or general supervision of a licensed physical therapist; and (ii) within the scope of practice of a licensed physical therapist assistant, as described in this chapter and by rule; (b) shall adhere to the standards of ethics described in: (i) the American Physical Therapy Association's Code of Ethics and Guide for Professional Conduct; and (ii) rule; and (c) may not be supervised by any person other than a licensed physical therapist.

13. Authority and Ethical Standards A physical therapy aide: (a) A physical therapy aide may not engage in the practice of physical therapy. (b) Notwithstanding Subsection (3)(a), a physical therapy aide may provide routine assistance to: (i) a licensed physical therapist while the licensed physical therapist engaged in the practice of physical therapy, if the physical therapy aide is under the on-site supervision of the licensed physical therapist; or (ii) a licensed physical therapist assistant while the licensed physical therapist assistant engages in the practice of physical therapy, within the scope of the licensed physical therapist assistant's license, if the physical therapy aide is: (A) under the general or on-site supervision of a licensed physical therapist; and (B) under the on-site supervision of the licensed physical therapist assistant.

14. Joint Mobilization A physical therapist assistant or a physical therapy aide may not: (a) perform a physical therapy evaluation or assessment; (b) identify or label a physical impairment or injury; (c) design a plan of care for a patient; (d) perform the joint mobilization component of manual therapy; or (e) perform the sharp selective debridement component of wound management. Subsection (2)(d) does not apply to: (a) simple joint distraction techniques or stretching; or (b) a stretch or mobilization that can be given as part of a home exercise program.

15. Joint Mobilization cont. Joint Mobilization (definition by Kisner and Colby): Passive traction and/or gliding movements applied to the joint surfaces that maintain or restore the joint play normally allowed by the capsule so the normal roll-slide joint mechanics can occur as a person moves

16. Medicare Guidelines for PTA Utilization Use of Physical Therapist Assistants (PTAs) under Medicare Please note that physical therapists are licensed providers in all states and physical therapist assistants are licensed providers in the majority of states. As licensed providers, the state practice act governs supervision requirements. Some state practice acts mandate more stringent supervision standards than Medicare laws and regulations. In those cases, the physical therapist and physical therapist assistants must comply with their state practice act. For example, in a skilled nursing facility in New Jersey, a physical therapist must be on the premises when services are furnished by a physical therapist assistant despite the fact that Medicare requires general supervision. New Jersey's state practice act requires direct supervision rather than general supervision, and therefore, the physical therapist and physical therapist assistant would have to comply with this requirement. http://www.apta.org/Payment/Medicare/

17. Medicare Guidelines for PTA Utilization • Home Health Agencies (HHA) • Physical therapy services must be performed safely and/or effectively only by or under the generalsupervision of a skilled therapist. General supervision has been traditionally described in HCFA manuals as requiring the initial direction and periodic inspection of the actual activity. However, the supervisor need not always be physically present or on the premises when the assistant is performing services. • Inpatient Hospital Services • Physical therapy services must be those services that can be safely and effectively performed only by or under the supervision of a qualified physical therapist. Because the regulations do not specifically delineate the type of direction required, the provider must defer to his or her physical therapy state practice act. • Outpatient Hospital Services • Physical therapy services must be those services that can be safely and effectively performed only by or under the supervision of a qualified physical therapist. Because the regulations do not specifically delineate the type of direction required, the provider must defer to his or her physical therapy state practice act.

18. Medicare Guidelines for PTA Utilization • Private Practice • Physical therapy services must be provided by or under the direct supervision of the physical therapist in private practice. CMS has generally defined direct supervision to mean that the supervising private practice therapist must be present in the office suite at the time the service is performed. • Physician's Office • Services must be provided under the direct supervision of a physical therapist who is enrolled as a provider under Medicare. A physician cannot bill for the services provided by a PTA. The services must be billed under the provider number of the supervising physical therapist. CMS has generally defined direct supervision to mean that the physical therapist must be in the office suite when an individual procedure is performed by supportive personnel. • Skilled Nursing Facility (SNF) • Skilled rehabilitation services must be provided directly or under the general supervision of skilled rehabilitation personnel. General Supervision is further defined in the manual as requiring the initial direction and periodic inspection of the actual activity. However, the supervisor need not always be physically present or on the premises when the assistant is performing services.

19. APTA has adopted PTA Direction/Supervision Algorithm

20. Check Your Understanding • Select each activity, based on the algorithm, the PTA can be expected to do: • Know when to provide care or hold care • Ensure that the patient is safe and comfortable throughout the intervention • Decide if the intervention is producing the desired results • Modify the intervention within the plan of care to improve patient outcomes • Select data collection techniques to measure the patient’s progress • Determine when the patient is ready to be progressed within the plan of care • Determine when it is necessary to communicate with the physical therapist X X X X X X X

22. PTA Decision making Algorithm

23. QUESTIONS?

24. Survey Results Participants PT = 100 – 103 Participants PTA = 34-38

25. Years of Experience -- PT

26. Do you currently work with a PTA or have you worked with one in the past?

27. If you answered yes to question #2, Do you feel that you have a good relationship with the PTA with whom you work?

28. In your education, did you have a class in the role/utilization of PTA’s?

29. Food For Thought • It follows, therefore, that educational opportunities for you must be formulated with extreme care, and that you must with equal intensity watch and be involved in their formation. Appropriate utilization and direction/supervision of the PTA is a critical, critical skill in which every new PT grad must be competent by graduation. Yet they currently are not. Many PTAs know more about what is legal, ethical, and expected of them than do PTs. • Barbara Bradford, PT; PT in Motion; PTAs Today; “The History Makers” February 2010

30. What skills do you find most lacking in PTA’s? • 1. Critical reasoning when advancing or progressing the patient using ongoing assessment skills. • 2. Treatment technique skills; mainly manual therapy and advanced therapeutic exercise. • 3. Education and knowledge base; needs more schooling time like a 4 year or BS degree.

