Unit III

List the four categories that classify health care facilities
think, the health care facility ‘STOL’ my money
– size
– type
– ownership
– length of stay
define acute care facility
– a category of a ‘type’ of health care facility
– typical stay is 3-5 days
– if continued hospitalization is expected then discharge planning for transfer to a place like St. David’s or Seton
define size
– number of beds available in hospital
– can range from 24-500 or more
define subacute [long term acute care] facility
– a category of a ‘type’ of health care facility
– typical length of stay is 2 weeks to several months
– patient typically continues to require acute care type services
– examples: Cornerstone Nursing or a floor in an acute care hospital
define rehabilitation facility
– a category of a ‘type’ of health care facility
– expected length of stay can be from days – weeks
– high intensity focus on rehabilitation 3-4 hours per day
– examples: HealthSouth or Reliant
list the categories of health care facility types
– acute care
– subacute [long term acute care]
– rehabilitation
– specialty care
– ambulatory care
define specialty care
– a specific population catered to
– examples: Dell Children’s or Heart Hospital
define ambulatory care
– outpatient hospitalization
– examples: walk-in clinics like Concentra
list the categories of ownership
– Private
– Public-local government owned
define private ownership
– For profit like Reliant and HealthSouth
– Not for profit like St. David’s and Seton
define public ownership
local government owned
– city: Brackenridge Hospital [managed by Seton]
– county: Parkland [county hospital for Dallas]
– state: Austin State Hospital
– federal: Veterans Affairs [VA] Hospital
list the types of long-term facilities
think SIR
– Skilled nursing facilities [SNF’s]
– Intermediate [assisted living facilities: ALF’s]
– Retirement
describe Skilled nursing facilities [SNF’s]
– provide 24 hour per day extensive, intensive, medical nursing services with RN’s on all units and during every shift
– examples: Summit, West Oaks and Gracy Woods
describe Intermediate facilities [ALF’s]
– provide minimal medical services [assisted living facilities]
– examples: Summit, Heritage @ Gaines Ranch and Carestone
describe Retirement facilities
– provide very limited or no medical services located on the premise
– example: active 55+ living communities like Sun City
what are the five benefits of the interdisciplinary team approach
• enhances the knowledge of the other health care professionals
• more effective utilization of time [team members can share info]
• increased direction of goals and treatment due to increased supervision and coordination of team efforts
• encourages communication between team members to exchange ideas, brainstorm problems, and share knowledge
• provides leadership opportunities and encouragement between team members
list different health care providers we may come in contact with in our profession
– Primary Care Physician [PCP]
– Internist
– Neurologist
– Orthopedist
– Surgeon
– Physical Therapist
describe role of a Primary Care Physician [PCP]
general practice
describe role of a Internist specialty in particular physiological system
specialty in particular physiological system
describe role of a Neurologist
specialty in neuromuscular disorders
describe role of a Orthopedist
specialty in musculoskeletal disorders
describe role of a Surgeon
specialist in invasive treatment
describe role of a Physiatrist
specialty in physical medicine and rehabilitation
describe role of a Psychiatrist
specialty in mental disorders
describe role of a Clinical Psychologist
doctorate in clinical psychology
describe role of a Chiropractor
doctor of chiropractic medicine
describe role of a Osteopath
medical doctor who utilizes a holistic treatment approach
describe role of a Licensed Professional Counselor
therapist, social worker, case manager
describe role of a Certified Orthotist/Prosthetist
trained in evaluation and fabrication of braces and prostheses
list various Allied Health Professionals
o Physical Therapist Assistant
o Occupational Therapist
o Respiratory Therapist
o Speech and Language Pathologist
o Certified Orthotist/Prosthetist
list the major classifications of health insurance companies
think PIG:
• Private Health Insurance Companies
• Managed Care
• Government Health Insurance
describe Private Health Insurance Companies
– reimbursement is on a fee for service basis
– the subscriber can use any doctor, hospital, or health care facility
– there is a deductible and the subscriber pays a percentage of the cost
– example: ChampVA
describe Managed Care
has two components:
1. a predetermined payment schedule
2. a provider network consisting of providers who contract with the insurance company and agree to accept the payment schedule for their services
– example: BlueCrossBlueShield [BCBS]
list the types of Managed Care
– Health Maintenance Organizations [HMO]
