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It's a Team Effort

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Greg Rohrbach

on 17 October 2013

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Transcript of It's a Team Effort

It's a Team Effort
hmm, aah
Watch your step!
Who's driving
this walker?

Skilled Nursing Facility
For most skilled facilities, PTs are a part of companies that are contracted by the facilities. They get payment directly from the facility.
The Future
Erwin says that the PT board would like to see the direction of the PTs travel to a more direct access approach, geared toward independence from referrals from MDs. This would allow them to evaluate patients, create care plans and implement them without having to wait for an MD approval.
Soliciting Services
In California PT’s are required to have a diagnosis from a physician. Although a physical therapist may perform an evaluation without a diagnosis, one is required prior to the physical therapist providing any physical therapy treatment. Hence, the PTBC (Physical Therapy Board of California) is pushing for direct access, goal is by 2020.

When coordinating care with
RN’s, morning ABGs are
performed with RT’s 4am vent
checks, so RN’s know not to
suction or turn intubated
pts around this time, unless
necessary. For other routine care
like ETT tape changes, or major
dressing changes that require RT’s, the two usually make a schedule at the beginning of the shift or 1-2 hrs prior to the procedure.

PT, OT, RD & the RT
The RT’s perform resting metabolic studies to determine Co2 consumption. The dietitians determine the caloric requirements for the pt from these studies.
Usually, pts are seen by PT and OT during the day, but PT and OT will let the RT’s know early in the shift when they plan to stop by so the three can work together. It could be something as simple as helping them sit the pt on the edge of the bed, or help the pt get up and walk around the unit.
Challenges in clinical practice & the CNL
As RT’s, they deal with physicians who order unnecessary therapies, or worse, harmful to the pt. How they go about it, depends on how it affects the pt.
The CNL can address these challenges by encouraging good communication between all staff, and supporting the therapists when healthcare providers are unwilling to listen to reason.
Good communication will not only improve the work environment between the multidisciplinary team, but it will also improve pt outcomes and assure quality and safety
PT Scope of Practice

A Combination:
-exercise programs (level depends on ptnt tolerance)
-electrical stimulation
-training in ADLs
-patient education.

PT Scope of practice also encompasses:

Difference between Acute Care & Skilled Setting:

Acute Care: "our goal is to bring patients to a certain level of functionality"
Skilled: "where the goal is to DC patients to home, we modify our therapy to really improve functionality and mobility at home"

Erwin (PT): (skilled & acute care)
Focus is on physical impairments/disabilities
Promote mobility, functionality, and quality of life.
-> Assess prospective patients with functional issues
-> Establish plans of care and goals
-> Formulate a treatment plan & forward to MD for final orders
-> Implement treatment, evaluate intermittently
->may change tx plans on a daily basis
License, Certification, Education Degree
Post-graduate degree required now: Master's & DPT (doctorate of physical therapy); bachelor's of own choosing
as of 2009, the master's degree has slowly started to be phased out; DPT now the preference
Erwin, PT: bachelor's. Practicing for 10 years total (8 in skilled and 2 in acute care) thus "grandfathered in"
->does plan on going back to school
2 key differences of the role between the degrees:
Bachelor’s: 4 years: may make suggestions for treatments to MD. Can assess, make suggestions for treatments, implement with consent from MD, and evaluate. Education is mostly based on theories.
Doctoral: the preferred/required for a lot of acute care settings. EBP role, research, can make direct treatment preferences known to MDs.
Continuing Competency: As of November 6, 2009, new regulations now require all PTs who are renewing their licenses to complete required number of hours of continuing competency education, with focuses on basic life support, ethics and laws, and specific coursework.
Challenges and the CNL role

There remains a big problem with communication, especially between the administrators and the therapy department. They have also been on and off issues when it comes to agreeing on a specific plan of care. Communication has improved vastly since the department is now brought into interdisciplinary team meetings, but there are still gaps here and there that lead to breaks in continuity of care. Erwin suggests two ways in which the CNL role could vastly improve patient and staff outcomes, especially in congruence with the PT role:

a.) Help identify gaps in communication and bridge them, especially between therapy department and the rest of the staff.

b.) Assess training readiness in CNAs who do/will help with patient transfers, gait, and mobility. Erwin has expressed that a lot of CNAs/RNAs are not aware of their responsibility in helping patients continue their therapy even outside of their schedule therapy hours.

RT Practice
RT’s are responsible for oxygenation & ventilation of pts.
When they suspect the pt is failing at either, they perform ABG’s to verify it.
If the patient is failing to sufficiently oxygenate or ventilate themselves, RT’s use equipment to help reverse it. Equipment range from nasal cannulas to mechanical ventilators.

License and Certifications:
Educational requirements vary by state and institution. In CA, most colleges offer 2 year degrees (there are a few with 4 year degrees). The American Association for Respiratory Care (AARC) and the National Board for Respiratory Care (NBRC) are both trying to eliminate the 2 year programs, and make the degrees a graduate and post graduate degree.
To practice as an RT in CA, a Certified Respiratory Therapist (CRT) and a California Respiratory Therapist license is required. Some facilities require a Registered Respiratory Therapist (RRT) license/credential to work in the ICU.
In addition, there are also specialty credentials for those who work in the NICU, perform Pulmonary Function Tests, etc.
RD Scope of Practice (1983-)
Comprehensive nutrition assessments
Calculates nutritional needs, diet restrictions and food and drug interactions
2002-AB1444 passed
Medical Nutrition Therapy (MNT) - reimbursement for dietary counseling, assessment and treatment
order laboratory tests related to MNT
Take verbal or electronically transmitted orders
Exception: dangerous drugs, TPN or IV vitamins or minerals.

