Vol. 18 Issue 18
Home Health Forum
Guidelines for Visits and PTA Supervision
Question: What are the Medicare home health guidelines for PTA supervision? California PT Board guidelines are very non-specific. Our agency requires a 30-day joint supervisory visit but I may see the patient more often based on acuity, significant change in status, level of skill required, experience and skill level of PTA, etc. Please advise as to Medicare law and your professional experience.
Answer: Medicare guidelines regarding PT supervision of PTAs in home health state that a monthly supervisory visit is required. The practical application of this requirement is to make the visit no less than every 30 days. This is generally followed as the standard in the industry; some individual states may have practice acts that require more frequent supervision.
Be sure to check your state guidelines if you are not sure of your particular state's requirement. Also, no Medicare guideline requires that a joint visit be made that would include both the PT and PTA together.
There also may be factors that could serve to functionally alter this requirement in an individual case; it is important to be aware of these so all supervisory expectations are met. For example, a Medicare case involving a nurse, PT, PTA and home health aide presents specific supervisory requirements.
The case-managing nurse is required to make a supervisory visit every 14 days in order to supervise the aide. The documentation in her nursing visit note identifies the specific visit which includes the required elements: communication with the patient or caregiver as to the appropriateness and effectiveness of the aide and whether to continue the HHA service with or without modifications to the original care plan.
Simultaneously, the PT has to make a PTA supervisory visit every 30 days to meet Medicare guidelines in this particular case. When both a nurse as case manager and a PT each have their own specific and clear requirements, it is easy to remain in compliance.
However, if the nurse were to discharge the client after nursing goals have been achieved but chose to continue the aide service, the PT would now become the case manager. At this point, the PT now would have both 14- and 30-day supervisory requirements for the aide and PTA respectively. You can see how this can become confusing if not closely monitored for compliance.
More Frequent Visits
We also wanted to address the important issue you raised regarding the multiple reasons that could potentially require that you make more frequent PTA supervisory visits. Our practice has been to closely monitor cases so that we are able to remain in control of the clinical component of the episode at all times.
In the case of high acuity (or level of skill required), we may choose to keep a PT in the home as the clinician after the initial assessment. If the patient progresses so that a PTA may be assigned without concern for losing ground in the area of the clinical program, the PT may back away from the treatment picture and let the PTA complete the visits. In all cases, the PT must make the final visit in order to quantify progress and validate the discharge.
HHSM recommends development of a system of weekly OBQI-based case conferences for all Medicare clients. This allows thorough and consistent review of any PTA interventions and allows us to identify areas in need of attention.
Less experienced PTAs certainly require a more intense level of both supervision and direction; weekly case conferences help us all to stay (or get) on the same page.
In our own practice, we regularly alter our frequency of supervision in response to any concerns we may have regarding a particular PTA. We highly recommend that all supervising PTs approach PTA supervision with these options in mind. After all, as the PT of note on the case, the medical and legal responsibilities of the case are yours.
One last thought we'd like to share is that the concern for the quality of the PTA visit lies specifically with the individual PT in charge of the case. All PTs at HHSM gain insight into supervision of PTAs through the ongoing and consistent nature of our weekly case conferences.
As the PT becomes more fluent with the give-and-take of the conference conversation, he is able to get a better grasp on what the PTA may be doing as well as the effect of this on patient progress (or lack thereof). Clearly, there is a skill level to be achieved here also.
Because we maintain our OBQI-based case conference system without exception, we feel comfortable following the 30-day supervisory guideline. If you do not perform weekly case conferences, you may want to make supervisory visits more often.
Teri N. Thompson and Arnie Cisneros are physical therapists with more than 35 years of combined home care experience. They are co-owners of Home Health Strategic Management of East Lansing, MI; providing clinical service management and home care consulting expertise. They also lecture and provide OASIS, HHRG, OBQI, and P4P training at seminars nationally. Contact the authors at their Website, www.homehealthstrategicmanagement.com