– Preferred Provider Organizations [PPO]
– Point-of-Service Plan [POS]
describe Government Health Insurance
– administered by the federal government
– includes: Medicare, Medicaid, and workers compensation
define policy
– what will be done within an organization
– example: vacation or sick leave
define procedure
– how things will be done within the organization
– the ‘process’ of requesting leave for vacation or sick time
differentiate between a policy and a procedure
both must be:
– clear
– concise
– easy to read
– accurate
– comprehensive
– enforceable
– consistent
– accessible
– up to date
– positive
explain the steps required in a grievance procedure
Chain of Command:
1. verbally discuss with supervisor [wait 3 days]
2. written complaint to supervisor [wait 3 days]
3. written complaint to department head [wait 5 days]
4. written complaint to administrator [wait 30 days]
5. written complaint to Board of Directors [if no reply, request a hearing]
6. if still no reply, hire legal representation
define incident report
a report must be filed that day of injury/accident to include:
– date/time injury/accident
– what happened
– who was involved
– who witnessed the event
– what was done afterwards
explain the significance of an incident report
– if you or a patient is injured and you are involved, you have legal proof of what happened
– it could help exonerate you in a situation where someone may be blaming you for something that is not your fault
– it could also provide proof that you were injured on the job if you end up needing short or long term disability
define philosophy
a statement of purpose, common goal, or mission that can include definitions, relationships, clarifications, and limitations of the scope of the facility
define and explain the purpose of an organizational chart
– delegates lines of authority and communication; who is in charge
– shows the structure of a business, leadership, and departments within the organization
list the four factors one must consider when designing a physical therapy department
1. Safety
2. Space
3. Efficiency
4. Environment
define safety
be sure when considering your design both patients and staff will be safe while participating in activities and therapy
define space
– be sure your space is functional
– need room for equipment, interventions and space to walk around while others are performing their treatments
define efficiency
– do you have a properly sized waiting room?
– is bathroom easily accessible?
– are the people able to walk around others that are doing activities without interrupting them?
define environment
– the space should feel like a place where people go to work hard and get better
– if too calm, it may discourage
– if too much gym, may turn some off who are not motivated to work out
define Medicare, Part A
in general, covers:
– Hospital care
– Skilled nursing facility care
– Nursing home care
– Hospice
– Home health services
define Medicare, Part B
covers 2 types of services:
– Medically necessary services: services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice
– Preventive services: health care to prevent illness [like the flu] or detect it at an early stage, when treatment is most likely to work best
– examples: ambulance services, durable medical equipment [DME], second opinions
What are the factors that should be considered when purchasing equipment?
– types
– variety
– quantity
– maintenance
describe types of equipment
useful for the types of interventions to be used in PT department
describe variety of equipment
– to accommodate patients with different needs
– two different varieties of a machine that works on the same body parts
describe quantity of equipment
enough bought so no conflicts arise when you have multiple patients performing therapy at same time
describe maintenance of equipment
easily maintained so it can be used consistently for a long period of time without having to spend money to replace or fix it
list some fiscal management factors
think ABCD…U:
– accurate recording of financial information
– budget for optimal use of resources
– considers option of pro-bono services [charity case: patient without health insurance but requires treatment]
– direct and indirect expenses
– uses a fee schedule consistent with the cost of therapy services
list some indirect expenses
– equipment depreciation
– insurance
– taxes
define prospective payment system [PPS]
methods of paying hospitals, health systems and organizations in advance regardless of the costs they incur during the course of treatment
What do Resource Utilization Groups [RUGS] categorize?
patients based on their level of resources used, which determines payment to the facility
Why are budgets necessary?
for optimal use of resources
define productivity
the amount of time spent with the patient and the amount of units used within the treatment session
What are diagnostic related groups [DRGs]?
