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NCCE Discussion

CMS & Use of Students in Inpatient Rehab Facilities

Note: You will be listed as 'anonymous' unless you type your name and/or email in your response

24 posts, 0 answered
  1. sbrooks
    sbrooks avatar
    3 posts | Registered: 13 Jan 2018
    Posted: 26 Nov
    We encourage participants to share their name and role in their posting.  Posts will otherwise appear as "anonymous".
  2. Anonymous
    Anonymous avatar
    Posted: 27 Nov

    I am happy to be getting lots of questions about this situation from my staff therapists; people are paying attention! It makes sense to me that a patient who qualifies to be in an inpatient setting should have as much protection, if not more, than a patient in an ambulatory setting. I have over 20 years of experience in the acute care/ICU setting and in clinical education. It has been demonstrated to me time and time again, that students need some level of independence to perform to the best of their ability as they are often nervous and anxious when their CI is present. Once missing component that I often see in acute care supervision is the CI prepping the patient to be seen by a student, or following up with the patient following the intervention to see if they have further questions, feedback for the student or myself or other comments/concerns. I am concerned that the highlighting of this topic will cause the facilities that are already performing clinical education well in the spirit of collaboration and education to tighten their reigns on students and not allow the level of independence they need to see if they are truly independent in clinical decision making. We will be graduating a workforce that are have little experience or skill working with the geriatric population independently.

    Chrissy Ropp, DPT, GCS

  3. Anonymous
    Anonymous avatar
    Posted: 27 Nov

    Thank you Donna, Carol, Jay, & Kathrine and your respective organziations (ACAPT & APTE) for your actions toward addressing this issue.  In the email, it was mentioned that a future meeting between CMS, APTA, & others will occur.  Has this meeting been scheduled, and if so when?  It would be helpful to know an approximate time frame that programs will have to deal with this issue and focus our efforts toward education clinical sites, coordinators, and instructors.

    Thanks for all of your efforts on this issue.

    Jim Farris, PT, PhD

  4. Anonymous
    Anonymous avatar
    Posted: 27 Nov

    This is Donna Applebaum responding to Jim Farris' question. As of today, 11/27, the meeting between CMS, APTA, AOTA and ASHA has not yet been scheduled. I understand the parties have all made contact and the meeting date is pending.

    Donna Applebaum, PT, DPT, MS, NCCE Chair

  5. Anonymous
    Anonymous avatar
    Posted: 27 Nov
    For now, until the meeting occurs, should we advise our clinical sites to use the Part B guidelines, i.e. CI will be present and not engaged in other activity, while the student treats? I think most facilities will want to err on the side of caution until something firm is decided by CMS, and I'd like to help them feel protected while also keeping the affiliations ongoing.
  6. Anonymous
    Anonymous avatar
    Posted: 27 Nov
    Will the FSBPT be weighing in on this discussion?  As a protector of the public, they would seem to have a vested interest in the final decision.
  7. Anonymous
    Anonymous avatar
    Posted: 27 Nov
    I know this is not exactly clarified by CMS, but I feel students can learn and be independent even with their supervising therapist in the room and unoccupied. I have had many experiences as a student as I completed a PTA degree before going onto a DPT degree. I experienced 7 different clinical affiliations as a student and I was nervous when my clinical instructor was in the room. However, there were MANY more times when my clinical instructor was not with me. I also felt there were times that I had a question and needed some guidance during a treatment, but I had to wait until I had time to meet with my clinical instructor outside of patient care because they were not with me in the room during the treatment. 
    Being the clinical education coordinator (CEC) for the PTA program at Idaho State University, I hear regularly from my students that they do not feel that they were given enough guidance or supervision from their clinical instructors. I also worked in Home Health for many years and had multiple PTA & PT students. In home health, the supervising therapist is always in the home as that is considered on-site supervision. It was critical that I allowed my students to complete the treatments without always jumping in to help. However, I was there if they had questions. And for students on their final clinical affiliations, by the end, I was just sitting and watching. However, they were spectacular at performing their skills because they knew I would not always be critical of them, but that I was available if needed. 
    Nash S. Johnson PT, DPT
    johnnash@isu.edu
  8. Anonymous
    Anonymous avatar
    Posted: 27 Nov

    This is in response to the question above, "For now, until the meeting occurs, should we advise our clinical sites to use the Part B guidelines, i.e. CI will be present and not engaged in other activity, while the student treats? I think most facilities will want to err on the side of caution until something firm is decided by CMS, and I'd like to help them feel protected while also keeping the affiliations ongoing."

    We can't advise on this issue. Each clinic is going to need to determine what they feel comfortable with to ensure compliance with the regulations. As you suggest,  ongoing dialogue between academic programs and their clinical partners would be important.

