Midterm Exam Review 2024.pdf

Midterm Exam Review Professional Issues I Format Multiple Choice Short Answer General Guidelines Review course objectives What topics did we spend the most time on? What topics involved practical exercises? APTA Core Values Accountability Altruism Collaboration Compassi...

Midterm Exam Review Professional Issues I Format Multiple Choice Short Answer General Guidelines Review course objectives What topics did we spend the most time on? What topics involved practical exercises? APTA Core Values Accountability Altruism Collaboration Compassion and Caring Duty Excellence Integrity Social Responsibility Inclusion Who/What governs the practice of PT? Governing Entities National— Local—facility policies/procedures State– State Board/Practice Acts Federal—Medicare, ADA, HIPAA CAPTE The Commission on Accreditation in Physical Therapy Education The only accreditation agency recognized by the United States Department of Education (USDE) and the Council for Higher Education Accreditation (CHEA) to accredit entry-level physical therapist and physical therapist assistant education programs Establish baseline educational standards for PT/PTA education programs Federation of State Boards of Physical Therapy Our Mission: To protect the public by providing service and leadership that promote safe and competent physical therapy practice. Our Vision: To achieve a high level of public protection through a strong foundation of laws and regulatory standards in physical therapy, effective tools and systems to assess entry-level and continuing competence, and public and professional awareness of resources for public protection. Federation of State Boards of Physical Therapy https://www.fsbpt.org/ 6 Focus Areas 1. Examinations- Ensure the ongoing excellence, reliability, defensibility, security and validity of the NPTE® and related examinations. 2. Membership- Enhance the Federation's value to its membership by developing and maintaining programs and services responsive to membership needs. 3. States' Rights, States' Responsibilities and Professional Standards- Identify and promote effective regulation in physical therapy that ensures the delivery of safe and competent physical therapy care, while respecting states’ rights and responsibilities. 4. Education- Provide and promote educational programs and products for board members, administrators, the public and other stakeholders. 5. Leadership- To broaden the Federation's leadership role and recognition within the regulatory, professional and related communities. 6. Organizational and Financial Stability- Ensure the long-term organizational and financial stability and viability of the Federation. Other Elements to Guide your Practice Local/Facility/Employer Policies and Procedures Policies are principles, rules, and guidelines formulated or adopted by an organization to reach its long-term goals. They are designed to influence and guide major decisions, actions, and activities. Procedures are the methods used to put policies into action in day-to-day operations. Examples: Equipment Maintenance and Calibration Personnel Evaluations Emergency Response Documentation  State Practice Act and State Board Specify parameters for legal practice in that jurisdiction (Scope of Practice) Direct Access Manipulation Dry Needling Scope of Practice Diagnostic Imaging “Definition of the rules, the regulations, and the Supervision boundaries within which a fully qualified practitioner with substantial and appropriate training, knowledge, and experience may practice… Jurisprudence Exam/Education …..Such practice is also governed by requirements for continuing education and professional accountability.” Assessing Scope of Practice in Health Care Delivery: Critical Questions in Assuring Public Access and Safety, Federation of State Medical Boards, 2005. APTA Code of Ethics https://www.apta.org/apta-and-you/leadership-and-governance/policies/code-of- ethics-for-the-physical-therapist APTA Guide for Professional Conduct https://www.apta.org/your-practice/ethics-and-professionalism/apta-guide-for- professional-conduct APTA Standards of Practice https://www.apta.org/apta-and-you/leadership-and-governance/policies/standards- of-practice-pt APTA Standards of Practice https://www.apta.org/apta-and-you/leadership-and-governance/policies/standards- of-practice-pt Ethical & Legal Administration of Physical Therapy Service Patient/Client Management Education Advocacy Research Community Responsibility The Guide to Physical Therapist Practice (aka “The Guide”) https://guide.apta.org/ PTA Education and Scope of Work Coursework includes: Anatomy & Physiology Exercise Physiology Therapeutic Exercise Biomechanics/Kinesiology Neuroscience, Musculoskeletal, Integumentary, Cardiopulmonary, Behavioral sciences Communication Professional issues/Ethics/Values. “…prepares the graduate to perform selected* components of intervention and data collection and assess the patient's/client's safety and