Part 3 - Professional Services
Chapter 15 - Physical Rehabilitation Services
- Purpose. This revised chapter updates the policy and procedures for providing Physical Rehabilitation Services (PRS). The purpose of PRS is to provide eligible patients with essential physical rehabilitation evaluation and treatment, maximize their functional abilities, and improve their quality of life.
- Background. Initially, Indian Health Service (IHS) PRS were categorized as physical therapy (PT). However, over the years, occupational therapy (OT) and speech-language pathology (SLP) have been added to the IHS service plan. Each of the three physical rehabilitation disciplines has uniquely evolved in terms of provider academic and licensure requirements, areas of responsibility, and independence. All PRS therapies play a vital role in the IHS health care delivery system. In light of the addition of OT and SLP to the service plan and the expanding roles of PRS professionals, this chapter was renamed and revised.
- Authorities. The standards of practice and code of ethics as defined by national professional associations may be found at the following Web sites:
American Occupational Therapy Association (AOTA) www.aota.org
American Physical Therapy Association (APTA) www.apta.org
American Speech - Language - Hearing Association (ASHA) http://www.asha.org/
- Policy. All IHS staff involved in the delivery of PRS must follow the guidance established in this chapter and adhere to applicable national professional association standards of practice and code of ethics. Staff will provide services that are safe, effective, timely, efficient, equitable, patient-centered, and fulfill a vision of rehabilitation that facilitates the adoption of healthy lifestyles to prevent disease and disability.
- Objectives. The objectives of PRS are as follows:
- provide appropriate and effective intervention,
- optimize a patient's function, and
- help patients regain the ability to participate in meaningful activity
- Areas of Care. Areas of care may include, but are not limited to, cognitive-communicative, musculoskeletal, neurological, aero-digestive, and metabolic body systems. Treatment is provided to individuals of all ages who have (or are at risk for) developing an illness, injury, disease, disorder, impairment, or disability that has the effect of preventing or limiting a person’s ability to participate in activities of daily living.
- Autonomous Practice. Autonomous practice by a PRS professional is characterized by independent, self-determined, professional judgment and action.
- Clinical Privileges. Clinical privileges are categories of actions and specific privileges that a practitioner has been granted by a facility’s medical staff and governing body (e.g., diagnostic services, procedures, medications, and/or categories of care). This determination is based on the initial and ongoing review of a clinician’s professional licensure, education, training, experience, references, current competence, health status, and clinical judgment. (See Part 3, Chapter 1, “Medical Credentials and Privileges Review Process,” Indian Health Manual [IHM].)
- Competence. Competence is a standardized requirement for an individual to properly perform a specific job. It encompasses a combination of knowledge, skills, and behavior utilized to improve performance. More generally, competence is the state or quality of being adequately or well qualified, having the ability to perform a specific role.
- Credentialing. Credentialing is the process whereby a facility’s medical staff and governing body systematically collect and verify an individual’s professional credentials. This information is utilized and updated to document clinical competency and grant appropriate medical staff membership and/or clinical privileges. (See Part 3, Chapter 1, “Medical Credentials and Privileges Review Process,” IHM.)
- Occupational Therapy. Occupational Therapy is the therapeutic use of everyday life activities, also known as occupations or activities of daily living, to increase or improve an individual’s participation in home, school, workplace, community, and leisure activities. Occupational Therapy provides evaluation, diagnosis, rehabilitation, intervention, and care management for the physical, cognitive, psychosocial, and/or sensory aspects of human performance.
- Physical Rehabilitation Services. Physical rehabilitation services are the application of physical rehabilitation knowledge, skills, and training to diagnose, treat, and prevent disease. These services may include the disciplines of OT, PT, and SLP.
- Physical Therapy. Physical Therapy is the utilization of therapeutic interventions to address physical mobility and functional limitations, including general health. Physical therapists examine, evaluate, diagnose, plan, and intervene to prevent physical impairment, functional limitations, or disabilities. Physical Therapy also restores, maintains, and promotes health, wellness, and physical fitness.
