Standards for Appropriateness of Physical Therapy Care
Appropriate, skilled physical therapy treatment is intervention which is reasonable in terms of accepted physical therapy practice, and necessary to the recovery of function by the patient. Appropriate therapy services must be of such a level of complexity and sophistication, or the condition of the patient must be such, that the services required can be safely and effectively performed only by or under the direction of a qualified physical therapist.
A. Informed Consent
The physical therapist has sole responsibility for providing information to the patient and for obtaining informed consent in accordance with jurisdictional law before initiating intervention.
B. Initial Examination/Evaluation/Diagnosis/Prognosis
The physical therapist performs an initial examination and evaluation to establish a diagnosis and prognosis prior to intervention.
C. Episode of Care
Based on the examination, evaluation, diagnosis, prognosis, the physical therapist develops a plan of care, goals, and expected outcomes of physical therapy interventions for the identified impairments, functional limitations, and disabilities.
The physical therapist involves the patient/client and appropriate others in the planning, implementation, and assessment of the intervention program.
The physical Therapist, in consultation with appropriate disciplines, plans for discharge of the patient/client, taking into consideration achievement of anticipated goals and expected outcomes, and provides for appropriate follow-up or referral.
The physical therapist provides, or directs and supervises, the physical therapy intervention consistent with the results of the examination, evaluation, diagnosis, prognosis, and plan of care.
Documentation is the primary method available for justifying the appropriateness of care. Generally, appropriate care is indicated by progress toward established goals as a result of that care. It is generally expected that progress toward goals should be seen over any two-week period of treatment. If progress is not seen over a 30-day period, the documentation should show evidence of the following:
A. Re-evaluation and modification of goals and plan of care as indicated by re-evaluation.
B. Consultation with, or referral to, another health care practitioner.
C. A discussion of factors interfering with progress and rationale for continuing treatment, or
D. Discharge per APTA guidelines.
Indicators of inappropriate physical therapy care:
A. Non-skilled physical therapy
1) Routine exercises-repetitious exercise for ROM, strength or endurance without change in functional ability.
2) Routine assistance with transfers or ambulation - Repetitive assistance with ambulation without improvement in gait deviations or progress to a lesser assistive device
3) Palliative treatment - Repetitive treatment for palliative purposes which does not contribute to improvement in function.
B. Maintenance therapy - Continued treatment when patient has attained maximum functional level (except in some cases where the skill of a therapist is required to assure safe performance of the maintenance program).
C. Rehab potential - Goals are unrealistic or unattainable in view of patient's diagnosis or prior level of function.
Reasons for discontinuing physical therapy:
A. Patient has achieved Physical Therapy goals.
B. Patient has plateaued in progress or will no longer benefit from physical therapy.
C. Patient is unable to participate in the plan of care because of medical, Psychological or social complications.
Options for Continued Care:
In the event of limited funding and/or prescribed visits, the patient can be Presented with the following options:
A. Continue care on a private pay basis.
B. Assist patient in the appeal process to apply for additional funding.
C. Discharge patient at present recovery level.
D. Assist patient with pro bono care as available.
SPECIAL CONSIDERATIONS FOR DETERMINING APPROPRIATENESS OF CARE:
The physical therapist has an ethical responsibility under the "Guide for Professional Conduct" of the American Physical Therapy Association, not to provide care which "cannot result in beneficial outcome for the patient," which continues "beyond the point of possible benefit" or occurs "more frequently than necessary for maximum therapeutic effect." Sec. 3.3.C of the APTA Guide for Professional Conduct states "In turn, we have the same ethical obligation to avoid under utilization of P.T. Ö..services", P.T.s should inform their patients when they determine that the patient can benefit from P.T. Ö..despite the exhaustion of 3rd party sources of payment.
Documentation should support the effectiveness, adequacy and appropriateness of physical therapy care. Documentation should justify the necessity and value of physical therapy treatment provided to a given patient.
Each individual patient and each plan of care should be reviewed as a whole. While similarities exist between patients in relation to type of treatment provided, frequency and duration of treatment and rate of progress for a given diagnosis in a given treatment setting, each such course has its own unique variables.
A. Frequency of progress reports:
The standards of Documentation for Physical Therapy state the progress reports should be written no less frequently than monthly. In many patient treatment situations, especially those in which rapid change is seen, progress reports should be written more frequently to document change and justify continuation of treatment.
EXAMPLES: The patient with an acute back injury may demonstrate rapid change in his or her condition, in which case a progress report written on a weekly or even twice weekly basis would be appropriate. The pediatric patient with a diagnosis of cerebral palsy, however, may show only very slow progress in small increments as a result of therapy. In this case, a progress report written once a month is sufficient.
B. Slow or Minimal Progress
Some patients with pediatric or adult neurologic patterns, i.e., cerebral palsy or head injury, may show little or no functional change over the course of a month even though it is reasonably expected that continued therapy will produce change over a longer time period. A progress report should still be written on a monthly basis to review treatment provided, address reasons for slow progress, and justify continuation of treatment.
C. Prior level of function:
Goals and plan of care should be realistic and attainable for a given patient, based on the findings on evaluation and knowledge of the patient's functional abilities prior to the onset of the current condition. Documentation should reflect this prior functional level, or address why this information is not pertinent or available.
EXAMPLES: A patient who had been normally active and independent in ambulation and all ADL's would be expected to return to that functional level following rehabilitation post ankle fracture, and therapy goals and plan of treatment should reflect this. The goals and plan of treatment for the ankle fracture patient who had been paraplegic for ten years prior to the injury should be much different, reflecting this patient's individual situation.
D. Treatment setting:
Treatments utilized, frequency and duration of treatment, goals, rate of progress and outcome can vary based on specialization of the treatment setting and the typical patient found in that setting.
E. Physical Therapy Prevention:
Physical therapists may be involved in a series of occasional clinical, educational, and administrative services related to primary and secondary prevention, wellness, health promotions, and preservation of optimal function.
F. Physical Therapy Maintenance:
Patients who have reached a maximum level of function through physical therapy treatments may require an ongoing "maintenance" program to sustain this functional level. Many programs of this type can effectively be performed by the patient, a family member or other person, following instruction by the physical therapist. Periodic re-evaluations may be necessary to allow for modifications of the program. In situations where the program is of a high level of complexity or sophistication, or where considerations of patient safety require that skilled judgments be made, a physical therapist is the appropriate provider of "maintenance" therapy. Documentation needs to specifically address the reasons the skills of a therapist are required in these situations.