11 Chapter 02 – Lecture Unit 2: Structure, Settings and issues Shaping the Profession

SECTION ONE:

The organizational structure and operation of physical therapy

service in a variety of settings.

Our goal for section one is for you to develop comfortable describing the organizational structure and operation of physical therapy service in a variety of settings.  This is certainly a rather broad statement objective; one that needs a bit of unpacking if we are to address it. As we do so below, you will be prompted to view a number of short videos as well as refer to the Guide to answer questions of learn more detail on aspects of each topic.

To understand how the field of physical therapy is organized and how it is run, we need to first understand what is meant by physical therapy.  If we do, then we can:

Define physical therapy as it is stated by the American Physical Therapy Association and the Physical Therapy Practice Act of the Commonwealth of Pennsylvania.

The Guide DEFINES Physical therapy as a

“…dynamic profession with an established theoretical and scientific base and widespread clinical applications in the restoration, maintenance, and promotion of optimal physical function. Physical therapists are health care professionals who help individuals maintain, restore, and improve movement, activity, and functioning, thereby enabling optimal performance and enhancing health, well-being, and quality of life. Their services prevent, minimize, or eliminate impairments of body functions and structures, activity limitations, and participation restrictions

Sounds noble and like a pretty exciting field; that is why you are here now after all, right?  And at this point, you might be tempted to think that physical therapy, given its value to society, has been around since, well, forever. Maybe it could have been or should have been, but physical therapy, as you and I know it, is really a more recent phenomenon. It is worth taking a short trip back in time to learn the history of the profession you have chosen to pursue.  Doing so may just be the inspiration you need at this point in the semester.

Hopefully, now that you know your roots; now that you know the reasons physical therapy came into existence; now that you know whose footsteps you will be following, maybe all of you studying will seem a little more meaningful, relevant and less burdensome.  Hopefully, you are a bit more interested in learning more of our profession as our next stop is to check out the types of places you may work at, the types of patients you may see and the types of equipment you may use.

Thus far we have been attempting to unpack the primary objective of this section:
describing the organizational structure and operation of physical therapy service in a variety of settings. 

We have defined physical therapy, discovered a bit or its origins, had a look at where you may work, with whom you may be working and what you may be doing with them.  It is time to look a bit more closely on “what” the physical therapist is doing with the patient prior to ‘handing them off’ to you as that will address the “operation of physical therapy”.

If you remember, the last sentence of the Guide’s definition of Physical Therapy had a hyperlink in it.  It is time to read through the information provided regarding: “Their services prevent, minimize, or eliminate impairments of body functions and structures, activity limitations, and participation restrictions.”  We need now to learn what impairments are and how they relate to activity limitations and participation restrictions.

Now that we have a little more of an idea what the PT does before, we see the patient, it is time to look at your role in the “operation of physical therapy”.

The Guide offers considerable information regarding the education of the DPT and PTA.  Please review that material.  Below is an excerpt from the Guide (in green) regarding the education of the PTA.

After you have read this material, you can review Lecture PPT: The PT v PTA: Roles & Regulations   — then answer the questions following the excerpt.

Physical therapist assistants, under the direction and supervision of the physical therapist, play a vital role in providing the public with access to physical therapist services. Physical therapist assistant education culminates in a 2-year associate degree obtained in no more than 5 semesters. The physical therapist assistant curriculum includes general education or foundational content, physical therapy content, and clinical education experiences.

Physical therapist assistants are licensed or certified in all 50 states and the District of Columbia. Graduation from a CAPTE-accredited physical therapist assistant education program or its equivalency and passage of the national examination is required for licensure. Licensure or certification is required in each state in which a physical therapist assistant works and must be renewed on a regular basis, with a majority of states requiring continuing education as a requirement for renewal. The physical therapist assistant’s scope of work and supervision requirements are defined by the physical therapy practice act in each state.