    Donna Applebaum, PT, DPT, MS, NCCE Chair

  9. Anonymous
    Anonymous avatar
    Posted: 27 Nov

    As an ACCE, a working PTA with 22 years of experience, a clinical instructor, and a concerned citizen this movement by Medicare to effectively remove the validity of the SPT or the SPTA from educational services is more than frustrating!
    There is no other way to prepare students for reality except for exposure to real-time situations. Medicare’s stand that students are unable to perform satisfactorily, safely, and appropriately in a rehab facility is unsubstantiated.
    We are all devoted to educating and nurturing students to be the best they can possibly be and limiting exposures will only harm the profession and demean the value of our services.
    So… Does Medicare have a similar stance on medical students? Nursing students? Dental students? Pick a student! Are those supervised student services to the public scrutinized and ineligible for reimbursement in an effort to protect the public? If not, then how long until they do? And why is the therapy world being singled out? All this does is HURT the Medicare provider who is providing the Medicare services in the first place. If Medicare’s thinking isn’t somehow changed then the hit educators and students are going to take will be close to unrecoverable! That’s my two cents!

    Gina McDade, PTA, ACCE

     

     

  10. Anonymous
    Anonymous avatar
    Posted: 28 Nov
    I understand facilities wanting to make sure they stay compliant. But, it has been disappointing to have facilities jump to conclusions about students without having the full story. Just yesterday a blast email went out in my state that all hospitals were to stop allowing students to do any more than observe. I appreciate ACAPT keeping the membership informed, but wish when such big issues such as this arise they would be investigated before sending out a general message. This has opened pandora's box. 
  11. Anonymous
    Anonymous avatar
    Posted: 28 Nov

    Good morning, this is a response to the post above: "I understand facilities wanting to make sure they stay compliant. But, it has been disappointing to have facilities jump to conclusions about students without having the full story. Just yesterday a blast email went out in my state that all hospitals were to stop allowing students to do any more than observe. I appreciate ACAPT keeping the membership informed, but wish when such big issues such as this arise they would be investigated before sending out a general message. This has opened pandora's box."

    I have a question and a comment. Could you please identify the state that you are referring to, that is requiring student observation-only? We are interested in trends in response to this issue. I can assure you that the issue has been investigated to provide our community accurate information that is available now, and we will continue to do so. When the CMS webinar occurred on 11/15, news trickled out quickly and the very next day there were clinical sites informing academic programs that students would only be able to observe. The grapevine started, and there were different versions of events that occurred already circulating. When we learned of this APTA, ACAPT and APTE felt responsible to communicate with the information we KNOW, so at least the message was accurate. It may feel like Pandora's Box (and we are all feeling the uncertainty), but I feel this communication allows us to move forward collaboratively and operating on the same information. Thank you for your comments.

    Donna Applebaum, PT, DPT, MS-NCCE Chair

  12. Anonymous
    Anonymous avatar
    Posted: 28 Nov

    This issue is like a bad penny and it keeps coming back to haunt the clinical and academic communities. When this conversation occurs over and over again, it makes me question the backgrounds of the individuals who are driving these decisions. Do they understand that our models of education are different than medicine and nursing? Although the models are different, it does not mean that the PT/OT/Speech models are less effective in preparing new professionals.

    Ultimately, patients will be adversely affected if CMS does not recognize that patients can get skilled care while students perform services when a therapist provides direct supervision. There will be limitations as to the breadth and depth of clinical experience that students will have prior to graduation. The clinics will need to spend even more time training new graduates due to the limitations in experience that students will have prior to graduation. I question if clinics are prepared to dedicate the time, money and effort to support new hires with the level of supervision that will be required if these CMS changes are to be implemented.

    If this is to be the new policy, then FSBPT should consider a tiered licensure and CAPTE may have to consider if 30 weeks of full-time clinical experiences is reasonable, given the constraints for opportunities which students will have for clinical experiences.These changes will not happen overnight and, if this is going to be the new policy, all stakeholders need time to adjust.

    Ellen Wetherbee PT, DPT, MEd

  13. Anonymous
    Anonymous avatar
    Posted: 28 Nov

    Could there be a statement put in the notes by either the student or supervising therapist that would show insurances that the therapist is still involved. For instance, "supervising therapist present and assisting with all portions of treatment". Could a statement like this lay any suspicions to rest?

    Matt McCreary, PT,DPT,OCS

  14. Anonymous
    Anonymous avatar
    Posted: 28 Nov

    What needs to be emphasized to CMS is that every licensed therapist is responsible for their student and we have documents and guidelines for different types of supervision. 

