Embracing our PT Scope of Practice in Home Health Care. How Times Have Changed!

Transcription

1 Embracing our PT Scope of Practice in Home Health Care How Times Have Changed!

2 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

3 Session overview 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 3

4 Why this topic? 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 4

5 Why this topic? 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! 5

6 Why this topic? States vary as to Continuing Education licensure requirements Curricula have evolved to meet these training needs 6

7 Why this topic? RESULT: Clinicians who have been in the field for many years may have varying degrees of confidence in some areas of practice 7

8 How Has Care Delivery Changed? Industry Changes COMPLEXITY of PATIENTS REIMBURSEMENT CHANGES FRAUD, WASTE AND ABUSE 8

9 Industry Changes: Complexity of Patients 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 9

10 Industry Changes Complexity of Patients 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 10

11 Industry Changes Demographic Considerations 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 11

12 Industry Changes Reimbursement 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 12

13 Industry Changes Reimbursement 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 13

14 Industry Changes - FWA Fraud Waste and Abuse Obligation to reduce waste Duplication of services is considered WASTEFUL 14

15 Industry Changes Reducing Waste Duplication of services across disciplines must be avoided Areas where scope of practice OVERLAPS Right Discipline, Right Care, Right Time ZPIC audits 15

16 What does this mean for PT/PTA Practice in Home Health? Patient Centered Every Visit must stand alone and require skill of the practitioner Patient interventions vs nursing interventions 16

17 You re It! We all play a role in keeping our patients safely home Requires comprehensive assessment, communication 17

18 You re It! 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!) 18

19 You re It! OT PT Skin -Vitals Pain - Meds Risk: Fall - Rehosp ST SN 19

20 Challenges & Objections 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? 20

21 Handling Resistance 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 skill Let s hone in on what we can do to increase comfort with skills, if that is the issue 21

22 not enough time during the visit 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 22

23 Current Practice PTs admitting more, therapy only cases Oasis comprehensive assessment More supervision as PTA utilization increases Collaboration is CRITICAL 23

24 Comprehensive Assessment Vitals Lung Sounds Pain Skin Medication Management Risk Assessments Falls, Hospitalization, Depression Symptom management and monitoring Patient/cg ability: self- management Mobility, I/ADL 24

25 Essential Skills Vital Signs Lung Sounds Comprehensive Pain Assessment Comprehensive Skin Assessment Medication Management Symptom Management/Monitoring In some states PT/INR testing 25

26 Essential Skill: Vital Signs 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 26

27 Essential Skill: Vital Signs 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 27

28 Essential Skill: Pain 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? 28

29 Essential Skill: Pain Type: dull, ache, sharp, throbbing, etc Location Pattern: constant, frequency, duration, with certain activities, interrupts sleep? Alleviating and aggravating factors Medications and Non-pharmacological 29

30 Essential Skill: Skin 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 30

31 Essential Skill: Skin Goal of Skin Assessment Identify any pressure ulcers that may be present Assist in risk stratification Determine if there other lesions or factors that predispose pressure ulcer development (dry skin, moisture associated skin damage) Identify other important skin conditions 31

32 Essential Skill: Skin 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 32

33 Essential Skill: Skin 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! 33

34 Essential Skill: Med Management 34

35 Essential Skill: Med Management 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. 35

36 Essential Skill: Med Management ~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. 36

37 Essential Skill: Med Management 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 37

38 Essential Skill: Med Management 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. 38

39 Essential Skill: Patient Self-Management 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. 39

40 Essential Skill: Patient Self-Management 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 40

41 The Minimum Standard 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 41

42 Self Assessment 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 42

43 Self Assessment Vital Signs RESTING Blood Pressure Heart Rate Respiratory Rate Oxygen Saturation Pain Vital Signs ORTHOSTATIC Vital Signs PEAK EXERCISE Vital Signs RECOVERY TIME SKILL SKILL Vital Signs integrating into documented patient goals Lung Auscultation identifying presence of diminished/abnormal breath sounds 43

44 Self Assessment Comprehensive Pain Assessment using proper tool/scale aggravating/alleviating factors impact on function SKILLS 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 44

45 Collaboration and Communication With Patient/Family Teachback With MD/Case Managers SBAR situation, background, assessment, recommendation, be concise and clear With Manager and Team Case Conferencing, , Voic , other 45

46 Collaboration and Communication 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 46

47 Collaboration and Communication But I don t have time!!!!! Under new CoP, Collaboration even more critical NOT AN OPTION no to communicate with the team Provision of patient schedule required During the visit when able - Use tools for efficient communication ( , vm) 47

48 Collaboration and Communication Better Care Better Patient Satisfaction Knowing that we communicate gives patients confidence in the care we are providing 48

49 Owning Professional Development 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 49

50 Owning Professional Development 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. 50

51 Owning Professional Development Individual clinicians are responsible to enhance their own practice development Identify areas where you are not comfortable and seek assistance. 51

52 Owning Professional Development Journal Articles Courses Joint Visits with manager, peers E-learning - modules and videos Case Conferencing OTHER 52

53 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! 53

54 Questions? 54

55 References 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 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): Article first published online: September 6, 2012;Issue published: April 1, 2013 DOI: Mary Calys, DPT, PT 1, Kendra Gagnon, PhD, PT 2, Stephen Jernigan, PhD, PT 2 1 North Kansas City Hospital, North Kansas City, MO, USA 2 University 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 G ) APTA Guide to Physical Therapist Practice Easyauscultation.com 55