Physical therapist assistants seek advanced education through continuing education courses, certification courses (eg, APTA’s Credentialed Clinical Instructor Program), and other health care related–certifications (eg, certified lymphedema therapist, certified ergonomics specialist, certified strength and conditioning specialist). APTA’s Recognition of Advanced Proficiency for the Physical Therapist Assistant25 is a mechanism to be recognized for advanced skills in specific content areas.

 

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SECTION TWO:

Current issues that are influencing the evolution of Physical Therapy.

With the general history of physical therapy being covered and some of the basic physical therapy operational information discussed, we now turn to a few current issues that are influencing the evolution of Physical Therapy.

1. Not that long ago, the terminal degree for the PT was a bachelor’s degree. During the 1990’s it became the “Entry Level Master’s Degree” and at the turn of the century, the APTA moved forward with “Vision 2020” – that that entry point for all PTs would be the dictate degree (DPT). However, the PTA terminal degree has remained unchanged. There has been copious amounts of discussion surrounding this topic: Most of the conversation surrounds reasons why the profession should or should not move the entry point for the PTA degree to the bachelor’s degree.
   One of the primary reasons this has not occurred is that most of the PTA programs in the country are found in community colleges – institutions that do not offer bachelor’s degrees.  Simply put, the move to the bachelor’s degree for the PTA would close all of those programs. Yet on the other hand, each year more and more information is expected to be included in the education of the PTA.  Many question how much longer this process of jamming a quart of information into a pint container can continue. The next CAPTE meeting set originally for late 2020 (now 2022) will address this very issue.

   Reflection: How might the differences in DPT v PTA education impact a student’s decision for a career path?  Do you think it is an inclusive practice? How might a DPT view the educational preparedness of a PTA?

    

    

2.  If you have been keeping up with any of the PT journals or even just the local news, you understand health care is constantly changing. Medicare and other insurance providers are continuously changing their reimbursement rates – for all services provided to the patient including those for physical therapy  As these insurance providers cut their costs by decreasing their reimbursements to therapy clinics and therapy departments, those running these establishments must adapt to these reductions in payment or go out of business.
   Can you think of ways in which providers of rehab services might respond to reductions in reimbursements?  Would any impact patient care? In what ways?
   
   

    

3. One of the initiatives of the APTA, to improve patient access to PT services, was to lobby for something called: DIRECT ACCESS.Direct access just means that a patient can receive some type of physical therapy without a physician’s referral. This benefit is that this reduces the time it typically takes a patient to first get an appointment with their primary care physician and then receive the referral for PT. PTs who want to be direct access providers must meet requirements put forth by the state they are practicing.  Additionally, it is important to note that direct access is governed by the individual states and that direct access providers (PTs) need to be keenly aware of their state’s regulations and rules.
4.  The last item for this section concerns process of performance improvement activities (QUALITY ASSURANCE) in the health care setting. In lab, much was noted about the value and importance of self-reflection as well as being able to objectively and effectively critique another therapist’s performance. That process of reflective critiquing is used extensively during quality assurance activities.  No doubt you have had the pleasure of being request to ‘just fill out this brief survey’ (who knows, you might even win a prize.)   Have you ever wondered though: “Why all the surveys???” You guessed it: Just part of performance improvement.  Admittedly, our pendulum in the customer-survey domain is out of hand, but the process of getting feedback from the customer (for us, our patients) is very helpful…if used to improve processes and enhance employee performance.Regardless of the setting you work in, you will find yourself part of a quality assurance process.  Perhaps it will involve patient surveys, perhaps review of medical documentation for thoroughness and accuracy, perhaps supervision my manages…perhaps all three and more.  In the end, the goal is to continuously be striving for excellence in patient care.

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SECTION THREE:

Structure and function of the American Physical Therapy Association (APTA).

By now, you can see how you are joining a noble and benevolent profession.  And yet, this connection is deeper than you might think.  In this final section of this chapter we will discuss the structure and function of the American Physical Therapy Association (APTA).

The mission and goals of the APTA as stated March 2018:  “Building a community that advances the profession of physical therapy to improve the health of society”

In the Lecture Video 6: APTA Structure and Benefits, the organizational structure of the APTA was presented and in addition to the benefits of membership. After viewing the PPT video, consider the benefits listed.

