Thursday, January 21, 2010

What’s the Goal of Rehabilitation?

Recently I had the pleasure to sit through a presentation by a well know Stroke specialists on the management of severe stroke. Two things I took away from the presentation.

The first was evident even when I entered the field of Physical Therapy some 18 years ago. People, especially younger people with severe unilateral strokes have a tremendous capacity for recovery. Despite the staggering deficits they may present with after their acute hospital recovery, there still may be great potential for functional recovery and a positive quality of life.

The second was that perhaps in acute and sub-acute settings we have the wrong priorities on the purpose of rehabilitation. What was discussed during the doctor’s presentation was that even in those patients those don’t have a significant recovery of function, can still have the capacity to be discharged home at a significantly lower cost of future care compared to placement in long-term care settings.
I can also draw a parallel from my past experience in working in a workers’ compensation focused rehabilitation facility. Traditionally, if I was to ask PTs what the most important goal was for PT to achieve with patients, the answer 90+% of staff would provide would be something like “maximize functional recovery” or “maximize quality of life”. While it took a change in paradigms, we move to a goal of “return to work” (which would seem obvious, give the workers’ compensation clientele)… if not the client’s original profession or employer, than any other employment. What resulted was we were suddenly getting a lot more clients back to into the workforce. Sure, some may still have had a capacity for further functional recovery, but the vast majority of clients (employees) and employers were more satisfied with services they received during their rehabilitation.

I have started to preach that the primary goal of rehabilitation in acute care is discharge, plain and simple. Discharge preferably to home, but, if not home, to some other less costly level of service like a rehabilitation facility or long-term care setting. All our initially energy in rehabilitation should be to facilitate this goal of discharge. Desirable results such as functional gains, independence, and quality of life should be secondary (but not forgotten).

PT Wonk

Wednesday, January 13, 2010

Liability Issues in Making the Best Use of Therapy Assistants

Recently, my organization started a comprehensive project to "enhance" the role of therapy assistants. My role, among many other participants, is to provide the acute care perspective. Knowing the staff as I do, I know that many PTs are resistant to idea of therapy assistants being utilized more. There concerns, among many, go beyond the usual concerns over fears that fewer PTs will be hired, that some PTs will be replace by assistants, etc... what really is a significant barrier to making better use of therapy assistants is a perception that doing so puts the professional at significantly more risk of lawsuits or loss of license to practice.

Recently I completed a literature review of what the liability risks are in collaborative practice and more specifically, the risk associated with a PT/therapy assistant relationship.

In general, the finding were comforting and what I expected. There is no significant increased risk to the PT as long as they are practicing professionally (I'll try to expand upon this more in a future blog).

A big challenge when we propose to "optimize" the role of the assistant is that we need to have an "ideal" to work towards. Despite my best efforts, I have yet to find any organization that feels they have defined or reached that ideal goal.

What I suggest is that we start with a few principles to guide both the professional staff and management. For the PT:

1. Only assign tasks to assistants that are competent to perform the task
2. If task is out of the scope of practice of the assistant, don't even consider assigning it
3. If make the decision to not assign a tasks, provide the rational for that decision
4. If the assistant is not competent, but the task is reasonably within their scope, implement a plan for the assistant to establish and maintain the competency.
5. Some tasks that could be assigned may, in some circumstances, be appropriately not assigned and still performed by the professional PT (for example, sometimes routine tasks that normally would be assigned to an assistant provide an opportunity to develop rapport with patients/clients and deal with difficult subjects, such as addressing issue of motivation or compliance to a treatment program).

For management, develop metrics that can allow comparisons between therapist. Identify and reward your good performers. Find opportunities to share the experience of exceptional staff with novice staff.

In my organization, I foresee it being very difficult to get some PT with decades of experience to assign more of their workload to assistants. New staffing allocation models will be resisted. But we must put a convincing case forward that changes are in the interest of patient care: improving outcomes, shortening length of stay, and improving staff morale. Don't focus on the dollars!