The Physical Therapist Assistant Profession Turns 50
While APTA's centennial may be a couple years away, there's another cause for celebration right here, right now: 2019 marks the 50th anniversary of the first physical therapist assistant (PTA) graduates.
Though a half-century may seem like a long time, the rise of the PTA from something that seemed like a good idea to a recognized, well-established, and in-demand profession integral to health care represents a remarkably short ascendance. Today, it's hard to imagine the delivery of physical therapy without PTAs on the team.
Here's a look at how the PTA profession came into being, and what's happened since.
The 1973 graduating class of PTAs from Greenville Technical College. Photo courtesy of APTA Library & Archive.
The Beginnings: A Clear Need, and a Creative Solution
The American Physical Therapy Association (APTA) first began to consider the idea of a physical therapist assistant in the 1940s, when physical therapists were treating soldiers injured in World War II, just as a new polio outbreak emerged. The United States had experienced 2 world wars, the Great Depression, and multiple polio outbreaks, resulting in high demand for the services of the approximately 2,500 physical therapists working at that time. Helen Blood, PT, FAPTA, a California Chapter member, introduced the House of Delegates (House) resolution to create a committee to consider a "physical therapy assistant occupation."
First PTA Programs Established
In 1967, the House adopted the policy statement "Training and Utilization of Physical Therapy Aides and Assistants" to establish educational standards, scope of practice, licensure, and eligibility for APTA membership. That same year, the first PTA education programs were established at Miami-Dade Community College in Florida and St Mary's Junior College in Minnesota (now St Mary's Campus of the University of St Catherine).
In 1968, Green River Community College in Washington admitted its first class of 26 students.
By 1971, APTA had approved 10 PTA education programs.
The number of PTA education programs grew steadily in the 1970s and 1980s, reaching the 100-program mark in the early 90s. After that, things really took off: today there are 393 accredited PTA programs across the United States.
The first graduating PTA class of St Mary's Junior College, Minnesota, in June 1969. Photo courtesy of APTA Library & Archive.
The PTA's Impact on APTA
PTAs were granted affiliate APTA membership in 1973. By 2018, PTA membership had grown from less than 100 to 7,736, along with 4,641 PTA students. APTA launched a #PTA10K initiative at the Component Leadership Meeting in June 2018 in an effort to reach 10,000 PTA members.
As PTA numbers and engagement in APTA continued to grow, so did a PTA sense of identity. In 1983, the Affiliate Special Interest Group (ASIG) was created, holding its first annual education conference in Topeka, Kansas, in 1987. Two years later, the House established the Affiliate Assembly, which succeeded the ASIG. In 1992, the House voted to give PTAs the opportunity to hold chapter and section officer positions.
To increase PTAs' knowledge and skills in a select area of physical therapy, in 2004 APTA established the Recognition of Advanced Proficiency for the Physical Therapist Assistant program, which was succeeded in 2016 by the PTA Advanced Proficiency Pathways (APP) program.
PTA Employment
In 1974, APTA successfully petitioned the American Medical Association's Council on Medical Education to recognize the PTA as a health care occupation. That same year, "Physical Therapist Assistant" was added to the US Department of Labor's Employment and Training Administration's Dictionary of Occupational Titles, assigned the code 076.224-010s.
By the early 1980s, there was once again a shortage of PTs and PTAs, and federal funding for education assistance was reduced. In response, many potential employers began offering health coverage, continuing education, association dues, and licensure fees—and some even offered to pay for the last year of school in exchange for signing a 1- or 2-year employment contract.
A 1983 survey found that only 37 states and Puerto Rico included physical therapist assistants in their state practice acts, 32 of which required PTAs to take a special examination in order to practice. All 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands now include PTAs in their practice acts.
The Bureau of Labor Statistics projects that PTA employment will grow 31% between 2017 and 2026. The median PTA salary in 2017 was $57,430—a far cry from the median 1977 salary of $8,500–$9,999.
In June 2018, APTA successfully lobbied for federal legislation to include PTAs as authorized providers under TRICARE. (The rule is not yet in effect.)
PTA Firsts
First PTA to serve in the United States Peace Corps: Carol McClaugherty, PTA, served in Rio de Janeiro, Brazil, beginning in 1974.
First PTA program designed for PTA students who are blind or visually impaired: In 1977, St Mary's Junior College in Minneapolis became the only school in the country with special facilities for teaching physical therapy and occupational therapy to students with blindness or visual impairment.
