Chapter 15 - Physical Rehabilitation Services

3-15.1   INTRODUCTION

1. Purpose.   The purpose of Physical Rehabilitation Services (PRS) is to evaluate, interpret, and treat patients experiencing physical as well as cognitive disabilities and impairments. The goals are to restore function, enhance performance, and regain independent and pain-free mobility. Physical Rehabilitation Service professionals include, but are not limited to Occupational Therapists (OT), Physical Therapists (PT), and Speech-Language Pathologists (SLP). The mission of the PRS is to advance the quality, availability, and accessibility of rehabilitation services for American Indians and Alaska Natives.
2. Policy.   This policy will establish guidelines, goals, and evaluation procedures for providing quality PRS, and health promotion/disease prevention services to American Indian and Alaska Native (AI/AN) patients. All facilities will develop and implement a local policy that is relevant to the needs of the service unit and contains, at a minimum, the following requirements:
   1. Local training requirements;
   2. Local process for quality improvement;
   3. Compliance with any regulatory/accreditation requirements (i.e., Office of Inspector General exclusion list);
   4. Local process for credentialing and privileging.
3. Objectives.   The objectives of the PRS in conjunction with other medical services are to:
   1. Provide necessary and effective patient care;
   2. Promote mobility, function and quality of life;
   3. Help patients regain independence and performance;
   4. Promote health and prevent disease;
   5. Promote skill development and independence in all daily activities. For adults, this may mean looking at the areas of self-care, home-making, leisure, and work; for pediatrics, this may mean looking at skills such as oral feeding and mobility within the patient and caregivers’ preferred community settings;
   6. Collaborate with other health care professionals to maximize a comprehensive network of patient care;
   7. Lower future health care costs;
   8. Create individualized patient centered care; and
   9. Develop staff to improve care and strengthen professional services.
4. Areas of Care.   Areas of care may include, but are not limited to, cognitive-communicative, musculoskeletal, neurological, integumentary, aero-digestive, cardiovascular and pulmonary, and metabolic body systems. Care is provided to patients of all ages who have (or are at risk for) developing a disease, injury, disorder, impairment, or disability that has the effect of preventing or limiting a person’s ability to participate in activities of daily living and vocation.
5. Definitions.   
   1. Collaboration.   Collaborative patient care involves interdisciplinary communication and cooperation. The expectation is that the PRS staff will coordinate care among the care providers and disciplines, other IHS resources, and non-IHS services, as appropriate.
   2. 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.
   3. Examination.   Examination is the process of obtaining a medical history; desired patient outcomes; obtaining prognosis and diagnosis; environmental obstacles, available support; selecting and administering tests and measures to gather data about the patient. The initial examination is a comprehensive screening and evaluation process. The examination process may also identify potential problems that require consultation with or referral to another provider. Test and measures will be in accordance with current acceptable professional standards as approved by the PRS Chief Clinical Consultant (PRS-CCC).
   4. 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 including prior medical history. Factors that influence the complexity of the evaluation process include the following: clinical findings, the extent of functional loss, social considerations, cognitive abilities, overall physical function, and health status. Physical rehabilitation therapists also assess the severity and complexity of acute or chronic impairments, the probability of prolonged impairment, functional limitations and disability, the living environment, potential discharge destinations, equipment resources, and the existence or absence of social support.
   5. Health Promotion.   Health promotion is basic educational patient care that emphasizes prevention and focuses on wellness, physical fitness, desired outcomes from providers, patient and the promotion of health including care of chronic conditions; it promotes skill development and independence in all daily activities. For an adult, this may mean looking at the areas of self-care, home-making, leisure, and work. For pediatrics, this may mean looking at the areas of physical activity, sleep hygiene, and chronic condition management.
   6. 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 will be accomplished in accordance with current acceptable discipline-specific professional standards as accepted by the PRS-CCC.
   7. 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.
   8. Occupational Therapist.   A highly trained health professional who is a graduate of an accredited Occupational Therapy education program and is licensed to practice occupational therapy in at least one United States (U.S.) jurisdiction.
   9. Outcome Measures.   As the patient reaches the termination of the 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 as applicable on the following areas of care: pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations; disabilities, risk reduction/prevention 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.
   10. Patient Population.   Physical Rehabilitation Services are provided to eligible patients of all ages experiencing physical impairments, functional limitations, and/or disabilities as a consequence of injury, disease, or other causes.
   11. Physical Rehabilitation Services.   Physical rehabilitation services are the application of physical rehabilitation knowledge, skills, and training to diagnose, treat, and prevent injury, or disease. These services include, but are not limited to, the disciplines of OT, PT, and SLP. Physical Rehabilitation Services may be provided across a beneficiary’s lifespan, addressing a wide variety of diagnoses in diverse clinical settings. Rehabilitation professionals provide treatment to patients in settings that include, but are not limited to, medical centers, hospitals, clinics, homes, schools, chapter houses, community centers, and nursing homes. The PRS providers are an integral part of a multi-disciplinary patient-centered care model that embraces collaboration with other medical providers in order to provide coordinated superior and individualized health care.
   12. Physical Therapist.   A highly trained health professional who is a graduate of an accredited Physical Therapy education program and is licensed to practice physical therapy in at least one U.S. jurisdiction.
   13. 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).)
   14. Speech-Language Pathologist.   A highly trained health professional who is a graduate of an accredited Speech-Language Pathology education program, holds a Certificate of Clinical Competence (CCC) and is licensed to practice speech-language pathology in at least one U.S. jurisdiction.
   15. Resource Requirement Methodology.   A system designed to project the staffing needs for a specific facility or primary service area. The system uses empirical data, such as workload or service population, called driving variables, to estimate the staffing requirements in full-time equivalents to provide comprehensive acute, chronic, and preventative health care services to Indian people.