    Student services are provided under the therapist's professional license.  No one wants to put their professional license at risk.  That is how we ensure quality.  Student skills and clinical decision making abilities are verified by the supervising therapist prior to progressing independence. 

    In the past we have received definitions and guidelines for different levels of supervision (direct, indirect, on site, line of sight). 

    I have a document titled "Chart: Supervision of Students Under Medicare" provided by the APTA and updated 9/5/14. The chart differentiates between Medicare Part A and B and the level of supervision required at different facilities.  Is there now only 1 type of permissible supervision? (line of sight?)

    SNF Y1 : recommendations state "Reimbursable: Therapy students are not required to be in line-of-sight of the professional supervising therapist/assistant (Federal Register, August 8, 2011). 

    SNF: PTA student: Y2  "Reimbursable : minutes of student services count on the minimal data set"

    Hospital Y3 : Unspecified, use Y1 for guidance, and defer to state law and standards of professional practice

    Acute Rehab: Y4: Unspecified, use Y1 for guidance, and defer to state law and standards of professional practice

    Perhaps the same resources used to create this chart should be brought out and presented to CMS again?

    Students "observe" and act as a "2nd pair of hands" PRIOR to therapy school as volunteers who are considering entering the profession.  Preventing students from demonstrating that they can independently manage all aspects of patient care is not beneficial to the future of our profession or our patients. 

    Sara Alhajeri

  15. Anonymous
    Anonymous avatar
    Posted: 28 Nov

    I share many of the concerns expressed already regarding how we can continue to operate a clinical education program and prepare students for practice.  I would like to offer an example from today of just one instance how this has already negatively affected the care to one of our patients.  I currently have a Medicare patient that got a late start for her appointment due to nursing needs.  My student and I saw the patient for 30 out of 45 minutes before we needed to move on to our next Medicare patient.  In stead of my student seeing our first patient for an additional 15 minutes (for balance exercises that we had previously discussed) and overlapping with our second patient we cut her session short and she was returned to her room.  This poor woman missed out on therapy that she desperately needs and is very motivated to participate in.  This change in policy has already been detrimental to us providing our patient with the care that they need. 

    On a side note, Lieutenant General Michael Nagata's 2018 lecture "Leadership in a Rapidly Changing World." could not have been more timely. 

    Randy Carson PT, DT, NCS, SCCE

  16. Anonymous
    Anonymous avatar
    Posted: 29 Nov

    Update on timing of the meeting between CMS, APTA, AOTA and ASHA: this is scheduled for the week of December 10.

    Donna Applebaum, PT, DPT, MS-NCCE Chair

  17. Anonymous
    Anonymous avatar
    Posted: 30 Nov

    Thanks Donna, 

    I can only hope that the conversation with CMS the week of 12/10 does not end with the suggestion to document that the therapist was in the room the entire time with the student and patient.  

    This would be a concession to requiring "line of sight" supervision, and we should instead be referring to our state practice acts and professional guidelines for various appropriate levels of supervision.  Requiring "line of sight" takes away the professional educator's discretion and does not account for the various levels of training and independence that students demonstrate.  

    Line of sight supervision requirements for entire therapy sessions would greatly reduce the number of students accepted on clinicals.

    Sara Alhajeri, PT, GCS, SCCE

     

     

  18. Anonymous
    Anonymous avatar
    Posted: 30 Nov
    I agree.  If a statement were to be required in the medical record something along the lines of "plan and treatment discussed with physical therapist prior to  implementation" would be a much better alternative to foster the development of our studnets to allow them to be better equipped to work with Medicare recipients as future licensed PT's.
  19. Anonymous
    Anonymous avatar
    Posted: 30 Nov

    Folks, As stated numerous times above: CMS, Medicare and all stakeholders are looking closely at this and other issues.  Thank goodness.  The trust with which we are imparted needs close scrutiny as well, the patients, students and each of us in "Healthcare" today.  If any one of us "paid out-of-pocket for our services, I would like think we'd value those same services to the extent of the cost.  (Does everyone know what CMS pays for one of your 15 minute units?)  Without scrutiny and growth we could never make progress or serve the complex needs of our populations.  That said, I hope any rare facilities exploiting students and doing "the worst case scenarios" are exposed and stopped.  We've all heard stories of student and CI with two caseloads being billed or "off-site" supervisors...  I am fortunate to work for a facility of high integrity, a teaching hospital where the quality is of much greater value and focus than the "quantity".  Here we provide one-on-one, direct supervision to students in PT, OT, and SLP.  It is rare to by outside line-of-sight, never out of direct verbal reach. (not by pager/iPhone/Vocera or other indirect electronic connection)  I have been a CI in PT for 19 years, performed "remedial" education for students who were not "performance art" oriented or may have been nervous with a CI in the room.  In those rare cases, my demeanor allowed them to select early treatments they were comfortable with delivering, and I would work directly to ensure that even awkward students were involved in  treatment in "Qualified Manner".  With my close proximity and immediate knowledge of both pt and student, I could allow failures. learning and teaching moments to evolve regularly in excellent, meticulously guarded safety.  Any facility worried about more stringent laws or oversight, should perhaps look at their own practices.