response to the interventions provided under the direction and supervision of a PT” CAPTE PTA Education and Scope of Work selected* components of intervention the procedural intervention, associated data collection, and communication- including written documentation associated with the safe, effective, and efficient completion of the task. (CAPTE) PTAs implement components of patient care, obtain data related to the treatments provided, and collaborate with the PT to modify care as necessary. (APTA) The physical therapist is responsible for the services provided by the PTA. PTAs are not permitted to perform evaluations, assessment procedures, or certain complex procedures; nor do they design plans of care or develop treatment plans. Accordingly, PTAs do not possess an independent “scope of practice” as do PTs. (CMS Report to Congress) Interventions Exclusive to PTs Risk Management in PT Practice Available from APTA Website PTA Direction Algorithm https://www.apta.org/contentassets/fe6172e394964ca0866ed2f5cb775662/ pta-direction-algorithm-chart.pdf Within PTA Scope of Work Stable Predictable Personal KSAs* of PTA Risk/Liability mitigation Payer requirements KSA- Knowledge, Skills, Abilities Risk Management in PT Practice Available from APTA Website PTA Supervision Algorithm https://www.apta.org/contentassets/fe6172e394964ca0866ed2f5cb775662/ pta-supervision-algorithm-chart.pdf Clear/ongoing communication Safety Patient progression PTA Problem Solving Algorithm https://www.apta.org/contentassets/fe6172e394964ca0866ed2f5cb775662/ problem-solving-algorithm-ptas-patient-intervention.pdf Key Takeaways PT is solely responsible for examination, evaluation, diagnosis, prognosis, plan of care, re-examination PT directs the PTA; PT does not delegate to PTA State Practice Act is your go-to document; PT responsible for care provided by PTA Use most stringent criteria to guide your practice APTA House of Delegates Position Ramifications of going against professional guidelines? Autonomy Practice Variability Credibility Risk Management in PT Practice Maintain responsibility of patient management Provide direction and supervision to the PTA in accordance with applicable laws and regulations Conduct periodic reassessment/reevaluation of the patient as directed by the facility, federal and state regulations, payers, and the needs of the patient; and Provide support to the PTA and, when appropriate, assist in developing the PTA’s knowledge and skills necessary to perform selected interventions and related data collection Transitioning/Transferring Care to PTA Communicate, Communicate, Communicate Patient, PTA No ambiguity Regular meetings and follow up Document, Document, Document Any and all communication No ambiguity Sign/Co-sign Types of Supervision (APTA House of Delegates, 2019) General Supervision: General supervision applies to the physical therapist assistant. The physical therapist is not required to be on site for direction and supervision but must be available at least by telecommunications. The ability of the physical therapist assistant to provide services shall be assessed on an ongoing basis by the supervising physical therapist. Types of Supervision (APTA House of Delegates, 2019) Direct Supervision: Direct supervision applies to supervision of the student physical therapist and student physical therapist assistant. The physical therapist, or the physical therapist assistant when supervising a student physical therapist assistant, is physically present and immediately available for direction and supervision. In both cases, the physical therapist, or physical therapist assistant will have direct contact with the patient/ or client during each visit that is defined in the Guide to Physical Therapist Practice as all encounters with a patient/client in a 24-hour period on each date of service. Telecommunications does not meet the requirement of direct supervision. Types of Supervision (APTA House of Delegates, 2019) Direct Personal Supervision: Direct personal supervision applies to supervision of a physical therapy aide. The physical therapist, or where allowable by law the physical therapist assistant, is physically present and immediately available to direct and supervise tasks that are related to patient/and client management services. The direction and supervision is continuous throughout the time these tasks are performed. Telecommunications does not meet the requirement of direct personal supervision. The physical therapist maintains responsibility for patient and client management at all times. Supervision by Payer Medicare: https://www.apta.org/your-practice/payment/medicare- payment/supervision-under-medicare/ptas-under-medicare Under Medicare, a physical therapist must supervise physical therapist assistants. The level and frequency of supervision differs by setting (and by state or local law). General supervision is required for PTAs in all settings except private practice, which requires direct