3-15.2   RESPONSIBILITIES

1. Chief Medical Officer.  
   1. The IHS Chief Medical Officer (CMO) is administratively responsible for the issuance of this policy.
   2. The IHS CMO selects and appoints the PRS-CCC for a term of 3 years. A selected PRS-CCC may be appointed for more than one term.
2. Physical Rehabilitation Services - Chief Clinical Consultant.   The PRS-CCC serves as the coordinator, consultant, and advisor for all matters relating to the provision of rehabilitation services throughout the IHS.
3. Area Director.   The Area Director is responsible for:
   1. Ensuring that administrative support and necessary resources are available for the implementation and maintenance of this policy within the Area; and
   2. Ensuring that this policy is fully implemented within the Area.
4. Area Chief Medical Officers.   The Area Chief Medical Officers (CMOs) are responsible for:
   1. Monitoring facilities for compliance with this policy within the Area; and
   2. Selecting and appointing an Area Physical Rehabilitation Services Consultant (APRSC) in Areas with IHS medical programs. The terms of service varies depending on the needs of the Area and at the discretion of the Area CMOs
5. Area Physical Rehabilitation Services Consultant (APRSC).   The APRSC works closely with the PRS-CCC to develop policy and implement strategies that improve clinical practice and promote patient advocacy.
   1. The APRSC participates in national PRS meetings and other appropriate Area leadership activities.
   2. The APRSC provides consultation to the Area CMO and the Area Director on the PRS issues.
   3. Consults with Service Unit (SU) Physical Rehabilitation Directors or respective SU Chiefs of discipline specific services (e.g., PT/OT/SLP) promoting quality rehabilitation services through management, guidance, encouraging staff development, and quality improvement.
   4. Coordinates staff development.
   5. The APRSC also serves as a resource for SU senior management in the selection of rehabilitation services leadership and other issues requiring perspectives from outside the SU.
   6. The APRSC may assign Area clinical consultants to provide guidance for the 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.
6. Chief Executive Officer.   The SU Chief Executive Officer (CEO) is responsible for ensuring that the facility's PRS policy is fully implemented, reviewed, and updated per Area Governing Board procedures.
7. Service Unit Physical Rehabilitation Services, Clinical Director.   The SU Physical Rehabilitation Services Clinical Director is responsible for:
   1. Establishing and implementing the PRS policy relevant to the needs of the service unit;
   2. Recruiting, reviewing, counseling, and promoting the continuing education of PRS staff;
   3. Conducting quality improvement and risk management reviews.
8. Physical Rehabilitation Service Professionals.   All PRS staff will:
   1. 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; and
   2. Improve the level of care available to AI/AN people by increasing access to the PRS for eligible patients.

