Best Care: Why Scope of Practice Matters
July 2007 Issue
Who can provide a medical or allied healthcare-related service is determined by scope-of-practice standards and licensure laws. Who should provide care is perhaps an even more important question.
For instance, "Any physician is licensed to do practically anything that is healthcare related, but no individual physician is actually qualified to do it all," notes healthcare attorney John Latsko, of Schottenstein, Zox & Dunn, Columbus, Ohio. Thus, legally defined scope of practice, licensure, and credentialing don't tell the whole story. A profession's scope of practice may overlap somewhat into other disciplines. Then what?
What should guide the decision? Ideally, of course, the deciding factor should be who can provide the best outcome for that particular patient. Scope-of-practice issues aren't exclusive to orthotics and prosthetics. According to Latsko, "They come up all the time, especially between physicians in specialty areas and between registered nurses (RNs) and licensed practical nurses (LPNs)."
Although there is a range of healthcare professionals providing prosthetic and custom orthotic care, this article centers on the question of who should provide rehabilitation therapy as it is related to certified prosthetists/orthotists and physical therapists.
To gain some insight into how the two professions can collaborate effectively to help provide the best patient outcomes, The O&P EDGE talked with several dual-credentialed practitioners:
Within the O&P profession, there are a number of practitioners who have completed the education and the credentialing/licensure requirements to be dual-credentialed in both professions. In fact, John Wall, PT, CPO, FAAOP, owner of Wall Prosthetics & Orthotics Inc., Peabody, Massachusetts, estimates the number to be at least 100, about 25 of whom are in the New England Chapter of the American Academy of Orthotists and Prosthetists.
Interestingly, most-and possibly all-were educated and practicing in physical therapy before O&P. "I don't know anyone who went the other way, becoming a prosthetist/orthotist before becoming a physical therapist," says Wall. These dual-credentialed practitioners have insight into both professions.
Although none are currently practicing or billing for physical therapy, all worked as physical therapists before obtaining their education and certification in O&P and feel that their physical therapy background has benefited them and their patients. Their comments may help other O&P professionals see ways to improve their communication and care coordination with physical therapists to better benefit the patient.
Better Understanding, Better Communication
One of the most important benefits these practitioners have realized as a result of their dual certification has been how their understanding of physical therapy has helped open the line of communication with the patient's therapist. When prosthetists/orthotists and therapists consult effectively, they can better coordinate patient care.
There are other benefits as well. "If you work well with your physical therapist, they'll give an extra set of eyes to help you see how the patient is progressing and if problems are developing, since they may be seeing your patient as often as three times a week," says Matt Parente, PT, CPO, Hanger Prosthetics & Orthotics, Vernon, Connecticut, and curriculum coordinator for Newington Certificate Program, Newington, Connecticut. "Also, if the therapist has an understanding of the prosthesis or orthosis, and if you have a good rapport with the therapist, they're more likely to call you rather than try to adjust something themselves."
Parente adds, "Orthotically, I often recommend stretching programs. If I have a question on the stretching or home exercise program the therapist has provided, I'll call the therapist and touch base and let them know what advice I've given the patient."
When Karen Acton, PT, CO, New England Brace Co. Inc, Hooksett, New Hampshire, works with a patient, she says understanding what the therapist is trying to accomplish with treatment, and why, influences her choice of device. And because she has worked in the physical therapy field, she has developed many positive relationships that have helped make consulting on patient care with physical therapists easier and more effective.
According to Scott Cummings, PT, CPO, FAAOP, Next Step Orthotics & Prosthetics Inc., Manchester, New Hampshire, having a physical therapy background has helped him to think globally rather than locally about patient care. "My physical therapy background gives me a more complete picture of what the patient has gone through before he reaches me, having done it myself as a physical therapist," he says.
Cummings often works on a rehab team in a clinic setting and says this approach allows the input of all members of the team when developing a prescription for the patient rather than having a more general prescription handed down from the physician, which the O&P practitioner must then interpret on his own.