First PTA student to receive APTA's Mary McMillan Scholarship: Melinda Hong, De Anza College, earned the scholarship in 1980.
First PTA students to receive APTA's Minority Scholarship Award: Karen Aitken-Douyon, Essex County College; James Lee Howlett, Wallace State College; and Mary Man, Tulsa Junior College, received scholarships in 1996.
PTA student Melinda Hong receives the Mary McMillan Scholarship in 1980. Photo courtesy of APTA Library & Archive.
First PTA to receive APTA's F. A. Davis Award for Outstanding Physical Therapist Assistant Educator: Barbara J. Behrens, PTA, received the award in 2000.
First recipients of the APTA Outstanding Physical Therapy/Physical Therapist Assistant Team Award: Edie Knowlton Benner, PT, PhD, and Juliana Robine, PTA, were recognized in 2006.
First recipient of the APTA Outstanding Physical Therapist Assistant Award: Roy Christopher Junkins, PTA, ATC, was awarded in 2007.
Lisa Finnegan, PTA, lead accreditation PTA programs specialist, became one of the first physical therapist assistants to work at APTA in 2006. "I've never believed that I'm ‘just a PTA,'" says Finnegan. "PTAs have many rewarding job opportunities—I've had the pleasure of treating patients in clinical settings, teaching in a PTA program, writing books for PTA students, and working for APTA and CAPTE. I'm proud to be a PTA and an APTA member."
For more on the history of the PTA, watch for PT in Motion magazine's special feature in the upcoming May issue.
Got MIPS Questions? We Have Answers.
The Merit-based Incentive Payment System (MIPS) is now in effect for many physical therapists. At a recent live webinar, APTA answered some of our members' most pressing questions. (In case you missed it, you can listen to the recorded webinar in its entirety.)
We've recapped some popular questions here. Not finding the question you need answered? You can email advocacy@apta.org. APTA members can also post questions, and review answers to other member questions on the Medicare MIPS Discussion Board on the Medicare Quality Reporting Hub.
What is the quickest way to find out if my practice is required to participate?
The Centers for Medicare and Medicaid Services (CMS) website has an easy lookup tool. Just type in your national provider identifier (NPI) number and you'll see whether you are required to participate as a practice, or as an individual.
APTA's MIPS resource page has a lot of information, including a decision tree to help you understand MIPS eligibility and required vs voluntary participation.
In brief, you must participate if you are an individual PT in private practice and exceed all 3 criteria for the "low-volume threshold":
- Receive more than $90,000 in Medicare part B payments each year
- Provide care for more than 200 Part B-enrolled Medicare beneficiaries annually
- Bill more than 200 professional services annually
My small practice is going to participate in MIPS. Because we have fewer than 15 PTs, we are allowed to report via claims instead of through a registry or QCDR. What are the business considerations for choosing one method or the other? Can we switch from claims to registry reporting later, or are we stuck with whatever choice we make?
If you report via claims, you can submit your quality data on your claim form. However, you will not get feedback on your performance until after the end of the reporting year, when it will be too late to make changes that could help your MIPS score. Even though you will incur a cost using a registry, it will provide you with feedback throughout the year. The type and frequency of feedback may vary by registry. You can switch data submission methods mid-year. CMS will base your score on your top 6 measures.
Does MIPS apply to hospital-based outpatient practices?
No. For 2019, if you practice in a facility-based setting such as a hospital outpatient department, skilled nursing facility (part B), or rehabilitation facility you are not able to participate in MIPS.
Our physical therapy clinic is part of a multispecialty practice in which the physicians already report as a group. The PTs do not meet the low-volume threshold as individuals. Do we need to report as part of the group?
It may depend on your specific multispecialty practice. You can contact us at advocacy@apta.org to address your questions.
We have 6 PTs in our practice, and none of them exceed the low-volume threshold individually. But as a group, we do. Do we have to report?
The group is not required to participate, since MIPS only mandates individual PT participation. However, because the practice as a whole exceeds the threshold, it can choose to participate in MIPS to take advantage of the potential 7% incentive payment.
Our practice exceeds the threshold, but only 1 of our PTs does individually. How does that work?
You have 2 options: The PT participates alone, or the practice can participate as a group. Only the PT who exceeds the threshold is required to participate. However, because the whole practice also exceeds the threshold, it can participate in MIPS. If you choose group participation, all therapists will be considered fully participating in the program.
What are my options for reporting improvement activities? Do you have recommendations?
CMS offers over 100 improvement activities, which can be found on the CMS QPP website. APTA has created a condensed list of activities that may appeal to PTs.
