Embracing our PT Scope of Practice in Home Health Care …€¦ · Learning Objectives •...

Embracing our PT Scope of Practice in Home Health Care

How Times Have Changed!

Learning Objectives• Understand factors contributing to evolution of PT

Practice in the Home Health setting

• Identify specific areas where practice change may result in gaps in comfort level with certain skills

• Perform self-assessment of key clinical skill sets

• Develop an individualized plan to own your professional development, starting NOW

©2018 VNA Care. All Rights Reserved.©2018 VNA Care. All Rights Reserved.

Session overview

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• Why this topic, at this time? • How has care delivery changed?• What does that mean for PT/PTAs in HH?• Essential skills review and self-assessment• Collaboration and communication• Owning our professional development


Why this topic?

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• PT Role in Home Health has changed dramatically over the years

• PT Scope in ALL settings has evolved• Practicing at the top of your license


Why this topic?

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We’ve come a long way, baby….

• From our humble beginning as Rehabilitation Aides in 1917

• To today’s entry level Doctorate and pursuing Autonomous Practitioner status!


Why this topic?

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• States vary as to Continuing Education licensure requirements

• Curricula have evolved to meet these training needs


Why this topic?

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RESULT:

Clinicians who have been in the field for many years may have varying degrees of confidence in some areas of practice


How Has Care Delivery Changed?Industry Changes

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COMPLEXITY of PATIENTS

REIMBURSEMENT CHANGES

FRAUD, WASTE AND ABUSE


Industry Changes: Complexity of Patients

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• Hospital LOS has decreased• ER diversions vs inpatient admissions • MD office/PCP referrals• 80% of our patients in HH have 1 chronic

disease, 25% have 4 or more


Industry Changes – Complexity of Patients

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Orthopedic cases vs. Chronic Illness Advances in ortho techniques - many

patients will go to outpatient sooner/directly in the future

More of our caseloads will be Chronic Illness Management

Focus on Pre-acute


Industry Changes – Demographic Considerations

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• The number of Americans ages 65 and older is projected to more than double from 46 million today to over 98 million by 2060, and the 65-and-older age group’s share of the total population will rise to nearly 24 percent from 15 percent.

• 80% prefer to receive care at home

• In the future, bed capacity in SNF would be insufficient if we treat patients as we do today


Industry Changes – Reimbursement

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• Medicare shifting from VOLUME to VALUE

• Risk Sharing ACOs, Bundled payment programs will account for 50-80% of payment models by 2018

• HOME HEALTH – low cost provider

• SHOW OUR VALUE through OUTCOMES


Industry Changes – Reimbursement

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• Bundles, ACOs, CJR are just the beginning–Reduce cost – lower SNF and rehospitalization

• Innovation will be essential to manage patients at home into the future

• Hospital at Home, Virtual Visits

• Pre-acute management of Chronic Illness


Industry Changes - FWA

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• Fraud Waste and Abuse

• Obligation to reduce waste

• Duplication of services is considered WASTEFUL


Industry Changes –Reducing Waste

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Duplication of services across disciplines must be avoided

Areas where scope of practice OVERLAPS Right Discipline, Right Care, Right Time ZPIC audits


What does this mean for PT/PTA Practice in Home Health?

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• Patient Centered

• Every Visit must stand alone and require skill of the practitioner

• Patient interventions vs “nursing” interventions


You’re It!

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• We all play a role in keeping our patients safely home

• Requires comprehensive assessment, communication


You’re It!

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• What does this patient need NOW to be safe until the next visit?

• Who else needs to know what I’ve assessed today?

• YOU may be the one to avoid a rehospitalization (don’t wait for the nurse!)


You’re It!

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Skin -Vitals

Pain - Meds

Risk: Fall -Rehosp

PT

SN

ST

OT


Challenges & Objections

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• “We never used to have to do this before”• “The nurse does the medications”• “I never learned that in school”• “I don’t have time to do therapy if I’m doing

all of these nursing things”

…sound familiar?


