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Hello this is Dr. Christine Balderas from San Diego Mesa College Physical
Therapist Assistant program. Today you will be watching a YouTube video
prepared for the DPT students at the University of St. Augustine and the PTA
students at San Diego Mesa College regarding the California rules and
regulations for the physical therapist and the physical therapist assistant. It
also will include a couple sample case scenarios from the APTA Learning Center
regarding teamwork for the PT/ PTA in the acute care setting.
This slide will give you the contact info if you have any questions regarding any
of the video content prior to our meeting. This has my name on here , Amanda
Johnson our program director, Professor Fischer who is our neurology professor,
and contacts at University of Saint Augustine, Dr. Matthews and Dr. Bellezza.
There will be several others from your school from the University of
Saint Augustine involved that you can also contact. I believe it's Dr. Rodriguez, Dr.
Volland and Dawnwho will be helping us with the debriefing. Here we go!
First we're going to talk about the PT Board of California definitions for
the physical therapist and the physical therapist assistant. You can
look on the PTBC website as well as a resource for yourselves if you want to
get a little bit more involved in the rules and regulations. You both will need
these prior to your board exams but you'll get these probably in your
curriculum as you go further on in your education in your programs. A physical
therapist means a person who is licensed pursuant to this chapter to practice
physical therapy. PTA means a person who is licensed pursuant to this chapter
to assist in the provision of physical therapy under the supervision of a
licensed physical therapist . Physical therapy assistant and physical therapist
assistant shall be deemed identical and interchangeable terms.
Currently we tend to use physical therapist assistant. That seems to
be the more accepted term .Also, the physical therapist assistant is the only
licensed extender to give care underneath the physical therapist. We
have the California business and profession codes and again you can look
that up under the PTBC board. Unfortunately here you can see there's a
little bit of an error so just get rid of that one dot there. (ptbc.ca.gov) That is our
consumer affairs. We are under division 2, the Healing Arts ,Chapter
5.7 Physical Therapy and Title 16 Division 13.2
if you're wanting to look specifically at our laws and regulations.
Here we're going to talk about Chapter 5.7 Article 2. The
Scope of Regulation and Exemptions -2622 (a)A physical therapist shall
be responsible for managing all aspects of the care of each patient as set forth
in regulations promulgated by the board. This is important that you as the DPT
when you become licensed are responsible for all care for that patient and so
that also includes any delegation you give to your physical therapist
assistant, to your aides ,anybody else that is helping provide care underneath
you. (b) A physical therapist shall not supervise more than two physical
therapists assistants at one time to assist the physical therapist in his or
her practice of physical therapy. (c) A physical therapist may utilize the
services of one aide engaged in patient related tasks to aide the physical
therapist in his or her practice of physical therapy. The next chapter 5.7
Article 2 is 2630.3 which is the Scope of Regulation
and Exemptions. This one is kind of the crux of what you as a DPT want
to be cognizant of when you're delegating to a PT assistant. A licensed
physical therapist assistant holding a valid unexpired and unrevoked physical
therapist assistant license may assist in the provision of physical therapy
services only under the supervision of a physical therapist licensed by the board.
A licensed physical therapist shall at all times be responsible for the extent,
kind, quality and documentation of all physical therapy services provided by
the physical therapists assistant. This is important that you realize when
you're writing your plan of care that you have the knowledge of the competency
of your PT assistant and that you as the PT assistant also feel comfortable that
you're competent to follow the plan of care that your PT has given you and to
realize that you cannot be supervised by a licensed
applicant like a PT licensed applicant. They have to be licensed before they can
start delegating to you. It is unlawful for any person or persons to hold
himself or herself out as a PT assistant unless at the time of doing so they hold
a valid,unexpired ,unrevoked PT assistant license issued under this
chapter as authorized in subdivisions F and G of section 2630.5 . So those
personal trainers ,athletic trainers, aides ,kinesiology specialists, regardless
of their competency cannot call themselves physical therapist assistants
and they are not allowed to bill and treat as the extender underneath the
supervision of that PT, licensed PT. We're going to keep going with a scope of
regulation so number (c) the physical therapist assistant shall not be
independently supervised by a physical therapist licensed applicant which was what
I was just talking about or PT student. A physical therapist assistant shall not
perform any evaluation of a patient or prepare a discharge summary. The
supervising physical therapist shall determine which elements of the
treatment plan if any shall be assigned to the physical therapist assistant. Assignment of patient care shall commensurate with the competence of the commensurate with the competence of the
physical therapists assistant and we'll get into this a little bit more with
some samples and examples for you down the road. Basically this is just
saying that it's really important for you to know the years of experience
of your physical therapist assistant, their competency ,your communication with
them, the acuity of your patient ,the stability of your patient before you
delegate interventions for them. Now that being said where it says here they can't
perform any evaluation of the patient. prepare discharge summary. This is
absolutely true. They can help you with that evaluation but they cannot treat
that patient prior to you doing the evaluation, but if you're doing the
evaluation together and you're in the hospital and you're working on bed
mobility, transfer training, gait training, and you need two people and you're working
together and then you're going to pass that patient on
to the physical therapist assistant afterward, that works really as
a teamwork
role-model for you to use when you're in the acute care setting. Here's the
Title 16 Division 13 ,some of the different numbers that you can look up
in order to be able to have reference for different things depending on what
setting you're in will require certain supervision of your physical therapist
assistant and your students and your aides, licensed applicants all of the
above. These are just letting you know what those different numbers are so that
you can look them up. We'll go over the more important ones here. The
first one is that 1398.4. Adequate Supervision. Adequate supervision of a
physical therapist assistant shall mean supervision that complies with this
section. A physical therapist shall at all times be responsible for all physical
therapy services provided by the physical therapist assistant and shall
ensure that the physical therapist assistant does not function autonomously.