How can we follow our performance scores to tell if we are meeting expectations throughout the year?
This is a great question. If you report via claims, you will not know your score until the end of the reporting year. This is why APTA recommends using a vendor for reporting. It can help you improve your scores throughout the year. If you report using a "qualified registry," check with your vendor to see how frequently you will be able to get feedback. Some may only be quarterly or monthly.
As a qualified clinical data registry (QCDR), APTA's Physical Therapy Outcomes Registry gives you continual real-time feedback.
If you are attending CSM, Heather Smith, PT, MPH, APTA director of quality, and Kara Gainer, JD, director of regulatory affairs, will be presenting "Emerging Issues in Medicare: Quality Programs and Alternative Payment Models" on Friday at 11:00 am, where a CMS representative will be available to address attendees' questions. Heather Smith also will host a Q&A session at 2:00 pm on both Thursday and Friday at the Physical Therapy Outcomes Registry booth #1433 in the Exhibit Hall.
CSM Preview: Genomics and Precision Physical Therapy With Richard K. Shields and Eric D. Green
In his 2017 McMillan Lecture, "Turning Over the Hourglass," Richard K. Shields, PT, PhD, FAPTA, predicted that, as we learn more about the effects of exercise on genetic pathways that influence health, "precision physical therapy will emerge side by side with precision medicine." Genomic analysis, he said, is "laying the groundwork for physical therapists to dose movement in ways that we never considered possible."
Shields and colleague Eric D. Green, MD, PhD, will dive deeper into this topic at the upcoming APTA Combined Sections Meeting in January 2019. In "Personalized Physical Therapy: The Time Is Now," sponsored by APTA's Frontiers in Rehabilitation, Science, and Technology (FiRST) Council, the speakers will explore the implications of genomics for exercise science and performance and how knowledge of a gene's function could alter a patient's medical management and clinical outcomes.
The session will be moderated by FiRST Council co-chair Steven L. Wolf, PT, PhD, FAPTA, and was organized by Catherine Curtis, PT, EdD.
#PTTransforms spoke with Shields (RS) and Curtis (CC) to get some quick takes.
#PTTRANSFORMS:
First, what is the FiRST Council?
CC: APTA's Board of Directors established the Frontiers in Rehabilitation Science and Technology (FiRST) Council to help prepare its members for innovative medical technologies and approaches to clinical care, such as sensing technologies and robotics, regenerative medicine, precision medicine, telehealth, and imaging. Any APTA member in good standing can join the FiRST Council. Non-PT or PTA individuals who are in related disciplines, such as bioengineering or genetics, are eligible to be "Council Partners."
#PTTRANSFORMS:
What was the genesis for this session?
CC: Completion of the first reference sequence of the human genome in 2003 gave rise to a sea change in the biological and medical sciences. Francis Collins, director of the National Institutes of Health (NIH) and former director of the National Human Genome Research Institute (NHGRI), has said that virtually every human ailment, except some cases of trauma, is considered to have some genetic basis. Medicine is becoming more personalized, with a shift toward early risk identification and diagnosis, and targeted therapy. Physical therapists need to be aware of the effects of genetic variants on health and disease and be prepared to devise individualized lifestyle interventions for both prevention and wellness.
#PTTRANSFORMS:
How close are we to understanding how to use a patient's genetic information to tailor their physical therapy treatment?
RS: Physical therapists and their patients already are armed with new knowledge about genomics and how a patient's genetic makeup may influence personal health and health care treatments. Many patients will bring their own genotype to the clinic, whether acquired through a medical center screening program or a private vendor. Research is providing clinicians with increasing information about the effects of genotypes on health conditions. For example, we know that the homozygous ACTN3 577X genotype has been consistently associated with delayed onset muscle soreness and muscle damage after eccentric exercise. Clearly, dosing eccentric exercise may vary based on whether an individual has this known allele.
While we must be careful not to overstate, we must be cognizant of the power of regular, repetitive movement (exercise) on the epigenome—the system that can promote healthy genes and repress damaged genes. Physical therapists must understand the power of their own prescriptions from a fundamental science perspective.
CC: While genetic testing for rare disorders is available, regular testing for common disease variants is not routinely performed in clinical practice. There are issues with screening accuracy and sensitivity, and even if variants are identified, their clinical significance is still unclear. As we learn more, testing for common disease variants will likely become more routine, and genetic information will be increasingly available in clinical settings. These are some of the topics Eric D. Green will cover in his presentation, as well as how the NIH All of Us Research Program seeks to extend precision medicine to all diseases by building a national research cohort of 1 million or more US participants. By taking into account individual differences in lifestyle, environment, and biology, researchers will uncover paths toward delivering precision medicine.
