Physical therapists throughout the U.S. and around the world are answering the call to provide pro bono services to those in dire need.
They accomplish this through free clinics providing free PT services to those unable to pay or those who have met their Medicare caps; by offering free advice or consultation at health fairs; and through international aid or medical-related missionary work with nongovernmental and faith-based organizations.
The response by physical therapists to the 2010 earthquake in Haiti illustrates this well. In Jacmel, Haiti, Jennifer Watters, PT, DPT, directs and treats patients in a comprehensive rehabilitation clinic, where she trains Haitian technicians and assists local medical teams. Her efforts are made possible through a collaboration of PT clinics as well as other non-profit organizations.
Myriad tangible and intangible benefits result from pro bono work, including enhanced business goodwill, revenue enhancement and political clout gained from publicity. Pro bono work also results in the creation or enhancement of professional networks among colleagues performing similar services.
Step for Professionalism
Professionalism is the key core value at the heart of pro bono service delivery. Health care professionals should routinely evaluate their professional conduct and always strive to be clearly in compliance with legal and ethical mandates. A commonly cited example of this balance between altruism and legality is seen in the waiver of Medicare co-pays by some primary health care professionals in the name of relieving the health care cost burden of socioeconomically disadvantaged patients. Despite the apparent good intention, this practice violates a contractual agreement between the provider and the federal government, and circumvents the very measure in place to reduce overutilization of health care resources and patient and societal exploitation.
The Legal Professional Model
The American Bar Association (ABA Model Rule 6.1) states, "Every lawyer has a professional responsibility to provide legal services to those unable to pay. A lawyer should aspire to render at least 50 hours of pro bono publico legal services per year. (a) Provide a substantial majority of the 50 hours of legal services without fee or expectation of fee to: (1) persons of limited means or (2) charitable, religious, civic, community, governmental and educational organizations in matters which are designed primarily to address the needs of persons of limited means."
Additional pro bono services are also authorized for: (1) individuals, groups or organizations . where the payment of standard legal fees would significantly deplete the organization's economic resources or would be otherwise inappropriate; (2) .reduced fee to persons of limited means; or (3) .improving the law, the legal system or the legal profession.
An additional expectation in the legal profession is that lawyers voluntarily contribute financial support to organizations that provide legal services to persons of limited means.The State Bar Association in Texas echoes this challenge for lawyers in its Pro Bono Resolution, which mandates that lawyers:
• Aspire to render 50 hours of pro bono legal services per year.
• Engage in direct provision of legal services to poor clientele without expectation of compensation, or at a substantially reduced fee;
• Provide other legal services to the poor, to organizations serving the poor, and advocacy services;
• Represent indigent populations in criminal cases.
The resolution advises Texas-licensed attorneys that "financial contributions to organizations serving the poor and non-reimbursed, out-of-pocket expenses incurred while performing legal services to the poor, may be considered legal services to the poor." Attorneys who provide more than 75 hours per year of pro bono legal services to the poor are eligible for admission into the prestigious Pro Bono College of the State Bar.
APTA's Code of Ethics
Should the American Physical Therapy Association (APTA) quantify pro bono service expectations for physical therapists and assistants in its ethics core documents, as is commonly done in the legal profession?
Previous guidelines as well as the latest revision of the APTA Code of Ethics (which took effect July 2010) state clearly the expectation for pro bono work in the physical therapy profession. On the 20th anniversary of the first APTA Code of Ethics, a position statement in the House of Delegates explained what types of pro bono services were expected by the profession. They stated, "providing professional service at no fee or at a reduced fee to persons of limited financial means, donating professional expertise and service to charitable groups or organizations, engaging in activities to improve access to physical therapy, and offering financial support for organizations that deliver physical therapy services to persons of limited financial means" (APTA House of Delegates, 2009).
Principle 8 of the APTA Code of Ethics exemplifies an evolution of stronger language regarding pro bono service expectations, and reads in its current form: "Physical therapists shall participate in efforts to meet the health needs of people locally, nationally or globally. (Core Value: Social Responsibility)" (Code of Ethics for the Physical Therapist, 2010). This focus on addressing the needs of local and global communities of patients and clients is expanded in four subsequent sections:
8A. Physical therapists shall provide pro bono physical therapy services or support organizations that meet the health needs of people who are economically disadvantaged, uninsured and underinsured.
8B. Physical therapists shall advocate to reduce health disparities and health care inequities, improve access to health care services, and address the health, wellness and preventive health care needs of people.
8C. Physical therapists shall be responsible stewards of health care resources and shall avoid overutilization or underutilization of physical therapy services.
