Utilization of the Physical
Therapist Assistant
A Mentoring Relationship
Lindsay Pugmire MSPT, CCI
Amelia Partridge PTA, CCI
Objectives – first hour
•
•
•
•
•
•
•
Identify the main areas of the Utah PT Practice act that
pertain to the PTA
Understand the role of the PT, PTA and aide
Define Physical Therapist, Physical Therapist Assistant
and physical therapy aide
Define General Supervision and On-Site Supervision
and how they pertain to the PTA
Identify those items specifically mentioned by the
practice act which are outside the scope of practice of
a PTA
Identify the Authority of the PTA
Understand Medicare policies regarding supervision of
the PTA
Objectives – second hour
•
•
•
•
•
•
Identify skills Physical Therapists feel are most lacking
in the PTA.
Identify qualities that Physical Therapists expect in a
PTA regarding effective teamwork.
Identify leadership skills Physical Therapist Assistants
feel are lacking in Physical Therapists.
Identify qualities that Physical Therapist Assistants
expect in a Physical Therapist regarding effective
teamwork.
Describe current practice patterns when utilizing a
Physical Therapist Assistant in the state of Utah.
Define mentoring and foster a greater understanding
of effective mentoring/collaboration in the PT/PTA
relationship.
Utah Physical Therapy
Practice Act
Title 58, Chapter 24b
Utah Code Annotated 1953
As Enacted by Session Laws of
Utah 2009
Issued July 1, 2009
Physical Therapy Practice
Act Rule
R156-24b
Utah Administrative Code
Issued December 9, 2010
http://dopl.utah.gov/licensing/physi
cal_therapy.html
Utah Practice Act
Definitions
General Supervision
Supervision and oversight of a person by a licensed physical therapist
when the licensed physical therapist is immediately available in person,
by telephone, or by electronic communication.
On Site Supervision
Supervision and oversight of a person by a licensed physical therapist
or a licensed physical therapist assistant when the licensed physical
therapist or licensed physical therapist assistant is;
a) continuously present at the facility where the person is
providing services
b) immediately available to assist the person; and
c) regularly involved in the services being provided by the
person
Licensed Physical Therapist
A person licensed under this chapter to engage in the practice of
physical therapy.
Licensed Physical Therapist Assistant
A person licensed under this chapter to engage in the practice of
physical therapy, subject to the provisions of subsection 58-24b401(2) (a)
58-24b-401
A licensed physical therapist assistant:
(a) is authorized to practice physical therapy;
(i) under the on-site supervision or general
supervision of a licensed physical therapist; and
(ii) within the scope of practice of a licensed physical
therapist assistant, as described in this chapter and
by rule;
(b) shall adhere to the standards of ethics described in:
(i) the American Physical Therapy Association's Code
of Ethics and Guide for Professional Conduct; and
(ii) rule; and
(c) may not be supervised by any person other than a
licensed physical therapist.
58-24b-402
In practicing physical therapy, a licensed physical therapist shall:
(a) manage all aspects of the physical therapy of a patient under the
licensed physical therapist's care;
(b) perform the initial evaluation and documentation for each patient;
(c) perform periodic reevaluation and documentation for each patient;
(d) perform physical therapy interventions that require immediate and
continuous examination and evaluation throughout the intervention;
(e) perform all therapeutic intervention on a patient that is outside of
the standard scope of practice of a licensed physical therapist
assistant or a physical therapy aide;
(f) determine the therapeutic intervention to be performed by a licensed
physical therapist assistant under the on-site supervision or general
supervision of the licensed physical therapist to ensure that the
therapeutic intervention is safe, effective, efficient, and within the
scope of practice of the licensed physical therapist assistant;
(g) conduct the discharge of each patient and document for each patient,
at the time of discharge, the patient's response to therapeutic
intervention; and
(h) provide accurate documentation of the billing and services provided.
Under Utah State Practice Act, Both PTs/PTAs “shall
adhere to standards of ethics described in the American
Physical Therapy Association’s Code of Ethics and Guide
to Professional Conduct
Code of Ethics for the Physical Therapist
Standards of Ethical Conduct for the Physical Therapist
Assistant
Ethics Documents
Both Documents revised 2010
Code of Ethics for the Physical Therapist
Principle #5: Physical therapists shall fulfill their legal and professional
obligations.
(Core Values: Professional Duty, Accountability)
5B. Physical therapists shall have primary responsibility for supervision of
physical therapist assistants and support personnel.
Principle #3: Physical therapists shall be accountable for making sound
professional judgments. (Core Values: Excellence, Integrity)
3E. Physical therapists shall provide appropriate direction of and
communication with physical therapist assistants and support personnel.
Standards of Ethical Conduct for the Physical Therapist Assistant
Standard #5: Physical therapist assistants shall fulfill their legal and ethical
obligations.