#PTTRANSFORMS:
What are some opportunities and challenges regarding application of genomic research in practice?
RS: The key challenge is that public opinion may race ahead of scientific evidence. A great number of studies have found evidence for higher prevalence of certain genotypes in various populations. The public may infer causality where none exists, so physical therapists must be able to accurately interpret genomic information.
Physical therapists will have many opportunities to speak truthfully about the meaning of the genomics movement and continue to advance knowledge about the power of regular movement-based treatments. Accordingly, they should participate in educational programming that helps jump-start their knowledge of genomics and epigenetics.
CC: The Genomic Era is upon us, with advances relevant to health and wellness now emerging. The translation to clinical physical therapist practice is still very new, and the initial challenge for the profession is that all therapists must expand their knowledge in this area beginning with basic concepts and an awareness of the potential impact on the health and wellness of individuals. With this background, the opportunity for more and more research on direct application to practice will emerge.
#PTTRANSFORMS:
What other physical therapy–related genomic research is on the horizon?
CC: Physical therapists—including members of the FiRST Council genomics group—are increasingly engaged in genetics-related research relevant to clinical practice. Steve Cramer, MD, and Steve Wolf, PT, PhD, FAPTA, are studying how brain-derived neurotrophic factor (BDNF) Val66Met genotype is associated with greater brain atrophy after stroke. Cameron Mang, PhD, MSc, and Laura Boyd, PT, PhD, are exploring how genetic influences underlying acute aerobic exercise affect motor learning. Allon Goldberg, PT, PhD, is researching how angiotensin I-converting enzyme gene (ACE) polymorphism affects grip-strength correlations with balance and walking speed in older adults. And Laura Case, PT, DPT, and colleagues are examining phenotypic traits of infants with Pompe disease identified by newborn screening.
RS: There are many studies examining the relationship between genetic markers and functional outcomes in people with Parkinson disease, total hip/knee replacement, stroke, spinal cord injury, and diabetes. We are looking at the relationship between muscle exercise and tagging certain genes known to be strong signatures of metabolic health. The outcomes of all of these types of studies will help chart the course for using genetic biomarkers to guide us as we determine who will benefit from our prescribed movement-based interventions.
#PTTRANSFORMS:
What should people take away from this session?
RS: Be ready. Get your minds around the fact that genomics is and will continue to be a part of our profession. Start incorporating the needed content into curricula, but don't panic and don't "jump the gun" by promoting false information that sets the health care world back. There is still a long way to go before the evidence is sufficient to drive care. Stay calm and become a par excellence consumer of genomic and epigenetic literature so that you add value to the overall movement of precision health among the health care team.
For more in-depth discussion, listen to this recent podcast interview between PTJ Editor-in-Chief Alan Jette, PT, PhD, MPH, FAPTA, and Richard Shields.
To attend this exciting CSM session, register now at www.apta.org/CSM/. CSM advance registration discounts end December 5.
Easing Administrative Burden: APTA Makes It Easy to Make Your Voice Heard
Everyone hates unnecessary paperwork and red tape—it cuts into your time with patients, adds to a clinician's workload, and often can delay care. The Centers for Medicare & Medicaid Services (CMS) seems to have gotten the message, going so far as to propose a rule on reducing administrative burden. And you have an opportunity to weigh in on the issue: CMS is asking for public comment on regulatory burdens as it considers ways to streamline processes in future rules. Comments are due by November 19.
Carol Zehnacker, PT, DPT, has worked in a multitude of practice settings, including acute care, skilled nursing facilities, home health, and private practice. Zehnacker says, "There has been an explosion of regulations and administrative burdens that hamper our ability to provide quality care, and can lead to provider burnout."
"We all went into this profession with a desire to help others," says Theresa Marko, PT, DPT, MS. "The health care system sometimes inhibits progress due to unnecessary regulations. How do we fix any of this? How can one person make a difference? APTA has a team of people working to improve the system in which we operate. If we can rally together with one collective voice to let the powers that be know how we feel, wouldn't that be great? For this proposed rule, APTA has created an easy-to-use template you can download, edit with personalized comments, and send in to CMS."