3-15.3   SCOPE OF PRACTICE

1. Practice Competency.  
   1. All PRS staff, both licensed and non-licensed, must demonstrate competency. Competency for licensed staff will occur in the credentialing and privileging process. The PRS Director (or Discipline Supervisor) will be responsible for quarterly Primary Source Verification. The hiring process review will include verifying the following:
      1. Graduation from approved program in the appropriate discipline;
      2. Primary Source Verification to ensure the PRS staff holds a current and unrestricted state license or certificate;
      3. Any voluntary or involuntary termination of medical staff membership or limitation, reduction or loss of clinical privileges at another healthcare facility;
      4. National Practitioner Data Bank query to include any settlements or final judgments in professional liability; and
   2. At least two letters of reference or documentation from telephone references. Competency for all applicable staff will be maintained and updated as needed in the PRS Department Employee Folder.
2. Practice Setting.  
   1. The PRS providers may work at an individually autonomous and elevated level dependent upon the institutional mission, patient care model, and their advanced training.
   2. All eligible IHS PRS professionals will be granted clinical privileges to treat patients and engage in expanded roles and advanced practice (including accepting self-referred patients within provisions outlined by the licensing agency). Privileges are 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 IHM 3-1, "Medical Credentials and Privileges Review Process.”) Privileges will 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).
   3. 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.
   4. All therapists involved in the delivery of services, including independent 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.
3. Domain of Practice.   The PRS are limited to the care and services provided by or under the direction and supervision of a licensed OT, PT, or SLP. Service by PRS staff is characterized by the following areas of commonality within the domain of physical rehabilitation:
   1. Consultation.    The PRS 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.
   2. Educational Services.   The PRS therapist may be involved in:
      1. Communicating PRS information or techniques by conducting academic education, clinical education, and continuing education for PRS therapists, other providers, and students;
      2. Planning and conducting educational programs for Tribes, local organizations, State, and Federal agencies; and
      3. Planning and conducting programs for the public to increase awareness of issues in which physical rehabilitation therapists have expertise.
   3. Administrative Services.   All licensed professional PRS staff will:
      1. Provide clinical supervision of support staff;
      2. Manage the resources available for patient care activities, including but not limited to, orthotics, prosthetics, durable medical equipment, and home/occupational support devices;
      3. Help achieve the organization’s mission; and
      4. Assist with departmental operations.
   4. Physical Rehabilitation Services Supervision of Assistive Personnel.   The PRS providers oversee and supervise student interns, assistants, aides, technicians, and chiropractor/massage professionals if applicable. The supervising PRS provider remains responsible for delegated and supervised duties and tasks; and must document or co-sign their individual supervisory interactions and outcomes. The supervising PRS provider will meet with each individual student, assistant, aide, or technician routinely and as outlined by their respective licensing agency to discuss patient care management, delegated assignments, and quality improvement.

3-15.4   HEALTH INFORMATION MANAGEMENT

1. Medical Records.   Medical Record entries must contain information required to identify the patient and provider, support the diagnosis, develop a plan of care, document the course of treatment, provide instruction(s), define outcomes, and refer if necessary. In addition, all PRS documentation will meet the standards established by the various applicable external accrediting agencies. The PRS documentation will be included in the official patient medical record and be a part of the patient’s permanent record. A comprehensive history and physical examination, progress note(s), and discharge summary must be documented for each patient. The medical record is the official agency record and must be timely, complete, accurate, objective, professional in content, and handled with due diligence. The records may be used in quality improvement reviews, legal actions, and third-party billing. Incomplete and delinquent documentation negatively impacts patient care, financial resources, legal and regulatory defenses, clinical decision making, and organizational performance improvement activities. The PRS providers will follow, at a minimum, documentation standards as set forth by their institution, professional governance, and billing resources.
2. Confidentiality.   The patient medical record is confidential and will only be accessed by the PRS providers for official medical, quality, and operational use. The information must be handled in accordance with the Privacy Act of 1974, as amended, and Health Insurance Portability and Accountability Act of 1996, as amended, and will follow the requirements set forth in IHM 3-3, "Health Information Management."
3. Records Disposition.   A PRS File Manager will be assigned to each PRS Department to implement and oversee the PRS records disposition program, in accordance with the IHS Records Disposition Schedule.
4. File Management.   The PRS staff will maintain all patient medical records and administrative files in accordance with IHS file management guidelines. (See IHM 5-15, "Records Management Program.")

3-15.5   DEVELOPMENT AND TRAINING

1. Staff Development.   All professional licensed or certified PRS staff require continuing education and skills development as outlined in states’ licensing or certificate requirements to best perform at the continued expected levels of competence beyond entry competence. Funds for professional and non-professional continuing education are often limited, so care and planning will be used to ensure the broadest and most equitable use of available funds. National, Area, and Facility leaders are encouraged to develop cost-effective continuing education opportunities for the PRS staff.
2. 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 PRS professionals with commitment to the IHS. All PRS departments are encouraged to provide local training opportunities for the PRS students at the IHS facilities and foster a collegial relationship with the PRS clinical and academic programs. Departments are also encouraged to seek training and support directly from national professional organizations. Trainings such as Clinical Instructor or Advanced Clinical Instructor promote quality student clinical rotations. Highly qualified professionals will be assigned the duty of managing the student program. The quality of the student experience is an important element in recruiting and retaining high quality professionals 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; housing; meals; or the United States Public Health Service Junior Commissioned Officer Student Training and Extern Program, which may include pay, health benefits, housing, and travel allowances.