- Scope of Practice. Scope of practice refers to the rules, regulations, and limits within which a fully qualified practitioner, with substantial and appropriate training, knowledge, and experience, may practice in a field of medicine, surgery, or other specifically defined field. Such practice is subject to continuing education requirements, accountability to appropriate governing or licensure boards, and current professional standards of conduct.
- Self-Referral. Self-referral is the process that allows patients to directly access PRS providers for evaluation and treatment without prior authorization or third-party approval. In this scenario, a consultation or referral from a physician or other medical provider is not required to initiate evaluation and/or treatment.
- Speech-Language Pathology. Speech-language pathology (SLP) is the use of evaluation and diagnostic tools to select the most valid rehabilitative techniques to manage speech, language, cognitive-communication, swallowing, and/or other upper aero-digestive disorders. Speech-language pathology restores, maintains, and promotes a patient’s communication and swallowing-related functions and may enhance his or her ability to perform social, academic, and vocational activities.
- Total Rehabilitation Concept. The intent is to evaluate patients and treat them with a comprehensive package of rehabilitation services. Total rehabilitation is the inclusion of OT, PT, and SLP at a qualifying location’s service package as determined by projected department workload. (See the Health System Planning (HSP) guide for details about qualifying locations. The Web site address is: http://www.dfpc.ihs.gov)
- Physical Rehabilitation Service Professionals. All PRS professionals must be granted clinical privileges to treat patients and engage in expanded roles and advanced practice (including accepting self-referred patients). Privileges shall be granted according to established facility credentialing and privileging procedures. Clinical practice roles must be documented in the scope of employment in order to be covered by the Federal Tort Claims Act (FTCA). All PRS staff will:
- support a multidisciplinary model of care while working with Tribal, State, Federal, and private sector health systems or agencies to provide a continuum of patient care.
- seek to increase access by eligible patients to PRS to improve the level of care available to American Indian/Alaska Native (AI/AN) people.
- Chief Medical Officer. The IHS Chief Medical Officer (CMO) selects and appoints the PRS Chief Clinical Consultant (PRS-CCC) for a term of 3 years. A selected PRS-CCC may be appointed for more than one term.
- Physical Rehabilitation Services - Chief Clinical Consultant. Provides consultation to the Director, IHS, the CMO, and the Director, Office of Clinical and Preventive Services (OCPS), regarding policy, planning, and clinical care. Consultation includes using the Resource Requirement Methodology (RRM) staff planning formulae; the Health System Planning (HSP) software for space planning updating Part 3, Chapter 15, “Physical Rehabilitation Services,” IHM; and other matters of concern to IHS senior leadership and/or the PRS-CCC.
The PRS-CCC also consults with the Director, Office of Public Health Support (OPHS), on matters concerning recruiting through the IHS Loan Repayment Program and the IHS Scholarship Program. The PRS-CCC also advises and consults with the Area Physical Rehabilitation Services Consultant (APRSC).
Other responsibilities include providing an IHS PRS annual report to the Director, IHS, the CMO, and the Director, OCPS; reviewing and assisting with tort claims, risk management, and advocacy issues; encouraging, promoting, and supporting continuing education opportunities; and planning and conducting the biannual conference of APRSC.
The PRS-CCC is a member of the National Council of Chief Clinical Consultants and may appoint committees and designate a Deputy.
- Area Chief Medical Officer. The Area CMO may select and appoint an APRSC in Areas with significant IHS direct health programs. The term of service varies depending on the needs of the Area and at the discretion of the Area CMO.
- Area Physical Rehabilitation Services Consultant. The APRSC works closely with the PRS-CCC to develop policy and implement strategies that improve clinical practice and promote patient advocacy. The APRSC participates in national PRS meetings and other appropriate Area leadership activities.
