Supervising Assistants, Students, and Aides: Upholding Your Ethics in a Challenging Health Care Environment

I think this is such a valuable topic, and as I put this course together, more and more things kept coming up with situations, scenarios, and questions. I think some of the scenarios, which are very real, will be quite an eye-opener for all of us. So with that, let's review our objectives.

The Role of the Physical Therapist

APTA and AOTA

The American Physical Therapy Association and the American Occupational Therapy Association are in complete agreement regarding the most prudent ways to exercise supervision in our sites, whether that is for students, for assistants, or for our rehab aides or rehab techs if we have them.

A Collaborative Effort

Within the scope of practice for OT or PT, supervision is a process aimed at ensuring the safe and effective delivery of therapy services. It’s also about fostering professional competence. I recently read about how supervision just isn't signing off on that document or making sure that somebody did their documentation; it's about helping the people who are working with you to improve their clinical competence, meaning that supervision is collaborative. It's a two-way street between the therapist and the assistant.  It is a joint effort to maintain and evaluate that level of competence and that level of performance. It's a mutual understanding between the supervisor and the supervisee about each other's experience, their education, and their credentials. Hopefully, it fosters growth, promotes effective utilization of our resources in our clinics, it encourages creativity and innovation, and it provides education. 

Responsibilities

Regardless of the setting the PT is providing services in, the following responsibilities are solely and completely for the physical therapist.

• Interpretation of referrals when those referrals are available.
• Initial examination, evaluation, diagnosis, and prognosis: An assistant may perform a standardized assessment but cannot interpret the results.
• Development or modification of a plan of care including goals.
• Expertise and decision-making. Determination of when the capability of the physical therapist requires the physical therapist to personally render physical therapy interventions and when it may be appropriate to utilize the physical therapist assistant.
• Reexamination of the patient/client in light of their goals and revision of the plan of care.
• Establishment of the discharge plan and documentation of discharge summary/status.
• Oversight of all documentation for services rendered to each patient/client.

The physical therapist assistant and OT assistant can certainly contribute to the evaluation process but cannot complete the true initial examination. The assistant may complete standardized assessments and provide verbal and or written observations of what the client is doing in the therapy program. Now again, the assistant can perform a standardized assessment, but keep in mind that the assistant cannot technically interpret the results. So what does that mean? While an assistant may complete a Berg balance assessment, a Tinetti, and/or a dynamic gait index, what the assistant cannot do is utilize the data to develop a goal, or to utilize it to develop interventions for that patient. The assistant should give the measurement back to the therapist who will then use that measurement in developing the plan of care.

Now the therapist is also responsible for developing or modifying the plan of care, which is based on that initial evaluation or a re-examination when that occurs.  That would also include the outcomes and the goals. If a goal needs to be added to a plan of care, again, that needs to be done by the physical therapist. That is not something the physical therapy assistant is able to do. Depending on the practice setting, the therapist may be offsite providing general supervision and there may be collaboration via phone. The assistant would document in the documentation that the collaboration or that conversation occurred, and the therapist recommended x, y, and z.   The therapist would come in later at some point and back up that documentation. So there is some of that collaboration, but without collaboration with the therapist, the assistant is not permitted to modify the goals, add modalities, or change that plan of care.

Additional responsibilities of the therapist include determining when the expertise and decision-making of the physical therapist requires that therapist to personally render the physical therapy interventions and when it might be appropriate to use the PTA.  It’s the PT who's going to determine the most appropriate utilization of the assistant that provides therapy delivery that is safe, that is effective, and that is efficient. This is critical.  

An example scenario related to supervision is a PT who did not want to provide the treatment to a client and delegated it to the assistant. The treatment was a lymphedema treatment, and the assistant had no expertise there and no idea what to do. The assistant was trying to read from a manual to provide the care. We need to make sure that both individuals are competent to do something that is delegated to him or her, and that it's okay to say, “I don't know about that,” or “I'm not sure how to do that.” “ I saw it in school but haven't done it since. “ If a patient is so complex or the technique is complex, then this should be done by the therapist and not the assistant.

Medicare and Insurance Carriers. State by state differs but some payers such as Medicare Administrative Contractors and other insurance carriers will determine that the therapist can only do specific tasks and not the assistant.