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The role of the physical therapist (PT) is extending beyond stretching and manipulating subacute patients to helping heal their wounds. A broad training in therapies being used in wound healing is giving PTs new attention, experts say.
Tucker (GA) Nursing Center, for instance, is gearing up to implement a wound management program by emphasizing physical therapy. The 147-bed skilled nursing facility (SNF) and its on-site subacute rehabilitation services have been open since January 1996. They are owned and operated by PersonaCare, a subsidiary of Alpharetta, GA-based TheraTx, which owns or manages rehab services at more than 200 SNFs across the country.
During the past five years, TheraTx has begun using PTs in many of the 29 skilled nursing facilities it owns.
A one-year national study being conducted by TheraTx is tracking the actual outcomes of nursing home residents who have had a PT involved with their wound care management. An analysis of the data will be available later this year.
"The benefits of using PTs for wound care management are a reduction in overall length of stay [LOS], a general improvement in function of the patient, and a quicker return to independent functional living," observes John Theofilos, a rehabilitation program manager with TheraTx at Tucker Nursing Center. "Physical therapists are adding a component of various modalities and techniques of debridement that only PTs are trained in."
Treatments PTs are trained to provide include:
• electrical stimulation;
• pulsed ultrasound;
• hydrospray at the bedside;
• therapeutic positioning (bed and/or wheelchair);
• other physical agents that purportedly promote wound healing faster than the agents nurses use.
"The PT can provide those services as well as do sharp debridement, dressing changes, and topical and superficial application of medications," Theofilos says. So in many instances, it may be more effective to use a physical therapist for much of the wound care management.
"A lot of nursing homes don’t have PTs on staff and need to use a physician or take the patient to a hospital [for wound care], which is expensive and hard on the patient," notes Julie Hancock Russey, PhD, PT, division clinical manager for TheraTx.
But for PTs to treat a wound and be compensated by Medicare, certain criteria must be met. "It has to be a stage III or IV wound, and it has to require a modality that only physical therapists are trained to do, such as electrical stimulation or ultrasound," explains Stephanie Howard, a physical therapist with TheraTx at Tucker. "When we write our documentation, we have to justify the need for physical therapy involvement over and above nursing [to qualify for Medicare reimbursement]," adds Hancock Russey.
The same goes for private insurers, says Carrie Sussman, PT, a physical therapy consultant and president of Sussman Physical Therapy in Torrance, CA. To determine whether PT intervention is necessary for a particular patient, Sussman suggests asking the following questions (if you answer "yes" to any one of them, then PT services are needed):
• Does the patient have a high risk for developing chronic wounds?
• Does the patient have skin problems that haven’t responded to other interventions provided by nursing?
• Will you be able to use PTs during early intervention to provide therapeutic reduction of the impairment?
PTs are trained to use technically advanced treatments that otherwise might not be used, notes Howard. "Through sharp debridement, we can clean the wound bed out faster than we can with the enzymatic debridement agents typically used by nurses," she says.
Physical therapists learn sharp debridement as part of their formal education and hone those skills during their clinical work. Most nursing schools, on the other hand, do not cover sharp debridement.
Exceptions are the wound, ostomy, and continence nursing schools, of which there are eight nationwide. Graduates of these accredited schools are certified in enterostomal therapy or as wound care specialists.
Increasing numbers of nurses have developed competencies for performing sharp debridement, says Bernadette Cullen, RN, MSN, CETN, vice president of the Wound, Ostomy and Continence Nurses Society in Costa Mesa, CA.
Cullen points out that each state’s board of nursing determines who can do sharp debridement. "In most states it’s within the scope of practice for both RNs and PTs to perform sharp debridement of nonviable tissue," she adds.
Reducing a patient’s LOS through aggressive wound healing is a key element in reducing overall cost, Theofilos notes. Plus, PTs can be used for the more severe wound care patients. That’s because Medicare uses salary equivalency (rather than fee for service) to reimburse for the subacute services from the contract company, such as TheraTx, in long-term care.
"It behooves us to be more aggressively involved with a lesser number of residents with more intense services such as wound care," Theofilos explains.
"If we provide wound management to a resident, it doesn’t necessarily reduce the cost of their physical therapy services, but it reduces the length of stay, which in turn is a cost-saving measure," notes Theofilos.
Kathy Battle, RN, MSN, director of clinical services for TheraTx, concurs."You end up spending less in the long run because you don’t have the wound as long [when you employ physical therapy]," Battle says.
Furthermore, she says, Medicare reimbursement is maximized because there is a higher reimbursement for physical therapy than there is for nursing.
Sussman does stress the unpredictability of Medicare reimbursement in contracted services and urges caution. "The fiscal intermediaries who contract with the Health Care Financing Administration [HCFA] in Baltimore to pay the bills to Medicare are given leeway in their interpretations of HCFA’s regulations and guidelines," she warns. "So there are discrepancies. For example, high-voltage electrical stimulation is paid by some [insurance companies] and not by others."
Reimbursement by private insurers for PTs also varies depending on the payer.
"Those who have had experience with PTs providing wound care welcome it, endorse it, and support it 100%. Those who do not have a level of experience with it are a little more apprehensive because it is a new source they are not aware of," explains Theofilos.
Keep in mind that PTs are just one element of a successful subacute wound care program, Theofilos says.
"It is a collaboration of PTs and the rehab nursing staff that incorporates positioning, proper medication, monitoring, and follow-up, as well as dressing changes between wound care sessions with a PT," he says. "It’s a matter of the correct dietary intake with dietary and nutritional care services actively involved. It’s certified nursing assistants working between therapy sessions if there’s an ambulation program or range of motion program to be followed up on. If there’s not a collaborative effort, it’s like running on a treadmill backwards. It just does not work."