- The APRSC provides consultation to the Area CMO and the Area Director on matters related to PRS, consults with Service Unit (SU) Physical Rehabilitation Directors or SU Chiefs of Service, and promotes quality rehabilitation services through management guidance, encouraging staff development, and quality improvement.
- The APRSC also serves as a resource for SU senior managers in the selection of rehabilitation services leadership and other issues requiring perspectives from outside the SU.
- The APRSC may assign Area clinical consultants to provide guidance for PRS clinical sub-specialties such as pediatrics, orthopedics, or others. These clinical sub-specialty consultants assist with SU program development as requested and conduct educational and skills development activities.
- Service Unit Physical Rehabilitation Services, Director. The SU PRS Director supervises and manages the PRS department and is responsible for staff recruitment, review, counseling, and continuing education. The SU PRS Director:<
- may also serve as a discipline supervisor and may supervise clinical specialists, senior staff, or staff therapists from a different physical rehabilitation discipline;
- ensures staff are qualified and competent to practice in their discipline;
- conducts quality improvement and risk management reviews; and
- may spend a significant amount of time providing patient care depending on the size of the department and the number of disciplines supervised.
- Physical Rehabilitation Services File Managers. A PRS File Manager will be assigned to each PRS Department to implement and oversee the PRS records disposition program, in accordance to the IHS Records Disposition Schedule. The PRS File Manager will ensure prompt disposal of records whose authorized retention period has expired; timely and systematic transfer and economical storage of records no longer needed in office space; and uniform identification and transfer of permanent records to the National Archives and Records Administration for permanent preservation, reference, and research use.
3-15.3 SCOPE OF PRACTICE
- Practice Setting. Physical Rehabilitation Services may be provided across a beneficiary’s lifespan, addressing a wide variety of diagnoses in diverse clinical settings. The PRS department includes OT, PT, and SLP, or any combination of these services. Rehabilitation professionals provide treatment to patients in settings that include, but are not limited to, hospitals, clinics, homes, schools, chapter houses, community centers, and nursing homes.
- It is expected that the SU PRS Director, APRSC, and PRS-CCC will promote the total rehabilitation concept by seeking to add appropriate disciplines not currently offered in a department or SU.
- All therapists involved in the delivery of services, including autonomous practice, must follow the guidance established in this chapter and adhere to applicable national professional association standards of practice and code of ethics. Local PRS plans will be adjusted to the needs of the SU, staff credentials, competencies, or granted privileges.
- Domain of Practice. Physical Rehabilitation Services are limited to the care and services provided by or under the direction and supervision of a licensed occupational therapist, physical therapist, or speech-language pathologist. Service by PRS staff is characterized by the following areas of commonality within the domain of physical rehabilitation:
- Patient Population. Physical Rehabilitation Services are provided to eligible patients of all ages who may have physical impairments, functional limitations, and/or disabilities as a consequence of injury, disease, or other causes.
- Collaboration. Collaborative patient care involves interdisciplinary communication and cooperation. The expectation is that the PRS staff will coordinate care among the disciplines, other IHS resources, and non-IHS services, as appropriate.
- Management of Patient Care Risk. The assessment and management of patient and staff risk is a continuous process, which seeks to determine and reduce factors and behaviors that may impact optimal patient outcomes and staff safety.
- Health Promotion. Basic patient care that emphasizes prevention and focuses on wellness, physical fitness, and the promotion of health.
- Consultation. The physical rehabilitation therapist may render professional services, or provide expert opinion or advice as it applies to the specialized knowledge and skills in identifying problems, recommending solutions, or producing a specified outcome on behalf of a patient. Such consultation may be requested by the patient, a health care provider, an organization, school, Federal Agency, or other organization.
- Educational Services. The physical rehabilitation therapist may be involved in:
- Communicating PRS information or techniques by conducting academic education, clinical education, and continuing education for PRS therapists, other providers, and students.