5B. Physical therapist assistants shall support the supervisory role of the
physical therapist to ensure quality care and promote patient/client
safety.
Although the Practice Act delineates specific interventions that
a PTA “may not” perform this is NOT the only defining limitation
to PTA interventions.
The Physical Therapist determines the appropriate interventions
delegated to the PTA.
58-24b-402
In practicing physical therapy, a licensed physical therapist
shall:
(a) manage all aspects of the physical therapy of a patient under the
licensed physical therapist's care;
(d) perform physical therapy interventions that require immediate and
continuous examination and evaluation throughout the intervention;
(f) determine the therapeutic intervention to be performed by a licensed
physical therapist assistant under the on-site supervision or general
supervision of the licensed physical therapist to ensure that the
therapeutic intervention is safe, effective, efficient, and within the
scope of practice of the licensed physical therapist assistant
Physical Therapy Aide
a person who is trained, on the job, by a licensed physical therapist; and provides
routine assistance to a licensed physical therapist or physical therapist assistant
while the licensed physical therapist or licensed physical therapist assistant
practices physical therapy within the scope of the licensed physical therapist’s or
licensed physical therapist assistant’s license.
PTA/ Aide may not:
A physical therapist assistant or a physical therapy aide may not:
(a) perform a physical therapy evaluation or assessment;
(b) identify or label a physical impairment or injury;
(c) design a plan of care for a patient;
(d) perform the joint mobilization component of manual therapy;
or
(e) perform the sharp selective debridement component of
wound management.
(a) is authorized to practice physical therapy;
(i) under the on-site supervision or general supervision of
a licensed physical therapist; and
(ii) within the scope of practice of a licensed physical
therapist assistant, as described in this chapter and by
rule;
(b) shall adhere to the standards of ethics described in:
(i) the American Physical Therapy Association's Code of
Ethics and Guide for Professional Conduct; and
(ii) rule; and
(c) may not be supervised by any person other than a licensed
physical therapist.
(a) A physical therapy aide may not engage in the practice of physical
therapy.
(b) Notwithstanding Subsection (3)(a), a physical therapy aide may
provide
routine assistance to:
(i) a licensed physical therapist while the licensed physical
therapist engaged in the practice of physical therapy, if the
physical therapy aide is under the on-site supervision of
the licensed physical therapist; or
(ii) a licensed physical therapist assistant while the licensed
physical therapist assistant engages in the practice of
physical therapy, within the scope of the licensed physical
therapist assistant's license, if the physical therapy aide is:
(A) under the general or on-site supervision of a
licensed physical therapist; and
(B) under the on-site supervision of the licensed
physical therapist assistant.
Joint Mobilization
A physical therapist assistant or a physical therapy aide may not:
(a) perform a physical therapy evaluation or assessment;
(b) identify or label a physical impairment or injury;
(c) design a plan of care for a patient;
(d) perform the joint mobilization component of
manual therapy; or
(e) perform the sharp selective debridement component of
wound management.
Subsection (2)(d) does not apply to:
(a) simple joint distraction techniques or stretching; or
(b) a stretch or mobilization that can be given as part of a home
exercise program.
Joint Mobilization cont.
Joint Mobilization (definition by Kisner and Colby):
Passive traction and/or gliding movements applied to the joint surfaces that
maintain or restore the joint play normally allowed by the capsule so the
normal roll-slide joint mechanics can occur as a person moves
Medicare Guidelines for PTA Utilization
Use of Physical Therapist Assistants (PTAs) under Medicare
Please note that physical therapists are licensed providers in all states
and physical therapist assistants are licensed providers in the
majority of states. As licensed providers, the state practice act
governs supervision requirements. Some state practice acts
mandate more stringent supervision standards than Medicare laws
and regulations. In those cases, the physical therapist and physical
therapist assistants must comply with their state practice act. For
example, in a skilled nursing facility in New Jersey, a physical
therapist must be on the premises when services are furnished by a
physical therapist assistant despite the fact that Medicare requires
general supervision. New Jersey's state practice act requires direct
supervision rather than general supervision, and therefore, the
physical therapist and physical therapist assistant would have to
comply with this requirement.
http://www.apta.org/Payment/Medicare/
Medicare Guidelines for PTA Utilization
Home Health Agencies (HHA)
Physical therapy services must be performed safely and/or effectively only by or
under the general supervision of a skilled therapist. General supervision has
been traditionally described in HCFA manuals as requiring the initial direction
and periodic inspection of the actual activity. However, the supervisor need
not always be physically present or on the premises when the assistant is
performing services.
Inpatient Hospital Services
Physical therapy services must be those services that can be safely and
effectively performed only by or under the supervision of a qualified physical
therapist. Because the regulations do not specifically delineate the type of
direction required, the provider must defer to his or her physical therapy
state practice act.