a classification scheme developed by the federal government as a means to establish a uniform reimbursement for a variety of diagnostic conditions
– patient’s diagnosis determines the amount the provider will be paid
list some direct expenses
– benefits
– building rent
– equipment
– wages
define fee scheduling
the listing of health care services in which a specific amount of money is associated with each service
explain what ‘skilled and medically necessary’ means
that all care needs to be skilled and medically necessary in order for third party payers [insurance companies] to reimburse healthcare organizations
reimbursement for physical therapy services can be received through what means
– diagnostic related groups [DRGs]
– prospective payment systems [PPS]
– resource utilization groups [RUGs]
– retrospective methodology [i.e. fee for service]
How can a physical therapy facility manage to create a profit?
– create a good payor mix
– decrease patient cost by increasing efficiency
– increase volume
– negotiate for increased capitation rates
define capitation
one payment per patient per year regardless of utilization of services
define quality assurance
the objective measurement of quality of patient care including responsibility to correct deficiencies
define peer review
an assessment of service done by professional equals
define quality improvement
to make the changes that will lead to better:
– patient outcomes [health]
– system performance [care]
– professional development
define criteria
specific elements of medical care considered appropriate and or relevant to each diagnosis or condition
explain the purpose of Professional Standards Review Organization [PSROs]
– reviewed and controlled both costs and quality assurance for patients covered by all federal programs
– PSROs eventually replaced by Peer Review Organizations [PROs]
define audit
the method of assessing the quality of patient care
What is the purpose of a utilization reviews?
– to evaluate the use of equipment, staff, and facilities
– to determine if care is medically necessary and appropriate
Define and explain the role of the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]
– a national accrediting body whose job is to review hospitals
– also called the Joint Commission
– at first established to focus on structure but now focuses on outcomes
list the requirements for a quality assurance system
think MIA:
– monitor patient care
– improve patient care
– assess patient care
list the objectives of a quality assurance system
think AEI…RR:
– assist in management decisions
– evaluate the level of patient care for the department and staff member
– improve documentation
– relate levels of patient care to productivity
– relate results of care to specific diagnosis, therapeutic interventions, and intensity of services
What areas may a quality assurance system assess?
think OPS:
– outcome
– process
– structure
list types of structures
– equipment
– licensure
– physical plant
– policies and procedures
– records
– staff
list types of processes
provision of services:
– approach
– efficiency
– intensity
– intervals
define and state the importance of outcomes
– status at discharge relative to admission
– will ultimately gauge the quality of care
What was the impact of reimbursement on access to physical therapy?
caused a shift from a retrospective reimbursement methodology to a prospective payment system [PPS]
What did the reimbursement shift force Physical Therapists to look at?
the actual costs of providing care on an ongoing basis
The reimbursement shift caused an implementation of new approaches to staffing and services to ensure what?
o cost-effective care
o maintaining quality care
o productive care
What do managed care organizations [MCOs] require?
– documentation of medical necessity
– a limit on the number of visits
– documentation of functional gains
What are drawbacks to the reimbursement shift?