- Planning and conducting educational programs for Tribes, local organizations, State, and Federal agencies.
- Planning and conducting programs for the public to increase awareness of issues in which physical rehabilitation therapists have expertise.
- Administrative Services. All licensed professional PRS staff will:
- provide clinical supervision of support staff,
- manage the resources available for patient care activities,
- help achieve the organization’s mission, and
- assist with departmental operations.
- Elements of Patient Clinical Management. The common elements of clinical management are designed to optimize clinical outcomes.
- Examination. Examination is the process of obtaining a medical history; performing a systems review, and selecting and administering tests and measures to gather data about the patient. The initial examination is a comprehensive screening and evaluation process that leads to a diagnosis. The examination process may also identify potential problems that require consultation with or referral to another provider. Test and measures shall be in accordance with current acceptable professional standards as accepted by the PRS-CCC.
- Evaluation. An evaluation is a dynamic process in which the physical rehabilitation therapist makes clinical judgments based on data gathered during the patient’s examination. Factors that influence the complexity of the evaluation process include the following: clinical findings; the extent of functional loss; social considerations; overall physical function; and health status. Physical rehabilitation therapists also consider the severity and complexity of acute or chronic impairments, the probability of prolonged impairment, functional limitations and disability, the living environment, potential discharge destinations, and the existence or absence of social support.
- Diagnosis. Diagnosis is a systematic process that includes evaluation and integration of the data obtained during the medical examination to describe a patient’s condition to guide the physical rehabilitation therapist in determining the prognosis, plan of care, and intervention strategies. This diagnostic process enables a therapist to verify each patient’s individual needs relative to similar individuals who are classified in the same general disease pattern. The therapist obtains and documents the patient’s unique concerns in meeting those needs specific to the patient’s particular socio-cultural and physical environment.
- Prognosis. Prognosis is a determination of the level of optimal improvement that may be attained through intervention and the amount of time required to reach that level. The care plan specifies the intervention to be used, along with the specific timing and frequency.
- Intervention. Intervention is the purposeful and skilled interaction of the physical rehabilitation therapist with the patient and, if appropriate, with other individuals involved in care of the patient, using various therapy methods and techniques to produce changes in the condition that are consistent with the patient's diagnosis and prognosis. Following treatment, the physical rehabilitation therapist re-examines the patient to determine changes in their condition and to modify or redirect intervention. The decision to re-examine may be based on new clinical findings or an absence of patient progress. The process of re-examination may also identify the need for consultation with or referral to another provider. Intervention shall be accomplished in accordance with current acceptable discipline-specific professional standards as accepted by the PRS-CCC.
- Outcome Measures. As the patient reaches the termination of PRS and the end of the episode of care, the physical rehabilitation therapist measures the therapy outcomes by characterizing or quantifying the impact of the interventions on the following areas of care: pathology/pathophysiology (disease, disorder, or condition); impairments; functional limitations; disabilities; risk reduction/pevention health, wellness, and fitness; level of patient support/resources and patient satisfaction. In addition, the physical rehabilitation therapist may conduct outcomes data collection and analysis, to develop statistical reports for evaluation of interventions.
- Federal Malpractice Coverage. Civil servants, United States Public Health Service (USPHS) Commissioned Corps Officers, health practitioners, and some health practitioner contractors working for the Federal Government are covered for malpractice under the FTCA, August 2, 1946, Chapter 753, Title IV, 60 Statute 842, (See the Clinician's Handbook of Federal Tort Claims Act, Edition II, a Health Resources Services Administration publication; and Risk Management & Medical Liability, A Manual for Indian Health Service & Tribal Health Care Professionals, Second Edition, April 2006.) The following are issues that affect individual malpractice coverage under the FTCA:
- Federal Supremacy. The Constitution’s Supremacy Clause (Article VI, Section 2) gives the Federal Government the power of preemption in relation to State law. Federal employees who are conducting authorized activities within the scope of their Federal employment are covered by the FTCA.
- Licensure. Indian Health Service PRS professionals who require licensure to practice may hold a license in any State. It is not required that the license be in the State where they currently work for the Federal Government.
- Credentialing and Privileges. All PRS staff will be credentialed and privileged in accordance with the instructions in Part 3, Chapter 1, “Medical Credentials and Privileges Review Process,” IHM.
- Scope of Employment. An individual’s position description (PD) defines the scope of employment by specifying an employee’s expected work, duties, level of supervision, and accountability. The PD also indicates where such duties may be performed. It is important to ensure that the PD states that the therapist may provide care in a variety of settings outside IHS facilities, such as community centers, chapter houses, schools, nursing homes, fitness centers, and other sites. Detailed instructions relative to this issue, are contained in the Risk Management & Medical Liability, A Manual for Indian Health Service & Tribal Health Care Professionals.
- Federal Disaster Declaration. In the event of a Presidential Federal disaster declaration in the United States, the Department of Health and Human Services (HHS) is the lead Agency for Emergency Support Function (ESF) #8 Public Health and Medical Support. As Federal employees, if deployed, USPHS Commissioned Corps Officers and civil servants retain Federal coverage for licensure or certification under the authority of the USPHS, liability coverage under the FTCA, and Workers’ Compensation coverage for injuries sustained while deployed.
Salary compensation is solely provided to the employing service, department, or Agency. No additional compensation shall be paid to individuals assigned to a task force in support of a Federal disaster site deployment.
3-15.4 RECORD KEEPING
- Medical Records. All PRS documentation must be included in the current official medical record and becomes a part of the patient’s permanent record. Patient medical records are legal documents and must be complete, accurate, objective, professional in content, and handled with due diligence. The records may be used in quality improvement reviews, legal actions, and for third-party billing. Medical records contain confidential information that must be handled in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as amended, and should follow the requirements set forth in Part 3, Chapter 3, “Health Information Management,” IHM.
- Medicare and Medicaid Reimbursement. The Indian Health Care Improvement Act, (Public Law 94-437), as amended, provides authority to the IHS to receive reimbursement from the Medicare and Medicaid programs for care rendered to eligible AI/AN people. To facilitate this reimbursement, all PRS professionals will comply with medical service documentation requirements and patient identification regulations. (See Part 2, Chapter 1, Section 2, “Persons to Whom Services May Be Provided,” IHM.)
- Physical Rehabilitation Services Department Records. All PRS departments must use the Resource and Patient Management System to track workload and record patient encounters. Patient encounter documentation by PRS staff must be included in the current official medical record and will be integrated into the patient’s permanent medical record. Physical Rehabilitation Services staff will maintain all patient medical records and administrative files in accordance with IHS file management guidelines. (See Part 5,Chapter 15, “Records Management,” IHM.)
- Program Planning. Expanding access for eligible beneficiaries is an IHS priority. Planning for a quality program may involve expanding the existing service plan within the general PRS scope of practice. Program development also includes efforts to improve care, delivery, or coordination within existing budgetary, staff, or space limitations.
- Staff Planning. Staff planning must be based on RRM calculations to determine appropriate staffing based on population workload projections. Newly constructed facilities will be allocated funding for a portion of the recognized total staff need. Efforts to obtain additional staff will typically be funded by the facility’s third-party collections. Existing PRS departments can use the RRM to estimate projected staff needs, but local facility leadership determines additional staff allocations. See the IHS Non-Medical Programs, Planning, and Evaluation section of the IHS Web site for the current RRM description and formulae.
- Physical Rehabilitation Services Facility Planning. Facility planning will involve utilizing the HSP methodology. The HSP system plans new facility space requirements based on user population, projected workload, numbers of staff, and equipment. Remodeled departments should also use the HSP system as a design guide, but implementation of recommended changes may be limited due to available funds and/or space considerations. As a practical matter, alterations to the recommended design in the HSP may be necessary for any given remodeling project. The HSP produces functional drawings, notes to planners, equipment lists, and operational concept templates that can be customized for local use. Area Facility Planning Officers have access to the HSP system. The PRS-CCC may serve as a resource throughout the clinic redesign process.
3-15.6 DEVELOPMENT AND TRAINING
- Staff Development. All PRS staff require ongoing training and skills development to perform at the expected levels of competence. Funds for continuing staff education are often limited, so care and planning should be used to ensure the broadest and most equitable use of available funds. National and local leaders are encouraged to develop cost-effective continuing education training opportunities for PRS staff.
- Long-Term Professional Education. A long-term professional education program, such as obtaining an advanced PRS degree, if approved, may be funded by the local SU and may require a service commitment.
- Competency Documentation. All PRS staff, both licensed and non-licensed, must demonstrate competency. A multidimensional competency tool may be used to document this requirement (see Manual Exhibit I-I-A). Competency for licensed staff should occur in the credentialing and privileging process, however in the absence of an established medical staff credentialing process for licensed PRS staff, the SU PRS Director (or Discipline Supervisor) will use a competence tool to assess and document competence and catalogue continuing educational activities. The process of documentation should be modifiable for specific clinic settings and may be used to assist with comprehensive staff management. Additional resources and assistance is available through the APRSC, as well as the PRS-CCC. The PRS Web site address is:
- Student Programs. The PRS-CCC can provide information regarding professional education programs, such as the IHS Scholarship Program and the IHS Loan Repayment Program. These two vital programs enhance professional recruitment and often produce new therapists. All PRS departments are encouraged to provide local training sites for students at IHS facilities. Departments wishing to provide such student services should seek training and support directly from national professional organizations to ensure a quality student program. Highly qualified professionals should be assigned the duty of managing the student program. The quality of the student experience is an important element in determining the quality of the future professional service they might provide and increases the likelihood that they will have a favorable impression of the IHS. Additional assistance for students is a local SU decision and can be provided in a variety of ways, for example, the SU may provide housing and/or meals to assist the student.
3-15.7 QUALITY MANAGEMENT AND PEER REVIEW
- Quality Management Program. A Quality Management (QM) Program shall be established in PRS departments to ensure that quality care and documentation is in accordance with the local SU QM Program plan. Quality management reporting may include, but is not limited to, quality control measures, staffing effectiveness, patient and staff satisfaction, documentation review, staff competency assessment, and outcomes measures of high risk/high volume processes. The objective of QM is to identify problems and find solutions to improve safety, promote effectiveness, efficiency, timeliness, and patient-centered care.
- Quality management programs establish a framework for planning, directing, coordinating, providing, and improving health care services that respond to community needs based on the Agency’s mission. Part of the purpose of the QM Program is to ensure that the scope of medical programs and services meet or exceed the requirements of the appropriate accrediting and certifying agencies.
- Given the variety of QM systems in use, it is recommended that individual PRS departments seek guidance from their SU or Area QM Program authority prior to applying specific methods and procedures.
- Peer Review. Peer review consists of an evaluation by a committee of medical providers to retrospectively determine if a clinician’s practice of medicine is within accepted standards of care. Peer reviews are organized and conducted in response to specific issues by the appropriate authority. Peer review is not synonymous with the quality improvement chart review process. A peer review inquiry may address any or all of the following:
- an individual’s personal and/or professional conduct;
- the quality of the care provided;
- the adequacy of the medical record documentation; and/or
- any adverse patient outcome
- Chart Review. A chart review is an internal review of provider medical chart documentation to ensure quality standards are being met. Chart reviews are generally conducted by providers of the same or a related discipline and recommendations may be offered to improve the quality of the documentation. Chart reviews are considered essential to clinical practice and must be conducted on a regular basis.
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