Using PTAs in Home Health Discharging
By Michelle Moffa-Trotter and Wendy K. Anemaet
Q: I have several questions regarding what a physical therapist assistant is allowed to do in the home health setting. Can a physical therapist assistant complete the discharge summary or discharge note; complete the discharge order that will be signed by the physician? If a physical therapist assistant has been seeing a patient for home care and the patient is admitted to the hospital then readmitted for home care, should a new physical therapy evaluation be done or can the physical therapist assistant resume care as per the previous plan of care?
A: It is not unusual to have questions about the scope of practice of a physical therapist assistant in home health care. The problem is there often are not clear cut answers. Since Medicare regulations for home care do not address your specific questions, the best place to look for answers is your state practice act. Because the content, detail and guidelines for physical therapist assistant use vary widely from state to state, you must consult your practice act for exact answers to the questions.
If your state practice act is vague, the next place to obtain answers is the American Physical Therapy Association guidelines for assistant use. With all this in mind, let's look at your questions one at a time.
Can a physical therapist assistant complete the discharge summary or discharge note?
The Medicare regulations found in section §484.48 of the Conditions of Participation simply state, "The discharge summary must be sent to the attending physician upon request and must include the patient's medical and health status at discharge." No details are given regarding who (the nurse, physical therapist or the physical therapist assistant) should complete the discharge summary. As you can see, Medicare regulations do not specifically address your question. Therefore, your state practice act is the place to look.
Many states, such as Louisiana, New Hampshire and Tennessee, require that the PT perform the discharge visit and complete the discharge paperwork. Other states, such as South Dakota and Texas, do not specify who is to perform the final visit. If your practice act is not specific, phone your state board to get the answer.
Another source to consult, which does address discharge summary completion, is Definition and Utilization of the Physical Therapist Assistant, APTA House of Delegates Policy (06-88-14-25). It states, "The physical therapist assistant shall not perform the following physical therapy activities: final discharge assessment/evaluation or establishment of the discharge plan. . . " Taken literally, this does not preclude the physical therapist assistant from completing the discharge summary--just from performing the discharge visit. We find, however, most therapists choose to perform the discharge visit, obtain the discharge data, and complete the discharge summary themselves.
Can a physical therapist assistant complete the discharge order that will be signed by the physician?
When a patient is discharged from home health physical therapy before or after the anticipated discharge date stated on the plan of care (the 485), it is assumed that someone has phoned the physician to receive a verbal order for discharge. The person receiving that verbal order should be the one to write the discharge order that is sent to and ultimately signed by the physician.
According to Medicare regulations found in the Health Insurance Manual (HIM) -11 §204.2 Coverage of Services, E. Use of Oral (Verbal) Orders:
"When services are furnished based on a physician's oral order, the orders may be accepted and put in writing by personnel authorized to do so by applicable state and Federal laws and regulations, as well as by the HHA's home health agency's internal policies. The orders must be signed and dated with the date of receipt by the registered nurse or qualified therapist (i.e., physical therapist, speech-language pathologist, occupational therapist or medical social worker) responsible for furnishing or supervising the ordered services."
Since the HIM-11 does not allow physical therapist assistants to receive verbal orders from the physician, a PTA should not be the one to complete the discharge order.
If a physical therapist assistant has been seeing a patient for home care and the patient is admitted to the hospital then readmitted for home care, should a new physical therapy evaluation be done or can the physical therapist assistant resume care as per the previous plan of care?
If the patient was discharged from home health care upon admission to the hospital (as frequently occurs for new diagnoses such as cerebral vascular accidents, myocardial infarctions, etc.), then most definitely the physical therapist will need to do a new evaluation upon readmission to home health care. If, however, the patient was not discharged from home health (as may be the case with overnight hospital admissions) it is not necessary for the physical therapist to perform a completely new evaluation. She can simply do a reassessment or re-evaluation. However, this reassessment or re-evaluation must be done by the physical therapist not the physical therapist assistant because there may be changes in the patient's condition and therefore in the patient's plan of care that only a physical therapist can perform.
According to Definition and Utilization of the Physical Therapist Assistant, APTA House of Delegates Policy (06-88-14-25), "The physical therapist assistant shall not perform the following physical therapy activities: . . . initial evaluation and re-evaluation; identification, determination or modification of plans of care (including goals and treatment program) . . ."
As you can see, the rules governing physical therapist assistant used in home health care are usually not found in the Medicare regulations. Your best sources for information regarding questions about the practice of physical therapist assistants in home health care is your individual state practice act and the American Physical Therapy Association House of Delegates Policy. For these reasons, it is essential that you obtain and consult a current copy of your state practice act. If other questions arise that are not addressed in your practice act, call your state board for consultation.
Since Medicare home health care will be under a prospective payment system in 1999, we can only expect to see an increase in the use of lower cost providers such as physical therapist assistants in home health care. As supervising physical therapists, we are legally responsible to utilize assistants appropriately. Therefore, even if you are currently not working with physical therapist assistants, you should begin familiarizing yourself with the existing guidelines now. In this way, you can cultivate a secure and comfortable working relationship with physical therapist assistants and be prepared to effectively face the future. *
Michelle Moffa-Trotter and Wendy K. Anemaet are both full-time home care therapists in Florida working in both the Medicare and private insurance sectors. They have authored The User Friendly Home Care Handbook (Learn Publications) and lecture nationally on the topic of home health therapy with GREAT Seminars. See their Web site, Home Care Corner, at http://members.aol.com/homecorner.
* Send questions regarding home health physical therapy to ADVANCE for Physical Therapists, Home Page, 650 Park Ave. West, King of Prussia, PA 19406-4025; fax (610) 265-8293; PTedit@merion.com