    David Grant, PT, MPT Baltimore, MD  Graduate 1998 Education Specialist, Sinai Hospital Baltimore (Experience in Acute care, Outpatient, Homecare and Acute Neuro-Rehab here and at numerous facilities in Maryland)

    Lastly, be aware that any "differential treatment" of patients based on their "Third Party provider" could constitute a breach of Ethical guidelines or potentially slip onto the slopes of fraud. 

  20. Anonymous
    Anonymous avatar
    Posted: 04 Dec

    Our facilities host about a hundred PT, OT and SLP students on their graduate school clinical affiliations each year. It is our understanding that these students may treat patients under the guidance and direct supervision of their clinical instructors. I understand that under APTA student practice guidelines, students are required to have line of sight supervision. At our clinics, we take a more direct supervision approach. The licensed therapist dictates the treatment and plan of care for the patient and is present throughout the entire session.

    If students do not have hands on experience, then how are they to learn? Student treatment under the supervision of a qualified practitioner is how our students learn and grow to be qualified practitioners when they graduate. If they are not allowed to have hands on experience and practice documentation in the medical and clinical setting, then they will not be prepared to be a licensed therapist and treat patients when they graduate.

    I have emailed CMS my concerns and I am looking forward to hearing more soon AND before our influx of new students in 2019!

    Julie Beth Miller, PT, DPT

     


  21. Anonymous
    Anonymous avatar
    Posted: 06 Dec

    Thanks to everyone for the thoughtful feedback and perspectives. We have compiled these comments and passed them along to individuals at APTA who will be meeting with CMS representatives during the week of December 10. We will look forward to the outcome of these discussions and will participate in dissemination of an update to the community once we have more clarification on the implications of the regulations on the role of students.

    Donna Applebaum, PT, DPT, MS; NCCE Chair

  22. Anonymous
    Anonymous avatar
    Posted: 12 Dec

    I'm sure when information is available it will be posted, but hoping someone on this thread may have an update from the meeting with CMS? Pending a change in direction from CMS, my organization has limited IPR student rotations to observation only.   We have several students slated for a rotation start date of January 1, 2019.  So far, the universities we are contracted with are waiting to hear on the results of this meeting prior to attempting to find new placements.

    Reuben Jessop, DPT, NCS

  23. Anonymous
    Anonymous avatar
    Posted: 12 Dec

    OT and SLP have spread the word today about this update:
    AOTA, ASHA and APTA held a meeting with the Centers for Medicare and Medicaid Services (CMS) on December 11, 2018 to discuss the issue of students in inpatient rehabilitation hospitals (IRFs) and acute  hospitals, which were raised on the IRF Payment and Coverage Policies National Provider Call on November 15, 2018. We wish to share the following points:

    The meeting with CMS staff was collegial.
    CMS confirmed that there has been no policy change this year on the use of students.
    CMS confirmed their support for clinical education for students.
    CMS agreed to provide additional clarification in writing to us in a very short timeline.

    See the previously issued Joint Statement from AOTA, APTA, ASHA on the Use of Students in Hospitals for background information. Watch the AOTA website for updates on CMS’s written clarification, which AOTA will share as soon as it is received. Please direct any questions to regulatory@aota.org.

    http://www.magnetmail.net/actions/email_web_version.cfm?ep=flbahtIHT9g6HWq4s8khYAmVSbmNsHont5kX8RsHDcUDrEfxowTKnA3qGZVJKdBEYneg7uMIQn_lFRCOiW6Ra7O3o04e-rwAHuNTaEXMV8DN9ytsNmPOt4aYXzsSOtB6

  24. Anonymous
    Anonymous avatar
    Posted: 5 days and 1 hour ago

    The APTA has also posted this update to their website:

    Senior staff from APTA, AOTA, and ASHA met with CMS officials on December 11, 2018. During this collegial meeting, CMS staff confirmed verbally that there has been no policy change in 2018 on the use of students. CMS also reaffirmed its support for clinical education. CMS concluded the meeting by agreeing to provide additional clarification in writing on this topic in the very near future. 
    Please watch this space for additional updates. http://www.apta.org/Payment/Medicare/Supervision/

    Donna Applebaum, PT, DPT, MS; NCCE Chair

     

     

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