Physical therapy is provided for individuals of all ages who have or may develop impairments, activity limitations, and participation restrictions related to (1) conditions of the musculoskeletal, neuromuscular, cardiovascular, pulmonary, and/or integumentary systems or (2) the negative effects attributable to unique personal and environmental factors as they relate to human performance.

On a daily basis, physical therapists practicing across the continuum of activity—acute, rehabilitative, and chronic care management—help individuals restore health and alleviate pain. They examine, evaluate, and diagnose impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes. Intervention, prevention, and the promotion of health, wellness, and fitness are a vital part of the practice of physical therapists. As clinicians, physical therapists are well positioned to provide services as members of primary care teams.

For acute musculoskeletal and neuromuscular conditions, triage and initial examination are appropriate physical therapist responsibilities. The primary care team may function more efficiently when it includes physical therapists, who can recognize musculoskeletal and neuromuscular disorders, perform examinations and evaluations, establish a diagnosis and prognosis, and intervene without delay. For individuals with low back pain, for example, physical therapists can provide immediate pain reduction through programs for pain modification, strengthening, flexibility, endurance, and postural alignment; instruction in activities of daily living (ADL); and work modification. Physical therapist intervention may result not only in more efficient and effective care, but also in more appropriate use of other members of the primary care team. With physical therapists functioning ina primary care role and delivering early intervention for work-related musculoskeletal injuries, time and productivity loss due to injuries may be dramatically reduced.

For certain chronic conditions, physical therapists should be recognized as the principal providers of care within the collaborative primary care team. Physical therapists are well prepared to coordinate care related to loss of physical function as a result of musculoskeletal, neuromuscular, cardiovascular/pulmonary, or integumentary disorders. Through community-based agencies and school systems, physical therapists coordinate and integrate provision of services to individuals with chronic disorders.

Physical therapists also provide primary care in industrial or workplace settings, in which they manage the occupational health services provided to employees and help prevent injury by designing or redesigning the work environment. These services focus both on the individual and on the environment to ensure comprehensive and appropriate intervention.

The International Classification of Functioning, Disability and Health (ICF) and the Biopsychosocial Model

The Guide is informed by a number of disablement/enablement models2 that have emerged during the past 3 decades—from Nagi3-4 to ICF6—that have attempted to better delineate the interrelationships among disease, impairments, functional limitations, disabilities, handicaps, and the “effects of the interaction of the person with the environment.”7

In 2008, the APTA House of Delegates endorsed the International Classification of Functioning, Disability and Health, known more commonly as ICF.6 This is a classification of health and health-related domains and is the World Health Organization’s (WHO) framework for measuring health and disability at both individual and population levels. This framework informs current physical therapist practice and has been incorporated into all relevant sections of this version of the Guide.

The ICF has 2 major parts (Figure 1-2). Part 1 is a description of the components of functioning and disability that are associated with a health condition. These components include body functions and body structures and the changes that occur in them, activities that the person carries out, and the participation of the person in life situations. Activities and participation can be further qualified by considering a person’s capacity (ie, what could be done in a controlled environment) and performance (ie, what the person actually does in his or her current environment). Functioning is used to encompass all body functions and structures, activities, and participation; conversely, disability is used to encompass impairments of is ability exist along a continuum of health.

Part 2 is a description of the contextual factors. Among contextual factors are external environmental factors (eg, social attitudes, architectural characteristics, legal and social structures, and climate and terrain) and internal personal factors(eg, gender, age, coping styles, social background, education, profession, past and current experience, overall behavior pattern,character, and other factors) that influence how disability is experienced by the individual. Personal factors are not yet classified by the ICF but do influence functioning.

The ICF recognizes all of these components as interactive constructs (Figure 1-3) and focuses on the complexity of the interactions among body functions and structures, activities, and participation, an environmental and personal factors to fully describe a person’s health status. Adverse changes in one aspect of the models do not necessarily result in adverse changes in another. For example, changes in body functions and structures that result in abnormalities (ie, impairments) do not necessarily result in disability

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