Far too often a nurse reviewer will decide simply from looking at the duration of a clinical or rehabilitative service that it should be discontinued.  What science these decisions are based upon is not always shared when insurance companies or government departments make them.  However, there are several important factors which are often ignored.  Further, in making these hands-off, arbitrary, often clinically negligent decisions, the patient faces potential harm and liability is created for all parties involved, including the nurse making the decision without intimate familiarity with the injured party.

When the injured party, such as in the Michigan PIP system, lives in an adult foster care home or a home for the aged, the rationale might be that direct care staff can keep the resident physically engaged, justifying elimination of rehabilitative therapies.  Physicians responding to such arbitrary reasoning often borrow from language such as the following:

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It would be medically inappropriate to discontinue occupational and physical therapy at this time.  While it is true a resident in a licensed adult foster care home can be engaged by direct care staff in some limited physical activity, this is not the clinical equivalency of the work performed by a licensed physical or occupational therapist nor their certified assistants.

In the Michigan Adult Foster Care system direct care staff are required to be trained in the following:

R 400.14204 Direct care staff; qualifications and training. – Courtesy of www.michigan.gov/orr

Rule 204. (1) Direct care staff shall not be less than 18 years of age and shall be able to complete required reports and follow written and oral instructions that are related to the care and supervision of residents.

(2) Direct care staff shall possess all of the following qualifications:

(a) Be suitable to meet the physical, emotional, intellectual, and social needs of each resident.

(b) Be capable of appropriately handling emergency situations.

(3) A licensee or administrator shall provide in-service training or make training available through other sources to direct care staff. Direct care staff shall be competent before performing assigned tasks, which shall include being competent in all of the following areas:

(a) Reporting requirements.

(b) First aid.

(c) Cardiopulmonary resuscitation.

(d) Personal care, supervision, and protection.

(e) Resident rights.

(f) Safety and fire prevention.

(g) Prevention and containment of communicable diseases.

This training does not make them rehabilitative or medical professionals. 

And in specialized homes, focused specifically on those with developmental disability and mental illness, the training requirements are:

R 330.1806 Staffing levels and qualifications. Rule 1806. (1) Staffing levels shall be sufficient to implement the individual plans of service and plans of service shall be implemented for individuals residing in the facility. (2) All staff who work independently and staff who function as lead workers with clients shall have successfully completed a course of training which imparts basic concepts required in providing specialized dependent care and which measures staff comprehension and competencies to deliver each client’s individual plan of service as written. Basic training shall address all the following areas: (a) An introduction to community residential services and the role of direct care staff. (b) An introduction to the special needs of clients who have developmental disabilities or have been diagnosed as having a mental illness. Training shall be specific to the needs of clients to be served by the home. (c) Basic interventions for maintaining and caring for a client’s health, for example, personal hygiene, infection control, food preparation, nutrition and special diets, and recognizing signs of illness. (d) Basic first aid and cardiopulmonary resuscitation. (e) Proper precautions and procedures for administering prescriptive and nonprescriptive medications. (f) Preventing, preparing for, and responding to, environmental emergencies, for example, power failures, fires, and tornados. (g) Protecting and respecting the rights of clients, including providing client orientation with respect to the written policies and procedures of the licensed facility. (h) Non-aversive techniques for the prevention and treatment of challenging behavior of clients.

A physical therapist on the other hand is trained to use specific modalities to assist a patient to:

• Eliminate or Reduce Pain.
• Avoid Surgery.
• Develop Mobility.
• Recover from a Stroke.
• Recuperate From or Stop a Sports or other catastrophic Injury.
• Improve Balance and Prevent Falls.
• Manage Diabetes and Vascular Conditions.
• Manage Age-Related Issues.

This same therapist, knowing the patient’s history and possessing a familiarity with their ability and inability to recall certain things they have been taught, crafts a long-term plan to promote:

1. Advanced chronic pain management
2. Agility
3. Improved Circulation
4. Balance
5. Overall coordination

The usage of professionals in the delivery of rehabilitative services must consider a frequency schedule based upon the patient’s ability to retain what they are being taught and their ability to use that knowledge.  Far too often, in cases of traumatic brain injury the patient cannot independently make usage of what is being imparted.  Therefore, even on a reduced scheduled, the work of a licensed therapist becomes justified long-term.

This is of special significance for those who may be fall risks or who are using therapy to manage pulmonary and circulatory issues which are potentially life-threatening.  Nurse reviewers making these decisions are now finding themselves forced out of their invisibility via depositions and even named as defendants in benefit restoration litigation.

How much more appropriate would be a meeting of the minds in conferences on clinical competence that results in what is best for everyone involved.  Specific goals and evaluation dates can be set with the result being real care along the continuum.  In the absence of this dialogue, it is just a chase of arbitrary numbers.

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