Physical Therapists frequently invest unreimbursable time to:
– advocate for more treatment sessions
– more documentation time required for the same reimbursement amounts
list four quality improvement strategies for therapists
– enhance employee contribution
– hold yourself accountable to areas where the facility falls short
– make patient and family a partner
– treat the whole patient
vital signs consist of what
– blood pressure [BP]
– pain [ 🙁 ]
– pulse [HR]
– respiration [RR]
– temperature [T]
define temperature
indication of intensity or degree of heat within the body [balance between heat produced and heat lost]
define pulse [heart rate = HR]
movement of blood in an artery that can be palpated at various sites of the body or measured through auscultation over the apex of the heart with a stethoscope
define blood pressure
– reflects the effects of cardiac output, peripheral vascular resistance and other hemodynamic factors
– it is the force exerted by blood against any unit area of the vessel wall
define respiration
the measurement of the rate, rhythm, volume and character of respiration
– the exchange of fresh oxygen [O2 in] and removal of carbon dioxide [CO2 out]
define pain
– an unpleasant sensory and emotional experience associated with actual or potential tissue damage
– highly subjective
– a self-report is the most reliable indicator
ranges for Temperature [T]
oral: 96.8 – 99.3 F
rectal: 97.8 – 100.3
ranges for Respiration Rate [RR]
[respiration: in/out = 1]
– adult: 12 – 18 per minute
– infant: 30 – 50 per minute
ranges for Pulse [HR]
– adult: 60 – 100 beats per minute [bpm]
– child: 80 – 120 beats per minute [bpm]
– newborn: 100 – 130 beats per minute [bpm]
ranges for Blood Pressure [BP]
– elderly: 120/80 – 140/90
– adult: 120/80
– adolescent: 100/65 – 120/75
– children: 100/60 – 108/70
– infant: 3 months – 1 year: 90/60 – 100/67
– infant: birth – 3 months: 85/35 – 90/65
How can one accurately record and document vital signs?
– for Temperature [T], record method: rectal [R], axillary [Ax] & degrees in Fahrenheit [°F]
– for Respiration Rate [RR], record number of breaths per minute
– for Blood Pressure [BP], record systolic pressure above diastolic pressure
What factors may affect Temperature [T] and how can it be affected?
– time of day: lower earlier, higher in afternoon
– age: decreases slightly with age and increased slightly in very young
– infection: increases
– physical activity: increases
– emotional Status: increases
– site of measurement: compared to oral, higher when rectal, lower when axillary
– oral cavity temperature: eat/drink hot/cold within 30 minutes of temperature recording
What factors may affect Pulse [HR] and how can it be affected?
– age: older decrease; younger increase
– gender: males slightly lower than females
What factors may affect Respiration Rate [RR] and how can it be affected?
– age: very young and elderly have higher rates
– physical activity: increases
– emotional status: increases with stress
– air quality: can cause increase or decrease
– altitude: increase until acclimated
– disease: usually increases
How can you correctly utilize the data collection tools used in the assessment of pain?
– document onset of pain
– ask patient to point to exact location of pain on body, or using pain questionnaire
– ask if pain radiates or spreads to other parts of body
– description of pain [example: “burning or tingling” can indicate neuropathic cause]
– ask what activities increase or decrease pain [helps design better Plan of Care]
– ask what the current pain is on a scale [may use visual or verbal scale]
describe the etiology of pressure ulcers
– pressure, friction or shearing
– temperature
– aging
How do pressure, friction or shearing play a role in pressure ulcers?
they are more likely to cause damage than the pressure ulcer alone
How does temperature play a role in pressure ulcers?
an increase in body temperature compromises the metabolism of ischemic tissue
define ischemic
loss of blood supply resulting in tissue death [necrosis]
How does age play a role in pressure ulcers?
– after 30 years of age, the skin’s pliability and elasticity decreases
– after 50 years of age, the skin’s blood flow decreases
– the elderly have a greater lack of mobility, poorer nutrition, complicated medical problems, and longer periods of confinement
What type of patients are considered “high-risk” for pressure ulcers?
those with:
– loss of sensation and or lack of mobility [SCI, MS, TBI, PD, etc]
– loss of consciousness [comatose or heavily sedated]
– an unwillingness to move due to pain
– contractures to limbs
– incontinence
– specific diseases [example: diabetes]
define contractures
limbs frozen in position from lack of movement
define incontinence
inability to control bladder and/or bowels
list some preventive measures for the development of pressure ulcers
think ERIE:
– Eliminate pressure [turn and reposition every 2 hours]
– Recognize skin breakdown [inflammation, redness, non-blanchable erythema]
– Identify high risk patients
– Educate patient and family [good skin care, etiology, consequences, patient morbidity]
Identify and explain the mechanism involved in the signs of impending skin breakdown.
red flags: inflammation, redness [blanchable or non-blanchable]
action: remove pressure to reverse damage
if untreated: ulceration progresses rapidly and the patient is at risk for a more serious pressure ulcer
How are pressure ulcers are managed?