The physical therapist has a continuing responsibility to follow the progress of
each patient and is responsible for determining which elements of a
treatment plan may be assigned to a physical therapist assistant. The PT
does not need to co-sign the license PTA's documentation. They repealed this several
years ago. The thought being that you are ultimately responsible as a licensed PT.
So anything you're delegating you have given that delegation based on what we
call adequate supervision defined.
We're going to kind of just go over this briefly as you guys are all students
right now so it's good for you to know how you should be utilized properly when
you go out to your clinical rotations or experiences.You need to be supervised by
a PT or PTA under the supervision of a PT if you're
a PTA student .Also there needs to be at least a PT, licensed PT on
staff, on the floor where you're at in order for there to be a PTA student
there. But a PTA, licensed PTA can be your clinical instructor. PT provides
on-site supervision of assigned patient care rendered by the student. The PTA
student or intern shall document each treatment and patient record along with
the signature. Their CI will countersign that with their initial and last name on
the same day as those tasks were performed, and the supervising PT
shall conduct a weekly case conference and document in the patient record that
they have been supervising and have looked over the chart and that the
interventions are appropriate. A licensed applicant PTA, I'm not going to read
over this right now because this really isn't going to
involve anything we're doing at our event .but this is just a reference for all of you
guys to have as far as like the amount of supervision you have to. You have to have direct
and immediate supervision by a PT until you have that official license as a PTA.
So basically all the rules that apply to you as a student still apply to you as a
licensed applicant. Here are the definitions for general supervision.
direct supervision .and direct personal supervision. We tend to follow general
supervision in most settings and direct supervision are those Medicare
outpatient Medicare B patients that we have to follow.
Here's Medicare supervision definitions for you and there's also a
resource to the Medicare benefit policy manual that describes that for you. In
most settings under Medicare A, it's general supervision. California state
regulation is silent on the level of supervision but emphasizes that if
physical therapists should at all times to be responsible for all physical
therapy services provided by the physical therapists assistant and shall
ensure that the physical therapist system does not function autonomously .So
if you're in a skilled nursing facility treating Medicare A patients your physical
therapist needs to at least be available by phone, text ,some kind of communication.
With the outpatient private practice, which is our Medicare B's and sometimes
you'll have Medicare B's in Skilled Nursing Facilities when they run out of
their Medicare A. Those require direct supervision, and so there the PT has to
actually be in the line of sight, there at the facility.
Here is a little cheat sheet that Dr. Kelly Prescher from San Diego
State created. The practice setting, the physical therapist student, the
physical therapist assistant student and the licensed physical therapist
assistant. You can see that as a PT student and a PT assistant student you
both require direct supervision regardless of what setting you're in.
Once you become licensed, Medicare and we talked about it for the PT assistant its
general supervision in the home health skilled nursing facility, outpatient
practice where we have Medicare B is direct supervision, and they don't really
specify inpatient/ outpatient hospital therapy services , so just based on
each facility's own regulations. California regulation is silent on all
these as far as supervision but it always seems to fall back on what your
insurance is going to reimburse for you.
This comes from the APTA Learning Center site on the PT/PTA teamwork
Models and Delivering Patient Care. I felt like this was a good synopsis of
how to decide as a physical therapist how you want to delegate to your PT
assistant, feel comfortable that your patient is going to get the best
care that they need and everybody's safe. The PT is solely responsible for
completion of the exam, the evaluation, the diagnosis and prognosis as well as the
development of the plan of care. The plan of care is where as you become more
skilled as a PT, the way you write that plan of care will really delegate how
much autonomy you want to give your PT assistant or how narrowed depending on
their experience level you want to make that. Once you have established a plan of
care, the PT may involve the PT assistant to assist with selected interventions.