supervision. However, if state or local practice requirements are more stringent, the PT and PTA must comply with their state practice act. For example, even though Medicare requires only general supervision in a skilled nursing facility when a PTA provides services, if a state practice act requires the PT to provide direct supervision then the state practice act must be followed. Steps 1 and 2: Examination/Evaluation History (Patient Interview) Review of Systems (ROS) Observe/Ask/Measure = OAM Framework Four Major Systems (Guide to PT Practice) Musculoskeletal Neuromuscular Cardiopulmonary Integumentary Tests and Measures Contextual Models Medical Model Social Model Personal problem due to Societal problem—complex diagnosis interaction of conditions Health Care is the solution Integrates persons with disability Aims at changing the person or into society his/her behavior Requires ideological change and social action  Borrell-Carrió F,Suchman AL,Epstein RM. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med. 2004;2:576–582 Biopsychosocial Model Considers whole person Integrates personal and environmental contexts Function is linked to biological, psychological, social, and environmental aspects The ICF, therefore, helps provide us with an understanding of what is important to our patient/client so we can better organize and focus our care International Classification of Functioning, Disability, and Health (ICF) Adopted by World Health Organization in 2001 Endorsed by APTA in 2008, incorporated in Guide to PT Practice 2010 Incorporates social and environmental factors into health and disability Less focus on the disability and more focus on impact of the disability Contributes to establishment of a comprehensive population health measurement framework https://www.who.int/classifications/icf/en/ Part 2: Part 1: Contextual Factors Functioning and Disability ICF Illustrated http://icfeducation.org/what-is-icf Arnold, Samuel & Riches, Vivienne & Parmenter, Trevor & Stancliffe, Roger. (2009). The I-CAN: Using e-Health to get People the Support they Need. Electronic Journal of Health Informatics. 4. e4. Step 3: PT Diagnosis Physical Therapy diagnosis is not the medical condition/pathology Identify dysfunction at which intervention is focused to address Addresses system(s) impacted Focused on: Impairments—loss of motion, decreased strength, impaired balance Functional Limitations—decreased ability to ambulate (walk), unable to reach cabinet, unable to put on shoes Signs and Symptoms– pain, joint stiffness, numbness Example: The patient is 2 weeks s/p R TKA (total knee arthroplasty) with decreased knee ROM and LE strength. He currently cannot ascend or descend stairs without assistance. Why do licensing boards exist? First and foremost, to protect the public To promote safety and competence of licensees What Does the State Board do? Manages licensees in their jurisdiction Process applications and fees for license Monitor Continuing Education Unit (CEU) or Continuing Competence requirements Investigate complaints; share information with other states Hold disciplinary hearings and take action (restrict licenses, suspension, revocation) Administer jurisprudence exams Promulgate regulations (not statutes) Interpret practice acts (statutes and regulations) Work with other state boards Hold regularly scheduled public meetings  State Processes Governor appoints Board Members State Legislature Judicial System State Board develops regulations and manages licensees Establish laws or statutes Key Terms Law (Statute) Regulation Practice Act is a statute Promulgated (to make known or Goes through legislative process public) by the Licensing Board Varies by state Varies by state Not everything in the Practice Act will be explicit Each state Practice Act varies in terminology Explicit—clearly articulated language about a certain area of practice Silent—not specified in the Practice Act language Can therefore be open to interpretation If in doubt, contact your State Board for clarification/guidance Scope of Practice evolves based on emerging evidence, practice patterns, advocacy, and legislative action Direct Access (ability for PT to see patient without physician referral) Dry Needling/Intramuscular Manual Therapy Request diagnostic imaging Telehealth Manipulation Key Elements of Practice Acts Direct Access Supervision of PTAs, aides, students Continuing competency requirements Code of Ethics Standards of Practice Documentation requirements Disciplinary actions/Fines What if there are conflicting rules? If in doubt, best to follow more stringent criteria If state law is more strict, it supersedes other policies or guidelines APTA Insurer Facility policy/procedure Critical to know the laws for the state you are practicing, even as a student What is the PT Compact? PTCompact.org The PT Compact allows PTs and PTAs more mobility in where they practice, which increases access to care. It is an interstate agreement between member states to provide a state-developed collaborative structure to protect the public by increasing consumer access to physical therapy services by reducing regulatory barriers to interstate mobility and cross-state practice. Check out the short video: https://www.youtube.com/watch?v=bFXM4Hip35g&feature=youtu.be Appraisal Focused Coping Strategies Adaptive Maladaptive Reframing Blaming God/others Spirituality Harmful beliefs Meditating Fanaticism Painting Excessive behavior Dancing Long walks Problem Focused Coping Strategies Adaptive Maladaptive Information gathering Intellectualization Questioning Avoidance Problem solving Excessive behavior Adherence Nonadherence Writing Helping others Emotion Focused Coping Strategies Adaptive Maladaptive Early denial Continuous denial Emoting Drinking Social support Drugs Counseling Self-injury Companionship Suicide Promiscuity Isolation Strategies to Assist Patients and Caregivers Offer to talk/listen based on patient cues Body language, tears, facial expressions Normalize their feelings “It is common to feel this way sometimes” Empathy—acknowledge the loss Listen, be present, note your body language Maintain hope Focus on smaller functional goals and progress Provide honest answers  Setting—Continuum of Care Acute Long Term Inpatient Skilled Nursing Home Health Outpatient Hospice Acute Care Rehab Facility (SNF) Rules vary regarding provision of care and payment depending on setting  SBAR a simple and concise format to relay important client information to another healthcare provider Situation Background Assessment Recommendation 50 SBAR Example Situation: “My client is a 57 year old male complaining of shortness of breath and chest pain.” Background: “He had a knee replacement 2 weeks ago and has not been able to ambulate as much as usual. His calf is warm and swollen, his BP is 140/90, and his heart rate is 115.” Assessment: “I am concerned he may be having a pulmonary embolism or cardiac event.” Recommendation: “I recommend we activate EMS and continue monitoring vitals and retrieve the AED and be prepared to begin CPR.” Situation-Background-Assessment-Recommendation (SBAR) (Impact of Communication in Healthcare, 2011) http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx 51 52 I PASS THE BATON 53 Why Take a History? 80% of diagnostic information Goals: Rapport Barriers to communication Learning style Patient goals Why Take a History SINSS—study definitions/examples in word document “Intro to Subjective Exam Guide” in session folder Severity Irritability Nature Stage Stability Early hypothesis Establish “baseline” Patient-Centered Interview Illness Experience50 Who is the patient? What does the patient want? How does patient experience illness? What are patient’s perceptions? What are patient’s feelings? Patient-Centered Interview Outcomes Increased patient satisfaction37 Improved patient outcome38 Increased provider satisfaction39-42 Improved efficiency43,44 Decreased patient anxiety38 Decreased malpractice claims45 No more time than biomedical7,32,44 Patient-Centered Interview Litigation Majority of malpractice allegations from communication problems47,48 More likely sued if not caring or compassionate45 How we communicate more important than content of communication45,49 Patient-Centered Interview Nature vs. Nurture (3,12,13,41,42,51-57) Can be Taught Can be Learned Can be Retained Summary Patient-Centered Care Improves satisfaction, outcomes, efficiency Decreases malpractice claims Can be taught, learned, retained Requires no more time Two Questions to Screen for Depression During the past month have you been bothered by feeling down, depressed, or hopeless? During the past month have you often been bothered by little interest or pleasure in doing things? 97% sensitivity, 67% specificity The Depressed Patient Impaired concentration May prohibit productive clinic visit “You appear to be down in the dumps today…” “You appear to be having a rough day…” The Depressed Patient Estimated 15% of majorly depressed patients commit suicide Feeling of hopelessness “Are you considering harming yourself or taking your life?” If yes, do they have a plan and available resources to carry this out? Verbal Skills Open-ended to closed-ended questions (funnel) Examples? Avoid biased questions Avoid jargon One question at a time Slow and deliberate questions Brief questions Communication Pearls Parallel thought Use patient’s words Avoid assumptions—CLARIFY Blame self first, rephrase…”I’m sorry, I wasn’t very clear with that…” “What I meant to say was…”  Special Questions/Review of Systems General Health Screen for disease (questionnaires) Medications Unexplained weight change Bowel or bladder changes (b/b) Fevers, chills, night sweats Dizziness/syncope Red flags vs. Yellow flags Take Home Points Assist in determining type and vigor of exam Clarify or determine more serious pathology Weight loss = cancer Fevers = infection Night sweats = TB B/B = spinal cord/cauda equina Medical referral required