– wound care
– a strict turn and repositioning schedule
What are the common areas for pressure points?
Think Bony Prominences: “I’ve got a bone to pick with you!”
– head
– ears
– shoulders
– elbows
– spine
– hips
– coccyx [tailbone]
– knees
– ankles
– feet
– heels
– toes [5th metatarsal]
Why is repositioning important?
– prevents soft tissue injury, pressure, and joint contracture
– provides patient comfort
– provides support and stability for the trunk and extremities
– provides access and exposure to areas to be treated
– promotes efficient function of patients’ body systems
– relieves excessive, prolonged pressure on soft tissue, bony prominences, and circulatory and neurologic structures
How are pressure ulcers categorized?
– “staged” I, II, III, or IV, based on their severity and amount of tissue damage
– all are categorized as chronic wounds
explain what an Unstageable pressure ulcer is
full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green or brown] and/or eschar [tan, brown or black] in the wound bed
Which body position simultaneously relieves pressure from both the sacrum and the trochanter?
– a 30-degree lateral position
– if needed, use pillows or a foam wedge to help the patient maintain the proper position
What are the characteristics of a Stage I pressure ulcer?
“the beginning stage”:
– skin intact
– skin appears red or ashen and doesn’t blanch [lighten in color] when touched
– area may be painful, firm, soft, warm or cool
What are the characteristics of a Stage II pressure ulcer?
“an open wound”:
– may look like a shallow, pinkish red bowl-like wound
– may appear as an intact or ruptured blister
What are the characteristics of a Stage III pressure ulcer?
“a deep wound”:
– has a crater-like appearance
– deep damage may expose a fat layer
– bottom of the wound may have some yellow dead tissue [called slough]
What are the characteristics of a Stage IV pressure ulcer?
“large scale tissue loss”:
– wound exposes bone, muscle or tendons
– bottom of the ulcer contains slough and/or dark, crusty dead tissue [called eschar]
– deep damage is extensive and well beyond the original wound
When positioning a patient in sitting, the hips and knees should be…
flexed to 90 degrees
Your patient’s BP is 120/60. What does 120 represent?
systolic number
The first step in a grievance procedure is what?
verbally discuss problem with supervisor
Patient call systems and emergency procedures are considered when designing a P.T. department. Which of the following factors would these be listed under?
safety
The term used to describe a decreased pulse [less than 50 bpm] is…
bradycardia [abnormally slow heartbeat]
You need to take your patient’s pre- and post-exercise heart rate. Documentation of your findings will include what?
think RRV:
– rate
– rhythm
– volume
The difference between the cost of the treatment [expenses] and the charge for the treatment [revenue] is what?
profit
Shearing force is more damaging than direct pressure and occurs in which of the following positions?
semi-reclining
Your patient will require 24 hour intensive medical services and physical therapy following discharge from the hospital. Which type of long term care or nursing care facility will your patient will most likely go to?
skilled
True/False: Pre-exercise HR for a patient you are seeing is 70 bpm. Exercise HR at peak intensity is 100 bpm. This is a normal response to increase in activity.
True
Your PT clinic is the preferred provider for X insurance company. Your patient must gain access to your service through a primary care physician and pays a co-pay for the treatment. X will not reimburse for PT provided by any company but yours. Their healthcare plan is most likely a:
Health Maintenance Organization [HMO]
A pressure ulcer that is very painful with partial thickness skin loss [sometimes referred to as a red wound] is a:
Stage II pressure ulcer
A patient with an existing pressure ulcer should receive instruction in what?
– pressure relief
– skin care
– prevention of infection
– nutrition
The normal adult range for respiration is what?
12-18 breaths/minute
When taking blood pressure with the brachial artery, where should the diaphragm of the stethoscope be positioned over?
palpable brachial pulse
Healthcare insurance provided by the government for the economically indigent is called…
Medicaid
True/False: Medicare part B typically reimburses for inpatient hospital and rehab stays.
False
When positioning a patient prone, the shoulders are supported with towel rolls to prevent what?
scapular protraction [abduction; shoulder blades moves away from the midline]
An arthritic patient or a post-op patient may be considered a high-risk patient for pressure ulcers because he has what?
increased pain
If a patient’s pulse has decreased volume and is easy to obliterate, it would be recorded as what?
weak and thready
Hospitals can be classified by the size, type, ownership and what?
length of stay
The PTA student is working in a large rehabilitation hospital. During the morning treatment, the student and a COTA worked together with the patient on standing at the counter and cooking a meal. The OT, PT and SLP are all working together to help the patient meet their goals. The student is asked to report the patient’s progress toward the goal in therapy during a team meeting in which the doctors, case mangers and family are present. The SPTA recognizes this method of communication and collaboration as the ______________________ team.
interdisciplinary
Which of the following health care professionals is not categorized as an allied health provider?
Physiatrist
According to the American Heart Association, the recommended adult blood pressure is?
less than 120 mm Hg [systolic]/less than 80 mm Hg [diastolic]
A physical therapist assistant is working with a student PTA when the student tripped over a patient’s walker and sprained his ankle. After elevating the LE and placing ice on it, the PTA showed the student how to fill out the incident report. All of the following belong in the report except:
the insurance company for the injured
A PTA is working in the hospital with a 65 yo patient recovering from a right hip fracture. The PTA recognizes that this patient most likely is covered by the following health insurance:
Medicare, Part A
Medicare legislation requires facilities who participate in the federally funded program to prove medical necessity of the treatment, skilled interventions and quality of care. Facilities do this through a retrospective process called:
Utilization review
A physical therapist assistant is working in a long term care facility with a patient who is on the skilled nursing floor [SNF]. The services are reimbursed by resource utilization groups [RUGs] and the therapist notes the minutes of treatment on the MDS. This system is called:
a prospective payment system [PPS]
Which of the following terms is defined as difficulty breathing while lying down?
orthopnea
A patient status post THA is requiring max assist for bed mobility due to pain. He tells the PTA that his backside really hurts. The PTA inspects the area and notes that it is red, hot and swollen. The PTA recognizes these as the signs of _________________. After repositioning the patient, she notifies the nursing staff and documents it in the medical record.
inflammation
How does one fit a patient for crutches [axillary] to be used in gait training?
– with patient trunk erect, the hips straight, the pelvis level, the knees slightly flexed, and the feet flat on floor
– measure from point at the anterior axillary fold [two finger space between fold and crutch] to a point on the floor approximately 2 inches lateral and 4-6 inches anterior to the patients toes for the overall crutch length
How does one fit a patient for Lofstrand [forearm] crutches to be used in gait training?
– top of forearm cuff should be located approx 1.0-1.5 inches distal to the olecranon process when the patient grasps the handpiece with the cuff applied to the forearm which is inverted and the wrist in neutral flexion-extension should be approximately 20-25 degrees
How does one fit a patient for canes to be used in gait training?
– hand grip of the cane should be placed at the level of the patients greater trochanter, the wrist crease, or the ulnar styloid process with the arm straight along the side
– place the cane parallel to the femur and tibia with the foot [tip] of the cane on the floor or at the bottom of the heel of the shoe
How does one fit a patient for quad canes to be used in gait training?
– position cane so tip is approximately 2 inches lateral and 4-6 inches anterior to toe of shoe
– observe angle of elbow flexion; should be approximately 20-25 degrees
How does one fit a patient for standard walker to be used in gait training?
– hand grip of walker should be placed level with the patients wrist crease, ulnar styloid process, or greater trochanter with walker positioned in front of and along the patient’s sides and with the patients arms straight along the side
– feet of walker should be resting on floor or even with the heels
– the hips and knees should be straight and shoes should be worn
How does one fit a patient for rolling walker to be used in gait training?
– determine the distance from patient’s greater trochanter to heel, with shoes on and with hips and knees straight
– observe angle of elbow flexion, should be approximately 20-25 degrees when the patient grasps the handpiece and positions the device in preparation for ambulation