"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Friday, November 12, 2010

Standards in Physical Therapy

This question came up from an interested reader and I'm re-posting it here to provide a forum for discussion. Let me know if you have any other questions along these lines...

Dear Tim,

"Are there specific standard functional levels for post acute cure patients in deciding what level of care is optimal for these patients:
  • In Patient Rehab
  • SNF
  • HH
  • Hospice
  • Outpatient Service?
I do understand there are multiple considerations in this decision making process as well as the payer coverage and patient/family desires/considerations... however I wondered if there were standards available.

I would appreciate any insight into the deliveries of care."

Thank you,

Dear NM,

You've brought up a great point: Are there standards for post-acute care for physical therapy patients? My experience is in outpatient delivery but these suggestions should be applicable to any ambulatory, post-acute setting.

Your question is rather broad so I'll take the liberty of addressing a specific portion - should we change over the course of care or discharge functional status?

This issue, incidentally, also begs the question of how to assess baseline status, medical necessity for physical therapy and progress in an expected time frame required for Medicare reimbursement.

At this time, a lot of work is being done assessing change over the course of care: you can do this work yourself using validated change scores like MCID or MDC for patient self-report (eg: ODI, LEFS, NDI...) and performance scales like Step Test, 10' Gait Velocity, et al.

You can also pay to have it done for you by groups like FOTO, AM-PAC or even DOTPA (you pay with your time).

Is there a standard for discharge function?

Not really.

Lots of groups have published age-and-gender matched norms for their tests (eg: Cybex, MedX and even tests like Single Leg Support) but these just give averages.
"Averaging stamps out diversity, reducing anything to its simplest terms.
In so doing, we run the risk of oversimplifying, of forgetting the variations around the average" - Kaiser Fung

To determine your optimal level of care you'll need to delve into your physical therapy evidence base (or pay to have it done for you). It's not that hard, in fact, the hardest part is just getting started.

This article discusses some of the predictors of function for shoulder patients, depending on how you assess outcome.

Prognosis in Soft Tissue Disorders of the Shoulder: Predicting Both Change in Disability and Level of Disability After Treatment

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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

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