The things you might consider as the PT to direct those interventions to your PTA
are the interventions within the scope of work of the PTA. So thus you
know you're not going to delegate an evaluation or a discharge summary to
your PTA, because we know that's outside their scope of practice. Is the
patient's condition sufficiently stable? Are the intervention outcomes
sufficiently predictable ? Is the intervention within the PTA's personal
knowledge ,skills and abilities?( so their competency )
Are there risk and
liabilities that should be considered prior to directing interventions to the
PTA? and that kind of goes back to number four and number three .Number
six :When any payer requirements be affected by the involvement of the PTA
in providing interventions ? That's where you need to go back to your
general supervision verses direct supervision and how you're going to
delegate that to them depending on where you're at. When the PT directs the
intervention to the PTA, the PT continues to maintain responsibility of
patient management. As we know that's part of your rules and regulations as a
licensed physical therapist, that ultimately everything as far as the
patient care is underneath your responsibility.
You provide the direction supervision to your PT assistant in accordance with
applicable laws and regulations. Some of you may end up working outside of
California so then you will need to know what those laws are for those specific
states. You're going to conduct periodic reassessment , reevaluation of the
patient as directed by the facility, federal and state regulations, payers and
the needs of the patient. This too is also just that constant communication
with your PT assistant and as a PT assistant with your PT when there's a
status change, whether it's a progression or a regression that you're talking with
each other on a daily basis as to how that patient is doing to give them
ultimate outcomes. Lastly to provide support to your PTA and when appropriate
assist the PTA's development of knowledge and skills necessary to perform selected
interventions and related data collection. So be their mentor, help them
take continuing education courses ,work with them on skills that you have to
share with them so that you become a team and you feel confident that they
can also share and do some of those interventions that you've helped mentor
them and got them competent in .Things that the physical
therapist assistant shall not do: They cannot perform measurement data
collection or care prior to the PT eval. They can help the PT during the eval
collect these things but they cannot do it prior to. They cannot document the
patient eval or the re-evaluation. They cannot write a DC summary .They cannot
establish or change a plan of care. They can communicate with the physical
therapist if they feel a plan of care needs to be revised. They can not write
progress reports to another healthcare professional . They cannot be the sole PT
representative in meetings with other healthcare professionals where patients
plan of care is assessed or may be modified. This is part of that rehab
team. They can be in there with the PT but they cannot be the only one in there,
because they cannot make those changes if the rehab team decides those things
that need to be done you need that licensed PT to be in there as well.
They cannot supervise PT aides in performing a patient related tasks and
they cannot provide treatment if the PTA holds a management position. Lastly
the PTA's can notify the PT of record and document in the patient record any
change in the patient's condition not within plan progress or treatment goals and
any other change in patient's general condition. Along with that though they
should actually verbally be communicating to the PT as well if they
can, ultimately so that they know what's going on and that helps with the
outcomes for that patient.
I won't read these out loud but these are for the physical therapists students
to just kind of know what a PTA basically our CAPTE criteria for them
of what we teach them and what they have to be competent in with the CPI once
they're done with their clinical rotations ,so that you feel comfortable
at that point in time being able to delegate to them. This talks about
communication, being able to establish things in the plan of care,
carrying out that plan of care. Being able to talk with the PT regarding the
plan of care ,Being able to critically think and adjust things based on that
patients outcomes. Educating the patient, their family members. Being able to act
in an emergency situation. Being able to document appropriately. Being able to
give feedback to the supervising physical therapist as far as needs of
that patient prior to discharge. Being able to keep up with
evidence-based research. Here's the couple sample scenarios for you to read
over. These will give you an idea of maybe a patient that you would feel
comfortable delegating interventions to and then one may be that you would be
holding off delegating until that patient was more stable. So I'll let you
guys go back and give you a little bit of time to read this one about the Total
knee patient that normally , a lot of times these are just
even an outpatient setting but this is a patient that's got some comorbidities.
They have a blood disorder and so there's a little bit more care taken and
them having to stay in the hospital, and The outcomes are pretty predictable,
the patient is stable. The PT and the PTA worked together on the evaluation and so
now the PT is going to feel comfortable delegating the interventions
to the PTA. This patient's a little bit more complicated. they are
pregnant with twins and they have some unpredicatability
as far as their pain .There's this here that we can have a discussion if we end
up doing some outpatient settings with you. The selected intervention of joint
mobilization is not within the scope of work of the physical therapist
assistant. In the state of California, our physical therapist assistants if they
have been trained appropriately and are competent and showed that skill they are
allowed to do joint mobilizations. So it just depends on the state. The APTA has a
position paper regarding this. It is kind of important for you to know the
difference between APTA position statements and what are actual rules and
laws in California. Sometimes that's a confusion and we can have that
discussion when we meet in person if you want to go into that a little bit more
in-depth. I can help you out with that. Also, this is a high-risk patient so
that's probably more the main reason why this patient is probably going to stay
on the PT's schedule for now.Thank you again
and I'll see you on February 5th.
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