8D. Physical therapists shall educate members of the public about the benefits of physical therapy and the unique role of the physical therapist. (Code of Ethics for the Physical Therapist, 2010).
The focused language within Principle 8 addressing service to the poor and uninsured or underinsured, barriers and inequities within the health care delivery system, and stewardship of resources conveys the standards expected of all physical therapists and assistants, whether members of the APTA or not.
Why, then, do so few PTs engage in pro bono service? It is likely that physical therapists and assistants, and their employing health care organizations, fear potential liability exposure associated with pro bono service delivery.
The desire to help those in need cannot eclipse the mandate to practice legally. The Texas Charitable Immunity and Liability Act of 1987 may provide a degree of legal protection for volunteers, including PTs and PTAs, licensed to practice in the state, who voluntarily provide health services without compensation or expectation of compensation.
A direct service health professional volunteer within a charitable organization may be immune from civil liability for any act or omission resulting in death, damage, or injury to a patient if:
1. The volunteer commits the act or omission in the course of providing health care services to the patient;
2. The services provided are within the scope of the license of the volunteer;
3. The patient signs a written statement which acknowledges that:
A. The volunteer is providing care that is not administered for or in expectation of compensation;
B. There are limitations on the recovery of damages from the volunteer in exchange for receiving the health care services. (70th Texas Legislature, 1987).
Thus, charitable immunity laws, in place in many states, may offer a degree of protection to health professional volunteers within their respective scopes of practice. Typical disclaimers include no immunity from liability for illegal practices such as sexual misconduct or other forms of patient abuse, or situations in which patients or clients pay a reduced fee vs. receiving free care. In the latter case, an individual provider-volunteer's professional liability insurance policy may provide protection for charitable work.*
Community Clinic Models
One of the most promising trends in physical therapy education is the emergence of faculty supervised, student-and-faculty-staffed free clinics within entry-level education programs, similar to those in professional medical and nursing schools across the U.S. and Canada.
One example, Samuel Merritt University's Physical Therapy Department's Neurologic Rehabilitation Clinic, is a student-co-developed project serving the East Bay communities surrounding Oakland, CA. Rolando Lazaro, PT, DPT, GCS, who supervises the program, reports that the initiative is fully integrated into Samuel Merritt's Doctor of Physical Therapy entry-level education program. For neurological patients who have exhausted insurance options, Samuel Merritt's six-visit model provides a bridge toward functional mobility and independence-complete with free parking at the university.
Another program recently highlighted in the media is the University of Kentucky's Samaritan's Touch student-supported free clinic in Lexington. This clinic has been in operation for about a decade, and celebrated the grand opening of a new location on Feb. 23, 2011. According to Lynne English, PT, MSEd, DPT, director of clinical education, four students from each year-group serve as clinic liaisons, ensuring smooth clinic operations, and 16 other physical therapy students (under faculty supervision) provide services to patients. Dr. English encourages emerging physical therapy education program-based pro bono clinics to collaborate with other medical disciplines for comprehensive patient service delivery.
Widener University's Chester (PA) Community Physical Therapy Clinic also provides physical therapy services to socioeconomically disadvantaged patients in the community. With students from each of the three classes involved in all areas of service delivery, from marketing to scheduling and operations, the clinic is truly student-focused.
According to faculty supervisor Jill Lattanzi, PT, EdD, while faculty members oversee the clinic's operations, most service delivery is carried out by licensed physical therapists who are alumni of the Widener program. The Widener clinic is a free-standing structure on campus, and faculty, staff and students strive not only to build relationships with the community, but also to educate referral sources that the clinic is not in competition with them for patients and clients, since only patients unable to pay for services and those who have met their insurance limits are eligible.
These same challenges face patients of a fourth, recently media-highlighted pro bono physical therapy initiative-the Massachusetts General Hospital's Health Professions Physical Therapy Center for Clinical Education and Health Promotion in Boston.
Opened in May 2010, the clinic provides treatment to patients with neurological and musculoskeletal impairments, and students practice under the supervision of licensed MGHI faculty. A speech therapy clinic within the same building allows for interdisciplinary collaboration.
The APTA's core ethics documents make pro bono service delivery by physical therapists and assistants an integral ethical responsibility for the profession. Pro bono service delivery offers a myriad of tangible and intangible benefits for those providing such services.
Entry-level physical therapy education programs across the United States are setting a high bar for every physical therapist and PT assistant to emulate-meeting the altruistic aspirations of providing patients' physical therapy needs, and doing good while doing well.