Outpatient Hospital Services
Physical therapy services must be those services that can be safely and
effectively performed only by or under the supervision of a qualified physical
therapist. Because the regulations do not specifically delineate the type of
direction required, the provider must defer to his or her physical therapy
state practice act.
Medicare Guidelines for PTA Utilization
Private Practice
Physical therapy services must be provided by or under the direct supervision of
the physical therapist in private practice. CMS has generally defined direct
supervision to mean that the supervising private practice therapist must be
present in the office suite at the time the service is performed.
Physician's Office
Services must be provided under the direct supervision of a physical therapist who
is enrolled as a provider under Medicare. A physician cannot bill for the
services provided by a PTA. The services must be billed under the provider
number of the supervising physical therapist. CMS has generally defined direct
supervision to mean that the physical therapist must be in the office suite
when an individual procedure is performed by supportive personnel.
Skilled Nursing Facility (SNF)
Skilled rehabilitation services must be provided directly or under
the general supervision of skilled rehabilitation personnel. General
Supervision is further defined in the manual as requiring the initial direction
and periodic inspection of the actual activity. However, the supervisor need not
always be physically present or on the premises when the assistant is
performing services.
APTA has adopted PTA Direction/Supervision Algorithm
Check Your Understanding
Select each activity, based on the algorithm, the PTA can be expected to
do:
X
X
Know when to provide care or hold care
Ensure that the patient is safe and comfortable throughout the intervention
X
Decide if the intervention is producing the desired results
X
Modify the intervention within the plan of care to improve patient outcomes
X
Select data collection techniques to measure the patient’s progress
X
Determine when the patient is ready to be progressed within the plan of care
X
Determine when it is necessary to communicate with the physical therapist
PTA Decision making Algorithm
QUESTIONS?
Survey Results
Participants PT
= 100 – 103
Participants PTA = 34-38
Years of Experience -- PT
MORE THAN 13 YEARS
49
10-13 YEARS
9
7-10 YEARS
10
4-6 YEARS
11
LESS THAN 3 YEARS
21
0
10
20
30
Results
40
50
60
Do you currently work with a PTA or
have you worked with one in the
past?
NEVER
15
YES, IN THE PAST
43
YES, CURRENTLY
55
0
10
20
30
Results
40
50
60
If you answered yes to question #2,
Do you feel that you have a good
relationship with the PTA with whom
you work?
10
NO
91
YES
0
10
20
30
40
50
60
70
80
90
100
In your education, did you have a
class in the role/utilization of PTA’s?
NO
71
YES
29
0
10
20
30
40
Results
50
60
70
80
Food For Thought
It follows, therefore, that educational opportunities for you
must be formulated with extreme care, and that you must
with equal intensity watch and be involved in their
formation. Appropriate utilization and
direction/supervision of the PTA is a critical, critical skill in
which every new PT grad must be competent by
graduation. Yet they currently are not. Many PTAs know
more about what is legal, ethical, and expected of them
than do PTs.
Barbara Bradford, PT; PT in Motion; PTAs Today; “The History Makers”
February 2010
What skills do you find most
lacking in PTA’s?
1. Critical reasoning when advancing or
progressing the patient using ongoing
assessment skills.
2. Treatment technique skills; mainly manual
therapy and advanced therapeutic exercise.
3. Education and knowledge base; needs more
schooling time like a 4 year or BS degree.
Food For Thought
The two most mentioned skills lacking in the PTA
(assumption: skills that PT’s want PTA’s to have
based on the survey) are two skill sets limited by
the Utah State practice act.
•
•
(2) A physical therapist assistant or a physical
therapy aide may not:(a) perform a physical
therapy evaluation or assessment
(d) perform the joint mobilization component of
manual therapy. Utah Practice Act 58-24b-402
Food For Thought
(a). Where do we draw the line between a
formal assessment and the every second we
touch and intervene with a patient using clinical
reasoning and assessing skills to adapt the
technique or progress the patient based on their
response; or do we draw a line in the practice
act?
From APTA CPI for the PTA – One skill set the
PTA student is graded on is Clinical Problem
Solving.
What qualities do you feel are the most
important or that you expect from a PTA for
effective teamwork related to patient care?
1. Communication skills:
•
Effective
Timely
•
Openness
consistent
Collaborative
Ask Questions
2. Critical thinking/understanding of the big picture.
3. Awareness of limitations.
How many years have you been
practicing? -- PTA
MORE THAN 13 YEARS
9
10-13 YEARS
1
7-10 YEARS
2
4-6 YEARS
6
LESS THAN 3 YEARS
16
0
2
4
6
8
Column1
10
12
14
16
18
Do you feel that you have a good
relationship with the PT you
primarily work with?
