Guide to "The Guide"
[adapted from PT—Magazine of Physical Therapy, November 1997]
The Guide to Physical Therapist Practice... What is the significance of this landmark
document, and how can it best be utilized?
The Guide to Physical Therapist Practice was developed to describe the body of knowledge of physical therapy. The Guide is an expert consensus-based document that describes what we do and the benefits of the services we provide, and it identifies
our role in today's health care system," says Marilyn Moffat, PhD, PT, FAPTA, former APTA President, adding, "It's probably the most significant practice document in our history."
What is "The Guide"?
The two-part Guide that APTA members received with their November issue of Physical Therapy spans 480 pages. The document describes the elements of generally accepted physical therapist practice, puts forth standardized terminology, and delineates preferred practice patterns. The Guide is intended to help physical therapists improve quality of care, enhance patient satisfaction, promote appropriate utilization of health care services, and reduce unwarranted variation in the provision of services.
"Part One: A Description of Patient/Client Management" describes the elements of patient/client management and the examinations—including tests and measures—and interventions used in physical therapist practice. Part One is composed of three chapters: "What is Physical Therapy?" "What Types of Tests and Measures Do Physical Therapists Use?" and "What Types of Interventions Do Physical Therapists Provide?"
"Part Two: Preferred Practice Patterns" provides information about common management strategies for specific patient/client diagnostic groups. Part Two is organized into four practice patterns: musculoskeletal, neuromuscular, cardiopulmonary, and integumentary. According to the Board Oversight Committee, whose members included Moffat; Andrew Guccione, PhD, PT, now APTA Senior Vice President for Practice and Research; and Jayne Snyder, MA, PT, APTA Vice President, it is important to understand that the patterns are not specific protocols for treatments, nor are they to be construed or applied as clinical guidelines. "The patterns describe the boundaries within which physical therapists practice," says Snyder. "Each pattern describes for a particular patient the group, the relevant tests and measures, and the array of interventions from which a clinician may select."
Using the Guide in Practice
"This is the first time that the profession has had a document based on expert consensus that describes all of the examinations and interventions performed by a physical therapist," says Moffat. "The Guide utilizes a conceptual model in which patients are grouped together based on similar management of impairments, functional limitations, and disabilities rather than on medical diagnosis, and this distinguishes it from any other physical therapy document."
"Clinicians have their own approaches to intervention, so as they review the Guide, it will be an opportunity for them to step back and take a good look at the way they practice," says Cardiopulmonary Panel Chair Ellen Hillegass, EdD, MMSc, PT, CCS.
"For example, clinicians may consider how they would ordinarily manage a patient who has had a stroke. Clinicians will refer to the preferred practice pattern to which that particular patient belongs and see whether what they are doing fits within the
boundaries described there. If the intervention approach does not fall within the boundaries, clinicians must ask themselves if there is a rational reason why or if they should consider another approach. The patterns may also suggest interventions that clinicians may not have considered before."
Lt Col Debra Metzger-Donovan, MS, PT, who chaired the Integumentary Panel, says, "The patterns are expert opinions for preferred practice and should be regarded as such. The Guide is not intended to be a cookbook for what therapists should do for
every patient who has a wound, burn, or other condition involving the integumentary system, for instance. The Guide indicates what might be considered by the profession as boundaries of practice for that particular patient."
And different members will use the Guide in different ways, says Donna Cech, MS, PT, PCS, who chaired the Neuromuscular Panel. "For the more experienced clinicians, the Guide will serve as a way to confirm that they are making the right choices in examination or selection of interventions, and by reviewing the Guide,
clinicians may find other options to consider that they may not have utilized in their routine practice." Lisa Giallonardo, MS, PT, OCS, Musculoskeletal Panel Chair, agrees. She says, "The Guide will serve as a framework for clinical decision making for both the seasoned professional and the new practitioner. For instance, the Guide will serve as a good reference for the beginning clinician who will be meeting certain types of patients for the first time. New clinicians may ask what are all the things they should be examining to come up with the most comprehensive plan of care for a given patient/client. The patterns provide a whole menu of interventions from which to choose to best meet the needs of each individual patient/client."
The Guide and the Classroom
"Every student should have the Guide," says Jody Gandy, PhD, PT, APTA's Director of Clinical and Academic Education. "Students should have a clear perception and orientation as to what constitutes the world of physical therapy practice." And educators must use the Guide in the classroom. According to Moffat, the Guide will be incorporated into all physical therapy curricula because the content of the Guide has been incorporated into the Commission on Accreditation in Physical Therapy
Education (CAPTE) accreditation standards. Part One should be introduced early in the curriculum to help students become familiar with terminology and the thought processes behind examinations and interventions. Educators may choose to use some
of the practice patterns as part of case-based instruction.
The Guide can be used as a "check-and-balance" tool for faculty and students, says Gandy. "Faculty should use the Guide to ensure that what they are teaching is based on
what the profession says entry-level practitioners should know. Students should use
the Guide to help them understand where their education is headed and why. It describes the professional and serves as a goal for the student and entry-level practitioner in terms of growth."
"The Guide finally brings education and practice into synchrony. Students will see that what they are learning in their professional education programs leads to what they will be doing in practice," says Moffat, who is Professor of Physical Therapy at New York
University.
Guiding Reimbursement
The Guide is not only for use by physical therapists, physical therapy educators, and students, but is designed as a reference to help providers and third-party payers make informed decisions about reasonableness of care and appropriate reimbursement. Jim Nugent, APTA's Director of Reimbursement, says the Guide is a "huge step forward" for reimbursement. "Members should use the Guide to get in the door and have that dialogue with payers about what physical therapists do and why, and the reasoning
behind the number of visits that are needed."