31. Food For Thought • The two most mentioned skills lacking in the PTA (assumption: skills that PT’s want PTA’s to have based on the survey) are two skill sets limited by the Utah State practice act. • (2) A physical therapist assistant or a physical therapy aide may not:(a) perform a physical therapy evaluation or assessment • (d) perform the joint mobilization component of manual therapy. Utah Practice Act 58-24b-402

32. Food For Thought (a). Where do we draw the line between a formal assessment and the every second we touch and intervene with a patient using clinical reasoning and assessing skills to adapt the technique or progress the patient based on their response; or do we draw a line in the practice act? • From APTA CPI for the PTA – One skill set the PTA student is graded on is Clinical Problem Solving.

33. What qualities do you feel are the most important or that you expect from a PTA for effective teamwork related to patient care? • 1. Communication skills: • Effective Timely Collaborative • Openness consistent Ask Questions • 2. Critical thinking/understanding of the big picture. • 3. Awareness of limitations.

34. How many years have you been practicing? -- PTA

35. Do you feel that you have a good relationship with the PT you primarily work with?

36. What statement best describes how you currently practice?

37. Do you feel that the PT with whom you primarily work encourages growth and increased opportunities in developing your skills?

38. What leadership skills do you find most lacking in PT’s? • 1. Communication (especially with plans of care). • 2. Delegating appropriately • Too much Not enough • 3. Respect/Trust

39. What qualities in the PT do you expect or feel are the most important for effective teamwork related to patient care? • 1. Communication: • Effective Clear Timely • ApproachableListeningConsistent • 2. Respect/Trust • 3. Collaborative

40. What does the word mentoring mean to you in regard to the PT/PTA relationship? • In mentoring in regards to the PT/PTA relationship, I see it as a two way street. The PT has the ability to teach and educate the PTA so that patients can be effectively treated, however the PTA can also be proactive regarding what they know and teaching the PT their skills as well. • I see that word more appropriate for a new hire or a student, I feel it should be more of a colleague in terms of PT/PTA relationship.

41. What does the word mentoring mean to you in regard to the PT/PTA relationship? • I'm don't think that word applies in a working relationship between co-workers. • I would suggest a mentoring relationship would be good, but it assumes some give and take in communication and openness. If that does not happen, then it feels defensive. • Mentoring means that I get the opportunity to lead by example the behaviors I want to see in the PTA. • Not much.

42. What does the word mentoring mean to you in regard to the PT/PTA relationship? • I don't believe a PTA should have to be mentored. • All of us have something to learn from each other. Mentoring should be a respectful and consistent sharing of skills and knowledge for perpetual personal/professional growth and progression of care to those we serve. • Teaching, educating, working together, understanding, communication.

43. What does the word mentoring mean to you in regard to the PT/PTA relationship? • Having someone to bounce questions off of, and have open lines of communication regarding patient care. Mentoring should provide a comfortable environment for two way conversation and room to grow as a professional. • Mentoring means sharing our individual skills that complement each other & add to our own professional growth & development. Mentoring can certainly go both ways, based on education, specialized training & experience.

44. What does the word mentoring mean to you in regard to the PT/PTA relationship? • A leader who has patience, one that is passionate about their job, willing to explain/share their techniques and is also eager to learn alongside the PTA. • Being able to take years of experience and teach it to me little by little. Both having respect for each other. Patience in the learning process. • Mentoring to me means having a lead PT that is still willing to educate and challenge me as a PTA.

45. APTA Decision Algorithm…Sounds Like Mentoring

46. APTA Resources For PTA Utilization • Free Course • learningcenter.apta.org • “Leading the Team: A Practical Guide to Working With PTAs” • Note: Item 65: Mentoring PTA Career Development

47. Desired Characteristics of a Mentor • People Oriented • Good Motivator– A mentor is someone who inspires a mentee to do better. • Effective Teacher • Secure in position– A mentor must be confident in their own abilities so that the mentee’s accomplishments can be genuinely expressed. • An Achiever • Values Their Profession and work • Respects Others– A mentor is one who shows regard for another’s well being. Openness to others. (Quartermaster warrant officer mentorship guide – www.quartermaster.army.mil)

48. Desired Characteristics of a Mentee • Eagerness to Learn– Seek advice. • Ability to Work as a Team Player • Patient– Learning is a process, be committed. • Risk Taker– Move beyond tasks that have been mastered to accept new and more challenging experiences. • Positive Attitude (Quartermaster warrant officer mentorship guide – www.quartermaster.army.mil)

49. What has Worked For Us? • Mentoring where it has been collaboration with colleagues (Two-way street). • Consistent communication both directions. • Living the characteristics listed in the previous slides.

50. What has Worked For Us? • Co-Treating to model and coach skills. • Managing each other UP in the presence of the patient. • TEAMWORK.