SOMETIMES
6
NO
1
YES
27
0
5
10
15
Response
20
25
30
What statement best describes
how you currently practice?
I HAVE VERY LITTLE SUPERVISION OR DIRECTION FROM THE PT IN MY
TREATMENT OPTIONS.
11
I AM ALLOWED TO CHOOSE MY OWN TREATMENT OPTIONS FOR THE PATIENT
WITHIN THE PLAN OF CARE ESTABLISHED BY THE PT.
22
THE MAJORITY OF THE PATIENT TREATMENT IS DIRECTED TO ME BY THE PT.
5
0
Response
5
10
15
20
25
Do you feel that the PT with whom
you primarily work encourages
growth and increased opportunities
in developing your skills?
SOEMTIMES
11
NO
6
YES
17
0
2
4
6
8
Response
10
12
14
16
18
What leadership skills do you find
most lacking in PT’s?
1. Communication (especially with plans of care).
2. Delegating appropriately
•
Too much
3. Respect/Trust
Not enough
What qualities in the PT do you expect or
feel are the most important for effective
teamwork related to patient care?
1. Communication:
•
Effective
•
Approachable
2. Respect/Trust
3. Collaborative
Clear
Listening
Timely
Consistent
What does the word mentoring mean
to you in regard to the PT/PTA
relationship?
In mentoring in regards to the PT/PTA relationship, I see it as a
two way street. The PT has the ability to teach and educate
the PTA so that patients can be effectively treated, however
the PTA can also be proactive regarding what they know
and teaching the PT their skills as well.
I see that word more appropriate for a new hire or a student, I
feel it should be more of a colleague in terms of PT/PTA
relationship.
What does the word mentoring mean
to you in regard to the PT/PTA
relationship?
I'm don't think that word applies in a working relationship
between co-workers.
I would suggest a mentoring relationship would be good, but it
assumes some give and take in communication and
openness. If that does not happen, then it feels defensive.
Mentoring means that I get the opportunity to lead by example
the behaviors I want to see in the PTA.
Not much.
What does the word mentoring mean
to you in regard to the PT/PTA
relationship?
I don't believe a PTA should have to be mentored.
All of us have something to learn from each other. Mentoring
should be a respectful and consistent sharing of skills and
knowledge for perpetual personal/professional growth and
progression of care to those we serve.
Teaching, educating, working together, understanding,
communication.
What does the word mentoring mean
to you in regard to the PT/PTA
relationship?
Having someone to bounce questions off of, and have open
lines of communication regarding patient care. Mentoring
should provide a comfortable environment for two way
conversation and room to grow as a professional.
Mentoring means sharing our individual skills that
complement each other & add to our own professional
growth & development. Mentoring can certainly go both
ways, based on education, specialized training &
experience.
What does the word mentoring mean
to you in regard to the PT/PTA
relationship?
A leader who has patience, one that is passionate about their
job, willing to explain/share their techniques and is also
eager to learn alongside the PTA.
Being able to take years of experience and teach it to me
little by little. Both having respect for each other.
Patience in the learning process.
Mentoring to me means having a lead PT that is still willing to
educate and challenge me as a PTA.
APTA Decision Algorithm
…Sounds Like Mentoring
APTA Resources For PTA Utilization
Free Course
learningcenter.apta.org
“Leading the Team: A Practical Guide to Working
With PTAs”
Note: Item 65: Mentoring PTA Career
Development
Desired Characteristics of a Mentor
People Oriented
Good Motivator– A mentor is someone who inspires a
mentee to do better.
Effective Teacher
Secure in position– A mentor must be confident in their own
abilities so that the mentee’s accomplishments can be
genuinely expressed.
An Achiever
Values Their Profession and work
Respects Others– A mentor is one who shows regard for
another’s well being. Openness to others.
(Quartermaster warrant officer mentorship guide –
www.quartermaster.army.mil)
Desired Characteristics of a Mentee
Eagerness to Learn– Seek advice.
Ability to Work as a Team Player
Patient– Learning is a process, be committed.
Risk Taker– Move beyond tasks that have been mastered to
accept new and more challenging experiences.
Positive Attitude
(Quartermaster warrant officer mentorship guide –
www.quartermaster.army.mil)
What has Worked For Us?
Mentoring where it has been
collaboration with colleagues (Two-way
street).
Consistent communication both
directions.
Living the characteristics listed in the
previous slides.
What has Worked For Us?
Co-Treating to model and coach skills.
Managing each other UP in the presence
of the patient.
TEAMWORK.
QUESTIONS?
Lindsay Pugmire, MSPT – lindsay.pugmire@imail.org
Amelia Partridge, PTA – amelia.partridge@imail.org