Educational Requirements
Bachelors degree or above (50% have advanced degree)
Post-baccalaureate 1 yr internship (900 hours)
National exam
Certified Nutrition Specialist (CNS)
Advanced degree (master's level or above)
1000 supervised hours
Nutritionist and RD are often incorrectly used interchangeably
RD - institutional settings (hospitals, schools)
Nutritionists - private nutritional counseling service
or as a team member of an integrated medical clinic
Speech Language Pathologist
The speech-language pathologist is a professional who engages in clinical services, prevention, advocacy, education, administration, and research in the areas of communication and swallowing across the life span from infancy through geriatrics. Given the diversity of the client population, these activities are conducted in a manner that takes into consideration the impact of culture and linguistic exposure/acquisition and uses the best available evidence for practice to ensure optimal outcomes for persons with communication and/or swallowing disorders or differences. –American Speech-Language-Hearing Association (ASHA)

Speech-language pathologists must meet the following requirements
Hold a master's, doctoral, or other recognized postbaccalaureate degree.
Complete a supervised postgraduate professional experience for at least 1 year
Pass a national examination as described in the ASHA certification standards and receive the ASHA Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP).
Demonstration of continued professional development is mandated for the maintenance of the CCC-SLP.
Where applicable, speech- language pathologists hold other required credentials (e.g., state licensure, teaching certification).
VA Cardiac Rehabilitation Program
Stephanie Hasara 0.2 FTE RD
0.8 FTE outpatient consults
Video telehealth (CBOC's)and telephone encounters
No referrals needed for CR patients
Add as additional signer on EMR note
1-2 patient encounters during 12 week program (more if needed)
Focus on heart healthy fats, portion control and diabetes management
Food diary evaluation and recommendations
Meal planning
As care provider
Patients are overwhelmed with conflicting research findings/media
Media hype around single ingredient or food
Plethora of misinformation
Corporations funding research at University level
Scientific VS Marketing
QI projects-coordinate with RD's, i.e CHF education to reduce readmission rates
Care coordinator-include RD in rounding/care plan development
Scope of Practice
Speech-language pathologists address typical and atypical communication and swallowing difficulties in the following areas
Speech (sound production, articulation, apraxia of speech, dysarthria, ataxia, dyskinesia)
Resonance (hyper/hyponasality, mixed resonance)
Voice (phonation quality, pitch, loudness, respiration)
Fluency (stuttering, cluttering)
Language (comprehension, expression)
Cognition (attention, memory, sequencing, problem solving, executive functioning)
Feeding and swallowing (oral, pharyngeal, laryngeal, esophageal, orofacial myology (including tongue thrust) oral-motor functions)

Kris Meilahn, CCC-SLP
Owner, Children’s Speech and Language Services of Woodinville, WA
Master of Science(M.S) in Speech Language Pathology from University of Oregon
30 years of experience as an SLP

Scope of Practice
Potential etiologies of communication and swallowing disorders include
Neonatal problems (e.g., prematurity, low birth weight, substance exposure)
Developmental disabilities (e.g., specific language impairment, autism spectrum disorder, dyslexia, learning disabilities, attention deficit disorder)
Auditory problems (e.g., hearing loss or deafness)
Oral anomalies (e.g., cleft lip/palate, dental malocclusion, macroglossia, oral-motor dysfunction)
Respiratory compromise (e.g., bronchopulmonary dysplasia, chronic obstructive pulmonary disease);
Laryngeal anomalies (e.g., vocal fold pathology, tracheal stenosis, tracheostomy);
Neurological disease/dysfunction (e.g., traumatic brain injury, cerebral palsy, cerebral vascular accident, dementia, Parkinson's disease, amyotrophic lateral sclerosis)
Psychiatric disorder (e.g., psychosis, schizophrenia)
Genetic disorders (e.g., Down syndrome, fragile X syndrome)

As primary care providers for communication and swallowing disorders, speech- language pathologists are autonomous professionals; that is, their services are not prescribed or supervised by another professional.
Greatest benefits to clients include speech-language pathologist collaborations with other professionals
Healthcare and Educational system fragmentation hinder proper delivery of screening and preventative services; decreased funding for SLP services in schools
Insurance and reimbursement is difficult for independent practitioners
Cultural stigma towards people with communication and speech difficulties

CNL and SLP Collaboration
As an educator and information manager, the CNL can assist client(individuals and families) become familiar with SLP services and acquire those services as needed—increasing visibility and access of SLP services
As a member and leader of healthcare teams, the CNL works with teams that deliver treatment and services in an evolving health care system. The CNL can help facilitate collaboration and consultation with SLPs as necessary, and design, coordinate, and evaluate client care outcomes of SLP services—Decreasing fragmentation of care
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