*This discussion is intended as informational only, and not intended as legal guidance for any practitioner or organization. For specific legal advice, consult with your personal or facility attorney, who provides current, specific legal advice based on applicable federal, state and local laws and regulations.
Francis Bisagni earned his DPT in 2011 as a graduate of the University of Texas Health Science Center San Antonio, and is actively pursuing the establishment of a student-led pro bono physical therapy clinic in San Antonio. He practices with Texas Physical Therapy Specialists in Selma. Ron Scott is a professor at Rocky Mt. University of Health Sciences. The authors thank Drs. English, Lattanzi and Lazaro for their counsel, as well as classmates Steve Elliott, SPT, PTA, and Josh Trock, SPT, who helped with the article's development.
ADVANCE asked three student PTs who volunteer their own services to Jefferson University Hospital's Hands of Hope program in Philadelphia, PA, to talk about their pro bono experiences.
Q: How has working pro bono had an effect on your education and career in physical therapy?
Christina Cording: Working at a shelter throughout PT school as allowed me to practice my skills with a diverse group of men. These men are so thankful for our help making the entire experience so rewarding. This opportunity has let me see first-hand all the diagnoses and presentation of symptoms we learn about in class. Going to the shelter each week has been an invaluable experience that in the future will make me a better therapist since I now have the ability to treat patients without endless resources as well as having insight into environmental conditions and how it may affect my patients.
Courtney Yon: Being involved with Hands of Hope has allowed me to grow academically, while gaining cultural experience. Going to the Ridge Shelter on a weekly basis allows me to practice the skills I learn in the classroom as well as skills that cannot be taught. For instance, it is very rewarding working with this population, knowing that every little thing we can do to help, makes a difference. We evaluate and treat patients, providing them with education and necessary equipment (as able) while being supervised by a licensed physical therapist. It is great to be able to practice skills and documentation on patients outside of the classroom.
Our organization fundraises and provides everything from socks to ankle splints to exercise bands to personalized home exercise programs for the patients. It is excellent practice and preparation for our clinical affiliations. One of the greatest advantages about being involved with Hands of Hope is learning how to communicate and interact with all types of patients. You cannot teach someone to be personable and caring with patients, you have to learn from experience. The men are always so nice and thankful for the time we spend at the shelter every week. Also, participating in Hands of Hope aids the mentorship between physical therapy classes. There is always a third-year student paired up with a second- or first-year student. Each opportunity I get, I look forward to going out to the men's shelter and helping out.
Emalyn Phillips: Working pro-bono through the Hands of Hope organization has been a great adjunct to my physical therapy education. It has allowed the opportunity to develop skills learned in the classroom setting and apply them to real patients. I am able to practice taking vitals, gathering pertinent information and thinking on my feet coming up with exercises that can be done with the resources they have or helpful suggestions. It has also improved my communication skills with various patient populations. I have learned to relay information to younger and older men and am able to see firsthand cultural differences and learn from them. Volunteering at the shelter has also reinforced the importance of inter-professional care. The medical and pharmacy students here at Jefferson also provide services so we communicate with them about clients so that we can provide the best possible help and services.
Q: Has pro bono work increased due to the downturn in the economy? How are added caseloads handled in your experience?
Cording: In my experience at Ridge shelter, we have not seen more patients as a result of economic hardships, but the numbers within the shelter fluctuate based on availability and weather conditions.
Phillips: Specifically at the Ridge Shelter I have not noticed an increase in clients seeking services because of the economy.
Q: Any particular experience you remember on how having access to your services aided a patient?
Cording: The most rewarding experience of working pro bono are the smiles that come to the patients' faces when we walk in. We have returning patients who come in for simple things such as splints, socks, glucose testing, and other services. Having the resources and knowledge to provide these things for our patients, whether it's a treatment plan/braces/education/someone to talk to, allows to me to know I am improving their quality of life.
Yon: I remember when I was a first year student; I helped make a thumb splint for a patient at the Ridge Shelter. I was paired up with a second-year student and one of the guys at the shelter had osteoarthritis of the first CM joint. After evaluating him, we asked the physical therapist if a splint would be a possible intervention. We then traced his hand and took measurements on a kidney-bean shaped pattern. The next day at school, in our free time, the other student and I found some scraps and molded an in-hand thumb spica for the patient. The next time I went to the shelter, I brought the splint and some extra materials with me and fitted the man with the splint. It fit him perfectly and he looked so happy. We followed up with him a couple of weeks later and he reported his thumb felt better and thanked us for the splint.
Phillips: Seeing clients return each week to seek out our services or come over to say hi is always a great feeling. Knowing that you are making a difference for someone or impacting them in a positive way reinforces the importance of giving back to the community.