Both Zehnacker and Marko are submitting comments using APTA's template, which provides therapists with some specific content areas they can customize by providing their personal stories and highlighting other regulations that are overly burdensome on physical therapists. The content areas in the template letter include the following:
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Streamline the Medicare credentialing process.
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Institute a permanent moratorium on the direct supervision requirement for outpatient physical therapy services in critical-access hospitals.
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Eliminate or modify the outpatient therapy plan of care 30-day initial certification and 90-day recertification requirements.
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Eliminate prior authorization for Medicare Advantage patients or require same-day authorizations.
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Better ensure accurate beneficiary eligibility data.
In her comments to CMS, Zehnacker, a private practice owner who has a contract with a home health agency, described the "unnecessary requirement" of notifying the physician when the plan of care changes, such as a missed visit or a treatment or service as required by the plan of care. "This is time consuming for both the therapist and the staff at the physician's office. The physician has already ordered physical therapy in the home health setting. In reality, it is the physical therapist who develops the physical therapy plan of care and awaits the physician's sign-off."
You don't have to go to Capitol Hill to make your voice heard. Rather, you can use your voice, through written comments, to educate and influence executive and independent agencies, the bodies that create or publicize regulations by the authority of Congress.
"When regulatory agencies propose to take action on a certain subject that is of interest to you, it's important to take that opportunity to use your voice," says Kara Gainer, APTA's director of regulatory affairs. "It's the individuals who often provide the most compelling comments, offering the agency a different perspective that is both personal and closely connected to the issue at hand."
Although comments submitted by APTA, representing the physical therapy profession, are incredibly influential, "when CMS is making important decisions that will affect our everyday operations in our professions, they will take into consideration all the comments submitted by providers," says Marko. "Personalizing APTA's template and uploading it to the CMS website is easy—I was able to do it in about 15 minutes! As a private practice orthopedic PT I have experienced much unnecessary burden throughout my career. The template is an easy way for all of us to impact the system in which we operate and produce a positive outcome."
Visit APTA's website to download the template and submit your comments. (Scroll down to "CMS Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction.")
Understanding Trauma and Chronic Toxic Stress in Your Pediatric Patients
By Jessica Barreca, PT, DPT
In our profession, the word "trauma" typically leads us to think of a catastrophic injury, emergency medical care, and comprehensive rehabilitation services. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), however, trauma also includes "events or circumstances experienced by an individual as physically or emotionally harmful or life-threatening, which result in adverse effects on the individual's functioning and well-being."
ACEs Are More Prevalent Than You Might Think
The first study to examine trauma's long-term health effects was the CDC-Kaiser Permanente Adverse Childhood Experiences Study, which collected confidential surveys of over 17,000 Kaiser Permanente patients. Respondents were asked about their exposure to adverse childhood experiences (ACEs)— neglect, abuse, and "household dysfunction" such as domestic violence—and their current health status, risk behaviors, and disease. The study found that over 50% of participants had experienced at least 1 ACE and 25% had experienced 2 or more.
In 2013, the Philadelphia Urban ACE study (.pdf) surveyed a more racially diverse sample of adults and expanded survey questions to include topics such as community violence, racism, and neighborhood safety. More than 80% of those surveyed had experienced at least 1 ACE and nearly 40% had experienced 4 or more. Children of all ages and backgrounds experience ACEs, but poverty is a risk factor (.pdf).
To achieve optimal health outcomes for children who have or are experiencing trauma, physical therapists (PTs) and physical therapist assistants (PTAs) should practice SAMHSA's "Four Rs" (.pdf):
- Realize trauma's impact
- Recognize signs and symptoms
- Respond by integrating knowledge of trauma-informed care
- Resist retraumatizing patients
Realizing the Impact of Trauma and Toxic Stress
The brain is most plastic and develops most rapidly during early childhood. The influences of the environment and an infant's relationships with adults can significantly impact neural development. Stress plays a large role in all of our lives and is in fact essential to the development of a healthy stress response system, but the presence of a positive, caring adult is what helps a child avoid toxic stress, defined as "strong, frequent, or prolonged activation of the body's stress response systems in the absence of the buffering protection of a supportive, adult relationship."
According to the National Scientific Council on the Developing Child, our bodies respond to stress in different ways. A positive stress response may occur, for example, on a child's first day of kindergarten: The child's heart rate will increase and there will be a minimal rise in stress hormones. Under more challenging circumstances, such as the death of a caregiver or a natural disaster, a child experiences an elevated stress response system for a temporary period of time. In both of these scenarios, children learn to manage stress and regulate their stress response by receiving support from an adult who creates a nurturing environment and models effective coping strategies.
However, when a child is exposed to prolonged, significant, and/or cumulative trauma ranging from abuse, neglect, witnessing violence in their community, or living in poverty—without ongoing support from a caring adult—a toxic stress response occurs.
Research shows that trauma and toxic stress experienced in childhood negatively impacts the physical, mental, social, and emotional development of children, from developmental delays to learning and behavior problems. In the long term, ACEs are linked to risky health and lifestyle behaviors, chronic diseases, and even premature death.
Even when children experience significant trauma, there is still the capacity to develop resilience.
Recognize Signs and Symptoms of Trauma in a Pediatric Patient
The National Child Traumatic Stress Network provides a comprehensive list of signs and symptoms of trauma for individuals from infancy through early adulthood.
Infants and toddlers often don't have the ability to verbally express the events, experiences, and feelings of trauma. Be aware of sudden changes in a young child's behavior—all behavior is communication. Young children who have experienced trauma may exhibit increased separation anxiety, excessive clinginess, crying and/or whining, increased fear and anxiety, regression in global developmental progress, or failure to achieve developmental milestones.
Elementary school students ages 6–12 who have experienced trauma may exhibit a variety of different behaviors, such as increased anxiety, fear, and distress, as well as withdrawal and avoidance. These kids may also demonstrate decreased ability to focus, overreaction to auditory stimuli (a door slamming shut or fire alarm), a change in academic performance, poor impulse control, and challenges with authority figures or constructive criticism. Increased physical complaints (stomachaches and headaches) may be observed as well.
Respond by Integrating Trauma-Informed Principles Into Your Care
SAMHSA's trauma-informed principles can be incorporated into any type of health care setting or organization, and all patients and families, with or without a lived experience of trauma, can benefit from PTs adopting a trauma-informed approach. By adopting these principles, we shift our own internal dialogue from "What is wrong with you?" to "What happened to you?" and view our patients through a trauma-aware lens.
Often a family will miss multiple therapy appointments and will be labeled as a "no-show." By taking a trauma-informed approach, the PT recognizes the multitude of social, economic, and contextual factors that may contribute to missed therapy appointments. Instead of discharging the patient, the PT incorporates trauma-informed principles and meets with administrators, office staff, other team members, and the family to identify pertinent issues and create a solution that allows the child to regularly attend physical therapy. As a next step, the office administrator invites families, office staff, and the therapy team to review policies regarding the clinic's attendance policy. Through this process, policies are amended in a culturally sensitive and collaborative manner with all involved stakeholders to ultimately promote a more inclusive environment for children and their families.
Resist Retraumatizing Patients Inadvertently
PTs working with children and families can take concrete steps to build a culture of emotional and physical safety in their clinical, school, or hospital settings. When the health care team uses trauma-informed principles in partnership with a family-centered approach, it creates a safe environment with reduced potential for retraumatizing children and families. Often individuals who have experienced maltreatment as children are distrustful of authority figures, including health care professionals. By ensuring that families and children have a voice in their plan of care, we can work toward empowering patients through choice.
Jessica Barreca is a physical therapist with over 17 years of experience working with children in a variety of settings including outpatient, early intervention and school systems. She is the community site coordinator in the Center for Interprofessional Education & Research and adjunct instructor of physical therapy at Saint Louis University. Jessica is an ambassador for Alive and Well STL and is passionate about spreading knowledge and awareness regarding the widespread prevalence and impact of childhood trauma on families and children in our communities.
Interested in learning more about this topic? The 2019 APTA Combined Sections Meeting will be holding several presentations related to trauma, including: Sexual Assault and Communities of Color: PT Roles, Pain Science With Vulnerable Populations: Transforming the Human Experience, and A Trauma-Informed Pathway to Caring for Patients and Providers. Register now at www.apta.org/CSM/.
Jessica Barreca will be presenting Using a Trauma Sensitive Lens to Promote Shared Decision Making in Pediatric Practice at the Academy of Pediatric Physical Therapy Annual Conference in November, 2018.
CSM Preview: All You Ever Wanted to Know About MIPS
By Kara Gainer, JD
Value. Quality. Outcomes. Costs. The United States is moving away from the traditional fee-for-service reimbursement structure, one in which providers are rewarded solely for the volume of services provided, to one that holds providers accountable for patient outcomes and costs.
Beginning January 1, 2019, the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP), which offers incentive payments to help eligible clinicians focus on care quality and making patients healthier, will include many physical therapists who participate in Medicare Part B.
While we estimate only about 5% of Medicare-enrolled physical therapists in private practice will be mandated to participate or face a penalty, almost all physical therapists in private practice will be eligible. Considering that there are no more scheduled payment updates to the Medicare physician fee schedule after 2019, QPP participation is something you should seriously think about if you're one of those eligible PTs.
At APTA's Combined Sections Meeting in January, we will answer your most pressing questions about QPP:
- What do these acronyms mean?!
- How does it work?
- If I am not required to participate, what is the benefit to me if I do?
- What is the difference between the Merit-based Incentive Payment System (MIPS) and an Advanced Alternative Payment Model (APM)?
- How can I maximize my incentive payment?
Nothing is simple when it comes to Medicare, and QPP is no different. The devil is in the details—and there are a lot of them.
APTA Director of Quality Heather Smith, PT, MPH, and I will be diving into the nitty gritty of what physical therapists need to know if they want to successfully participate in QPP, whether through MIPS or Advanced APMs.
You may be asking yourself: "Do I really need to attend this session?" Well, here is what one California PT who attended a similar session on Medicare payment said:
So, if you're ready to get out of your comfort zone and transform your practice, join us on Friday, January 25, in downtown Washington, DC, for "Emerging Issues in Medicare: Quality Programs and Alternative Payment Models," where you will learn more about QPP and how you can participate in Medicare payment models that reward value over volume, achieving better patient outcomes.
CSM advance registration discounts end December 5.
Kara Gainer, JD, is APTA's director of regulatory affairs. You can connect with Kara on Twitter at @karagainer.
When Health Decisions Aren’t a Matter of Choice: Addressing Social Determinants of Health
Physical therapists (PTs) and physical therapist assistants (PTAs) focus on both restoring movement in those with decreased function and promoting healthy behaviors to prevent health problems such as obesity or high blood pressure. But in doing so, they also must consider how social determinants of health—economics, education, neighborhood, and other factors—influence the lifestyle choices patients and clients make.
Zachary D. Rethorn, PT, DPT, a home health PT, board-certified orthopaedic clinical specialist, doctoral student in health promotion and wellness, and adjunct professor at the University of Tennessee at Chattanooga, has been giving these ideas careful thought and incorporating them into his practice. In 2018, he co-presented on the topic of social determinants of health at APTA's NEXT Conference and Exposition, and earlier this year he published a blog post that further explored the topic. In the post, he writes:
. . .the narrative in our country is one in which personal responsibility is emphasized so much that we can forget we live in communities and systems which influence the choices we make. Say you have a prized rose bush (like I do). If it doesn't bloom this year am I going to uproot it, chuck it out, and get a new one? Of course not! When a flower doesn't bloom you fix the environment in which it grows. Not the flower.
#PTTransforms interviewed Rethorn to learn how PTs and PTAs can incorporate these concepts at the point of care.
#PTTRANSFORMS:
In your blog post, you write about the 5 areas of social determinants of health: economic stability, education, social and community context, health and health care, and neighborhood and built environment. Most of these areas pertain to things that neither the patient nor the provider can change, for the most part. You can't change the fact that your neighborhood isn't safe for you to get more physical activity, for example. How can a clinician use this information? Should we be screening for social needs?
ZR: The first question we have to ask ourselves is are we a profession which delivers health services? Or are we a profession that promotes the health of our neighborhoods, communities, cities, and states? If we believe that our role is to advocate for and improve the health of those we serve, then a good place to start is by considering the social and environmental context in which our patients live.
Screening for social needs can be very different from our typical medical or health screening tools. I want to caution readers that screening must be linked to the ability to provide appropriate referrals and treatment. Screening without the capacity to assist is ineffective and potentially unethical.
To mitigate negative unintended consequences of screening, here are 5 tips:
- Be patient-/family-centered in screening.
- Integrate screening with referral and linkage to community-based resources.
- Perform screening within the context of a comprehensive system that supports early detection.
- Acknowledge and build on strengths of patients, families, and communities.
- Engage the entire practice population, rather than targeted subgroups.
#PTTRANSFORMS:
How can a clinician evaluate this information and use it to help with shared decision making to improve the patient's health?
ZR: There are a number of evidence-based toolkits that clinicians and health systems can use to screen for social needs, including HealthLeads, PRAPARE, HealthBegins, and the Accountable Health Communities Screening Tool. These tools all provide a starting point with recommended core domains such as food insecurity, housing instability, utility needs, and financial resource strain. Based on a community's needs, additional domains such as child care and social isolation may be added.