The Guide may be an asset in gaining reimbursement for interventions that may have been denied or difficult to attain in the past. "For example, it is not generally known by payers that wound care is a service that physical therapists provide. In dealing with
payers who would question the appropriateness of wound care by a physical therapist, the clinician will now have some ammunition. The Guide has an entire section devoted to wound care in the integumentary patterns. I think the Guide will open a lot of doors to make it simpler to get certain interventions covered," explains Nugent.
Within each pattern is an "Expected Range of Number of Visits Per Episode of Care," which represents the lower and upper limits of the number of physical therapist visits required to achieve the expected outcomes or goals. Also explained are "Factors That
May Initiate New Episodes of Care or Modify Frequency of Visits/Duration of Episode." "Physical therapists who are trying to make a case for additional visits may take a pattern from the Guide to an insurer and show them that, for a particular condition, the Guide recommends between 10 and 20 visits. For instance, a patient may have had 10 visits, and perhaps the clinician believes the patient needs 2 more. Based on the Guide and the rationale provided within the pattern, the clinician has a far
stronger case to get those 2 extra visits," says Nugent.
"But if the Guide is used only to determine the number of visits, then a tremendous value of the Guide is lost. Educating the insurer about what physical therapists actually do and why, and the reasoning behind the desired number of visits, is equally
important. An educated payer is the preferred long-term outcome of the Guide, so a clinician won't have to return again and again to make that formal presentation for the additional visits."
Guiding Legislative Efforts
From Capitol Hill to the 50 state capitols, APTA members and staff can utilize the Guide to educate legislators and health care policymakers about the scope of physical therapist practice and to help guide legislative efforts that will have a positive impact on
the profession. In fact, content from the draft copy of the Guide to Physical Therapist Practice was used this summer by APTA Government Affairs staff in their effort to ensure that the $900 cap on outpatient rehabilitation services was pulled from the Senate Medicare package.
According to APTA Director of Government Affairs Nancy Garland, Esq, "With the Guide, we were able to show the Senate Finance Committee information about the most common types of conditions found under Medicare and the average number of
visits that clinicians would need for patients with these conditions using ‘standard' physical therapy practice. Based on information in the Guide, we were able to convince them that there was no way that $900 would cover what one beneficiary would need for rehabilitation services for a year. The Medicare limit was boosted to $1,500—a definite victory."
Garland says the Guide will be a terrific tool in lobbying efforts. "Whether members are lobbying at the state level for direct access legislation or for impending model practice act legislation, or are sponsoring a fitness clinic at a state capitol or a ‘legislative day'
with the state chapter, it is essential to use the Guide and have copies of the Guide at these events. The Guide is the resource that members can use when legislators have questions about physical therapy practice."
Guiding Research
The Guide was also developed to assist clinicians and researchers as they work together to develop testable hypotheses about intervention effectiveness and refine outcomes data collection and analysis.
According to Metzger-Donovan, who chaired the Integumentary Panel, "The Board
Oversight Committee helped to guide participants to think ‘functionally' and to create on paper the link between physical therapy interventions and outcomes. The ‘outcome' of the Guide is that it naturally lends itself to research and validation of specific interventions or approaches to patient/client management." "The Guide definitely provides a meaningful framework for promoting research because it establishes a consistent way for us to talk about what we do and what we know," says Guccione.
"The profession finally has a terminology it can use to describe the intellectual problems of the discipline, such as: ‘What is physical therapist practice?', ‘How does it work?', ‘Is a particular physical therapy intervention effective?', and ‘Under what conditions?'"
"The Guide encourages clinicians and researchers to ask what interventions are successful in remediating impairments, functional limitations, and disabilities," explains Moffat. "Some interventions are more successful than others, and different functional outcomes are associated with different levels of impairment and with different kinds of intervention. So the Guide immediately begins to structure clinical practice into answerable research questions about physical therapist intervention." She adds, "Whether you are a clinical researcher or a reflective practitioner for whom the main object of your inquiry is your own patient/client management, you need to have a consistent way of describing what you are doing that meaningfully communicates with others about what you have achieved."
The Future
"The Guide is a very rich document," says Moffat. "We all hope that members see its pertinence to their practice and their research and that members at the grassroots level come forth with suggestions about how to improve it based on its use and on research findings. The Guide is so extensive in its implications for physical therapy and in further defining the profession that we are only just beginning to understand what we have done here."
APTA President Jan Richardson, PhD, PT, OCS, encourages members to become active participants in using and refining the Guide. Says Richardson, "We now have a comprehensive document that unequivocally defines our practice. And while the Guide to Physical Therapist Practice is a landmark document, it must also remain dynamic. I encourage members to provide input as we refine the Guide throughout the years to reflect future directions in physical therapist practice, research, and education.
"As we keep our finger on the pulse of the future, APTA's Board of Directors will be working on a House of Delegates charge to draft a Vision Statement 2015 for the profession. The Guide will be an important part of this process. The Guide, along with the Vision Statement, will become the essential foundation on which we will define the future of physical therapy—so that we not only will survive, but will thrive, in the next century."
Copyright 1997 by the American Physical Therapy Association. Students and other academic customers may receive permission to reprint copyrighted material from Physical Therapy and PT—Magazine of Physical Therapy by contacting the Copyright Clearance Center Inc, 222 Rosewood Dr, Danvers, MA 01923. Similar inquiries by all others should be made to the APTA Editorial Office, Attn: Physical Therapy or PT—Magazine of Physical Therapy.
by Lisa Giallonardo, PT, MS, OCS
Insurers refer to the Guide. So do policymakers. Do you know how to make the Guide work for you, both in managing patients and in communicating with payers? Here's the Guide in action for a patient with THR. Focus is on examination, evaluation, diagnosis, and prognosis using Guide-based documentation.