Handling Resistance

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• Resistance or “pushback” can be due to more than one issue

• Sometimes it is a case of “I-don’t-wanna”• It may also represent lack of comfort with a

particular skillLet’s hone in on what we can do to increase comfort with skills, if that is the issue


“not enough time during the visit”

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• Not every intervention on the plan of care needs to be done every visit

• Prioritizing and identifying the patient’s #1 priority each visit is critical


Current Practice

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• PTs admitting more, therapy only cases

• Oasis – comprehensive assessment

• More supervision as PTA utilization increases

• Collaboration is CRITICAL


• Vitals• Lung Sounds• Pain• Skin• Medication

Management

Comprehensive Assessment

• Risk Assessments • Falls,

Hospitalization, Depression

• Symptom management and monitoring

• Patient/cg ability: self- management

• Mobility, I/ADL

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Essential Skills

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Vital Signs Lung Sounds Comprehensive Pain Assessment Comprehensive Skin Assessment Medication Management Symptom Management/Monitoring In some states – PT/INR testing


Essential Skill: Vital Signs

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Comprehensive Assessment Each Visit◦ Temperature◦ Orthostatic/positional, rest, peak, recovery HR, RR, BP, SaO2 if indicated◦ Lung Sounds Differentiate what is normal/abnormal, diminished Easyauscultation.com


Essential Skill: Vital Signs

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• Use Vital Sign monitoring to document skill and progress

• Link to function, activity tolerance, recovery time

• Use objective tests/measures

• Teach patients self monitoring: use RPE/Dyspnea scales to adjust activity


Essential Skill: Pain

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Comprehensive Assessment Each Visit Use appropriate scale Patient’s pain now, best/worst in last 24

hours, since last visit Observation - facial grimacing? Guarding? How does it relate to prior assessment?


Essential Skill: Pain

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• Type: dull, ache, sharp, throbbing, etc

• Location• Pattern: constant, frequency, duration, with

certain activities, interrupts sleep?

• Alleviating and aggravating factors

• Medications and Non-pharmacological


Essential Skill: Skin

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• Comprehensive Skin Assessment– Process by which skin of patient is examined for

abnormalities. Requires viewing skin from head to toe with emphasis on bony prominences and skin folds



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Goal of Skin Assessment Identify any pressure ulcers that may be present Assist in risk stratification Determine if there other lesions or factors that pre-

dispose pressure ulcer development (dry skin, moisture associated skin damage)

Identify other important skin conditions



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Performing the Skin Assessment◦ Always explain to the patient/family that you will be

looking at entire body with the purpose of identifying any potential skin problems◦ Conduct in a private place and minimize exposure

of body parts



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Performing the Skin Assessment, cont.◦ Focus on bony prominences- sacrum, ischial

tuberosities, greater trochanters and heels. Check skin folds, between fingers and toes and under and around medical devices for skin integrity. ◦ Communicate findings to interdisciplinary team◦ If you are unsure how to document/or what you

are seeing, ask!


Essential Skill: Med Management

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• Medications effect function (pain, inflammation, airway clearance, CV system, neuro system, falls)

• PTs monitor for medication effects on health, function, impairment and disability

• Comprehensive drug review is within the scope of P.T. practice. We can identify problems/concerns and collaborate with our nursing colleagues when needed to address issues.



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• ~400,000 preventable adverse drug events annually in the U.S.

• 4 med types account for ~67% of hospitalizations due to med errors: Warfarin, Hypoglycemics, Insulin, Antiplatelet meds

• Beer’s List-guidelines that apply to all elders. Includes a general list of medications to avoid in elderly and a list of medications to avoid based on certain diagnoses.



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• Medication Issues to Consider during Tx– Parkinson’s: time session when Sinemet is at its peak

– COPD: ½ hour after nebulizer treatment

– Diabetic: best when blood sugar is in range



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When you see a significant change in patient status, be sure to look back and ask about medication changes, missed doses or incorrect doses. P.T. is often the discipline who picks up on changes in status which result from medication issues.


Essential Skill: Patient Self-Management

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• Patients must take an active role in their recovery• It is our role to empower patients to self-monitoring

for long term successful management• Utilize patient educational materials to reinforce

teaching• Know when to call agency/MD – “Call us first”Example: COPD pt needs to be aware of S/S to report immediately - increased dyspnea with same activity level, changes in sputum, orthopnea, changes in SaO2.


Essential Skill: Patient Self-Management

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TEACH BACK is essential at every visit◦ Patients forget as much as 80% of what we teach

them during visit, only 50% of what they recall may be accurate◦ Example: “please tell me in your own words what

I told you about when to call the VNA based on your symptoms. I want to be sure that I was clear in my instructions”


The Minimum Standard

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The skills we reviewed are the expected standard of care within our scope as PTs

Challenge yourself to grow beyond these in order to best serve your patients◦ Postural drainage◦ Percussion/Vibration (BPH) “chest PT”


Self Assessment

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Rate your comfort level with each skill from:

1 Least confident - “I REEEEEALLY need to practice/learn this one” to

5 MOST confident - “I do this routinely and could teach this skill”


Self Assessment

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SKILLSKILL 1 2 3 4 5

Vital Signs – RESTING

Blood Pressure

Heart Rate

Respiratory Rate

Oxygen Saturation

Pain

Vital Signs – ORTHOSTATIC

Vital Signs – PEAK EXERCISE

Vital Signs – RECOVERY TIME

Vital Signs – integrating into documented patient goals

Lung Auscultation – identifying presence of diminished/abnormal breath sounds


Self Assessment

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SKILLS 1 2 3 4 5

Comprehensive Pain Assessment • using proper tool/scale• aggravating/alleviating factors• impact on function

Comprehensive Skin Assessment – baseline assessment

Skin assessment – turgor

Skin assessment – wound assessment/measurement/staging

Wounds: basic dressing changes

Medication Reconciliation

Using Teach Back with Patients

Using RPE and Dyspnea scales

Integrating symptom/patient self- management into goal writing


Collaboration and Communication

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• With Patient/Family– Teachback

• With MD/Case Managers– SBAR – situation, background, assessment,

recommendation, be concise and clear

• With Manager and Team– Case Conferencing, Email, Voicemail, other



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Coordinate visit days/times with other disciplines

Update team members on status/findings

Document coordination of care Coordinate discipline discharges and

discuss status throughout episode



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“But I don’t have time!!!!!”• Under new CoP, Collaboration even more critical

• NOT AN OPTION not to communicate with the team

• Provision of patient schedule required

• During the visit when able - Use tools for efficient communication (email, vm)



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• Better Care

• Better Patient Satisfaction– Knowing that we communicate gives patients

confidence in the care we are providing


Owning Professional Development

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Use your LIFELINES◦ Call your manager, peer◦ Ask for a co-visit

Know what you know, ask questions Don’t be afraid not to know it all



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APTA Code of Ethics and Guide for Professional conduct states that professional development, continuing competence, and life-long learning are integral to providing evidence based high quality patient care.

Standards of Practice state that the “Physical Therapist is responsible for individual professional development.”



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Individual clinicians are responsible to enhance their own practice development

Identify areas where you are not comfortable and seek assistance.



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Journal Articles Courses Joint Visits with manager, peers E-learning - modules and videos Case Conferencing OTHER


MY INDIVIDUALIZED PLAN• What are the skill

sets I need to develop?

• What resources are available to me at my agency?

• APTA Resources

• What is ONE thing I will do right away to OWN it!

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Questions?

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References

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•“Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions from Hospital to Community”. Physical Therapy, Vol 96, No 8, August 2016. Jason R. Falvey, Robert E. Burke, Daniel Malone, Kyle J. Ridgeway, Beth M. McManus, Jennifer E. Stevens-Lapsley.

•“A Validation Study of the Missouri Alliance for Home Care Fall Risk Assessment Tool”Home Health Care Management and Practice, Volume: 25 issue: 2, page(s): 39-44 Article first published online: September 6, 2012;Issue published: April 1, 2013 DOI: https://doi.org/10.1177/1084822312457942Mary Calys, DPT, PT1, Kendra Gagnon, PhD, PT2, Stephen Jernigan, PhD, PT2

1North Kansas City Hospital, North Kansas City, MO, USA2University of Kansas Medical Center, Kansas City, KS, USA

•APTA Official Statement: The Role of Physical Therapists in Medication Management

•Minimum Required Skills of Physical Therapist Graduates At Entry-Level (BOD G11-05-20-49)

•APTA Guide to Physical Therapist Practice

•Easyauscultation.com

•http://www.prb.org/Publications/Media-Guides/2016/aging-unitedstates-fact-sheet.aspx

https://doi.org/10.1177/1084822312457942

http://journals.sagepub.com/author/Calys,+Mary

http://journals.sagepub.com/author/Gagnon,+Kendra

http://journals.sagepub.com/author/Jernigan,+Stephen

http://www.prb.org/Publications/Media-Guides/2016/aging-unitedstates-fact-sheet.aspx

Embracing our PT Scope of Practice in Home Health Care …€¦ · Learning Objectives •...

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