Whatever tool you choose to use:
- Make it short and simple—no more than 12 questions, written at a fifth-grade reading level, translated into appropriate languages.
- Choose clinically validated questions designed to open a conversation.
- Integrate the tool into clinical workflows.
- Elicit patient feedback to prioritize screening items.
- Pilot before scaling.
Once a clinician has gathered information about an individual's social context, it is essential to open a conversation with that individual regarding what he or she wants and believes will be most helpful. This is place where the clinician can provide advice and not only refer the individual to other services, but also facilitate access to those services in a sensitive, culturally acceptable, and caring way.
#PTTRANSFORMS:
What modifications can a PT make to account for, say, a neighborhood where a patient feels unsafe? Or lack of access to fresh fruits and vegetables?
ZR: The first step to take if individuals are saying that a neighborhood is dangerous or there is no access to fresh fruits and vegetables is to understand what local resources are available. Often, there are resources available that the person may not be aware of.
For the first few years of my practice, I worked in a neighborhood where many of my patients felt unsafe going outside. But as I got to know the neighborhood better, I realized there were opportunities for physical activity outside but perhaps in ways different from what I first envisioned. Instead of coaching individuals to take walks by themselves, I started walking groups. Suddenly, this became a feasible way for many of the older adults I worked with to feel safe and be more social in their neighborhood.
If a creative solution is truly unavailable, this is where advocacy comes into play. My clinic was located in a food desert, where the closest grocery store with fresh produce was 2 miles—but 3 bus changes and 50 minutes—away. As I heard more and more that lack of access to healthy food was a perceived need in my population, I took this to a local farming nonprofit that agreed to begin hosting a mobile market in the neighborhood 2 afternoons per week.
These examples are not extraordinary. They come from carefully listening to the individuals I serve and reimagining my role as a PT from one who simply delivers interventions to one who is invested in and cares about the health of my patients. Caring about the health of my patients necessarily means that I care about the social and environmental context they live in, because the context is what shapes their health behaviors and choices.
#PTTRANSFORMS:
When working with a patient, how do you balance empowering the individual to make healthy choices with the knowledge that some things you just cannot control?
ZR: When I work with a patient, I am considering health influences at multiple levels. At purely an individual level, I am examining their health behaviors such as physical activity, diet, stress, and sleep. During my history taking, I will ask about these factors and coach the patient to change their health behaviors based on their desires and resources.
At a wider level, I am cataloguing the individual and systemic barriers that individuals are relating to me. Perhaps a number of individuals are telling me that the sidewalks in their neighborhood are in disrepair. At this point, I can gather more information from a neighborhood association, search for data related to sidewalks in the city, or go to a city councilor to bring up the need related to sidewalk repair.
The goal is to find pain points where social and economic factors present barriers to individuals' ability to engage in health behaviors. From there I can use clinical experience and research evidence to advocate for social change which will improve the health of the population I serve.
#PTTRANSFORMS:
Is there a danger of implicit bias here? How can clinicians avoid making assumptions about the relationship between a patient's health and these 5 areas? Or do social determinants of health help us respect the personal, economic, and cultural circumstances our patients face?
ZR: Current data suggest that, first, implicit bias is a real phenomenon. We all hold underlying attitudes and stereotypes toward members of other groups. But not only is it real, health care providers exhibit the same amount as the general population. This bias is shown in positive attitudes toward Whites and negative attitudes toward people of color. Further, this implicit bias may impact the clinical decision making of health care providers toward their patients.
Addressing implicit bias must be a conscious decision. One way to avoid making assumptions is to commit to screening for social determinants of health across your entire patient population and not just for select subgroups. If you target only demographic variables such as age, education, residence, underrepresented minority status—it may reinforce stereotypes and prejudicial presumptions and could stigmatize the screening process.
Another strategy is to improve your understanding of health disparities and bias in health care. Once I understood the daily challenges that my population faced, I became more empathetic and better equipped to facilitate positive changes in the community.
#PTTRANSFORMS:
Do you see social determinants of health taking a larger role in health research in the future? How so?
ZR: Research on the social determinants of health is already robust. The influence that the social and environmental context plays on individuals' and populations' health is clear. The question is: Do we have the social will to take what we already know and implement it? Are we willing to address health where it starts, not just where it ends? Can we make the healthy choice the easy choice in culturally sensitive and appropriate ways from neighborhood to neighborhood and city to city?