When he has a patient with a difficult condition and is not in the clinic setting, Cummings says he still tries to take a collegial approach. "I often call the physical therapist whom the patient is seeing," he says. "Typically, PTs see the patient before we do. So I get the therapist's perspective on what that patient's needs are, which is a key to providing the right design for the device."
Consulting with each other and "being on the same page" helps when both make recommendations to the physician or surgeon regarding rehab care, Don Shurr, PT, CPO, American Prosthetics Inc., Iowa City, Iowa, points out.
Wall agrees. His practice is mainly pediatric orthotics, and he says he has established a great working relationship with early intervention therapists. "They will frequently ask me to consult with their patients, and ask me questions such as, What do you think is the next step? Does this child need an AFO?'"
Wall's dual certification has helped him create a better overall environment for the youngsters he treats, which he says aids their progress. Every month, he works closely with several school programs with special-needs youngsters. "I may see 1516 kids on a school day," Wall says. Although he can't bill for his services, he consults with the therapists, teachers, and paraprofessionals in the classroom. "For instance, if a child has a new TLSO, I make sure that everyone knows how to put it on properly. Often, very involved children with cerebral palsy will also develop scoliosis. You may have some youngsters with AFOs, TLSOs, elbow orthoses, and knee orthoses. Sometimes it takes the paraprofessionals in the classroom 20 minutes to put on all the equipment before they can put the children in their stander or gait trainer. It's important for the staff to know how to put the equipment on properly so that the youngsters are getting the benefit of all the devices that we're providing them."
Why Learn about the Other Profession?
Being able to "speak each other's language" and having a good understanding of what the other does helps both disciplines provide good patient care. To that end, Shurr teaches physical therapy students at the University of Iowa about orthotics, and Parente teaches O&P students in the Newington program about physical therapy.
"A textbook I have co-authored [Prosthetics and Orthotics, Second Edition, by Donald G. Shurr and John W. Michael, Prentice Hall, June 1, 2001] aims to help physical therapy students understand the process that orthotists and prosthetists go through," explains Shurr. "It helps them to understand the components, materials, and the biomechanics and forces involved, so they understand the difficulty that some of their patients may have in adapting to and using the devices.
"The actual evaluation, fabrication, and design of those devices need to stay as the forte of those who are educated and have completed residencies in orthotics and prosthetics," Shurr says.
Parente says he tells his students that he's not teaching them to be a physical therapist but rather "create an understanding of what physical therapists do."
Without that mutual understanding, orthotists/prosthetists and physical therapists may inadvertently undermine what the other is trying to achieve for the patient. "I wish the physical therapists would keep up more on the latest O&P technologies," says Acton. "Some of the exercises they have the patients do are sometimes counterproductive to what we're trying to do in prosthetics. For instance, there are different ways the amputee needs to work with all the various knees and feet. For some of them, the amputee really needs to work the hip extensors to keep the knee stability, but with the new microprocessor knees, you don't rely on that as much for gait training."
In addition, Parente says, "A physical therapist needs a good understanding of some of the functional aspects of the components and be able to incorporate that into the patient's rehab. The physical therapist may have to work with the patient on balance a bit differently with a higher-tech prosthetic foot than a SACH foot.
"Understanding the difference between a prosthetic problem and another patient problem is huge," he continues. "I might get a call to come out and fix a prosthesis [because] the patient feels he is falling forward. Then I find out that the therapist has taken the patient out of the parallel bars and has put him in a walker. He's now bent forward at the waist, which is changing the angle of the alignment. It's important too for O&P practitioners to understand the challenges the therapist is facing and what they expect from the prosthetist or orthotist."
Out of Bounds: Where Do You Draw the Line?
Even with a better understanding of one another's profession and improved communication, the question remains: Are there areas in orthotics and prosthetics in which physical therapists should not get involved? And conversely, are there areas overlapping into physical therapy that are better left to PTs?
"A lot of therapists like to do off-the-shelf AFOs such as protective and prophylactic bracing, and they do have some education in that area," Parente says. "But custom AFOs and triplanar deformities and understanding the mechanisms that go along with those can be potentially tricky ground for physical therapists."
"Therapists need to be careful about making any physical changes to the prosthesis, any changes in componentry, or any socket adjustments without consulting the prosthetist. For instance, a patient is having pressure problems in the socket, and changing the alignment helps relieve the pressure. Then, if the therapist decides, I'll just heat the socket and move this out a little bit, because I've seen/done this before,' then my strategy for solving the problem is no longer valid. There is now another variable in the mix.
"On the flip side, the prosthetist's role in rehab should be limited to aspects that directly relate to the prosthesis, such as stretching the residual limb," Parente continues. "I think the prosthetist has to have some of this knowledge, since not every amputee goes to physical therapy. If you just send the patient out on his own, saying, I'm not a physical therapist; I can't advise on stretching or exercises,' you're doing the patient a tremendous disservice. I don't think we should do cardiovascular rehab, but we should do what directly relates to their residual limb and their overall prosthetic outlook."
Cummings agrees and says that custom devices and the more sophisticated prefabricated devices-custom-fit, high-require the expertise of a certified O&P practitioner.
There are areas that some of the practitioners agree require the expertise of a physical therapist. For example, some expressed reservations about orthotists being adequately qualified to provide functional electric stimulation (FES) devices being marketed to them.
"I don't think orthotists are qualified to provide FES devices without the assistance of a physical therapist, because global muscle physiology education-an important aspect of FES-isn't provided in-depth in O&P education," says Wall. "A weekend course just isn't enough. I haven't done e-stim [electrical stimulation] since school, so I don't feel qualified to do it either, even though I know the science behind it."
Says Acton, "Functional electrical stimulation is usually a full course in physical therapy, including all the modalities. There are certain cycles for pain control, certain cycles for muscle stimulation. As an orthotist, I had no training in electrical stimulation and the proper use of it, whereas as physical therapists, we had it pounded into our heads. This is an interesting crossover."
The Bottom Line
Good communication, understanding scope of practice, and knowing how both relate to successful patient outcomes are keys to answering the question of who should provide rehab therapy, according to Parente. "If you and the therapist both understand your limitations and your scope of practice as it relates to the other discipline, then you have better patient results."
Even within the same discipline, some clinicians may have more expertise or experience in certain types of cases, and for best patient outcomes, others may want to refer these patients to them. For instance, Wall notes that he has been asked to fit plagiocephaly helmets, but he's never done one. "I don't feel comfortable just taking a weekend course and then suddenly practicing plagiocephaly helmet fitting. I refer all those to Children's Hospital in Boston. I would only feel comfortable if I had been doing them with someone else for a number of months before doing them on my own."
Even if they are allowed to provide a particular service, Parente concludes, healthcare professionals need to make the decision as to whether or not they are the right person to provide a certain service for a particular patient. "Ask yourself if your sister, father, grandparent, any loved one needed this service, where would you take them? We have to remember that those patients who come through our door are somebody's sister or brother, grandparent, etc., and ask ourselves, 'Am I the best person to treat this patient-or not?'"
Miki Fairley is a contributing editor for The O&P EDGE and a freelance writer based in southwest Colorado. She can be contacted via e-mail at firstname.lastname@example.org
CMS: Who Is a Qualified Provider?
According to www.OandPCARE.org, the informational website of the American Board for Certification in Orthotics and Prosthetics (ABC), the Centers for Medicare & Medicaid Services (CMS) has deemed that certain specialties, licensed or certified by the state or an approved entity, are qualified to furnish prosthetics and certain custom-fabricated orthotics. As defined, the qualified providers include the following:
There are two aspects to supplying and billing for devices under Medicare, notes healthcare attorney John Latsko, Schottenstein, Zox & Dunn, Columbus, Ohio:
"Facility accreditation will shortly be a requirement to become a Medicare supplier and obtain an NPI number, with accreditation being mandatory by August 31 for facilities under the competitive bidding program, and later for others," Latsko reminds. "In states with orthotic, prosthetic, and pedorthic licensure, practitioners must be licensed...even medical groups will need accreditation in order to enroll as a Medicare supplier and be paid as will physical and occupational therapists."
Physical Therapists to O&P Practitioners: