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Establishing a Post Rehab Service in a Physical Therapy Setting
By Michael K. Jones, PhD, PT
Post rehab or aftercare programs are becoming a standard component of the rehabilitation process for patients with neurological, cardiovascular and musculoskeletal disorders. The changes in medical reimbursement over the past decade have made post rehab a part of the rehab spectrum. Many PT clinics and sports medicine centers are slow to embrace the post rehab concept. Obviously, issues such as “scope of practice” and “direct supervision” are major concerns for physical therapists and chiropractors when thinking of post rehab services. Post rehab services can be both profitable and improve positive rehabilitation outcomes. In this article, I will discuss the necessary steps to establish a safe, effective and profitable post rehab program that clearly is within legal and ethical boundaries.
The first step is to clearly establish the role and scope of practice of the post rehab program. The name of the program should clearly delineate the role of the program. “Northeastern Post Rehab and Aftercare Services” clearly establishes the role of the program. A name that leaves open the role of the program such as “Northeastern Rehab and Conditioning Services” leads one to possibly misinterpret the program as being a physical therapy facility.
The definition of post rehab services is as follows: “the development and implementation of fitness and conditioning services for clients with special population and post rehab disorders”. Post rehab does not purport to provide any aspect of medical treatment for a client’s condition. The post rehab program may provide the following services:
  1. Fitness Assessments
  2. Strength Training
  3. Flexibility Training
  4. Cardiovascular Training
  5. Functional Conditioning
  6. Aquatic Fitness Training
  7. Weight Reduction
  8. Spinal Stabilization Training
  9. Hypertension/Diabetes Training
These nine activities or services make up the post rehab “scope of practice”. Services beyond these activities may encroach into the realm of the licensed medical professional. I should also note here the absence of cardiac rehabilitation on this list. As cardiac rehab programs are disappearing, one might consider the establishment of a cardiac rehab component in the post rehab program. However, cardiac rehab – at a minimum - should be done in a setting with a licensed cardiac rehab nurse supervising the program. The facility should be equipped with an emergency crash cart, defibrillator, and a telemetry system to monitor the clients when exercising. If your facility does not have the personnel or equipment noted above, then stay away from cardiac rehab.
The post rehab program should be staffed with exercise physiologists, kinesiologists, personal trainers, and/or conditioning specialists. These staff members develop, supervise and modify the conditioning programs for clients while working within the post rehab protocols and guidelines established by the client’s physician and/or physical therapist. Each staff member must have specific training in post rehab, not simply training as a rehab technician. The experience gained in the rehab setting is vital, but the rehab technician does not have the skill to progress the post rehab client’s exercise program. The certified post rehab professional should have:
  1. Basic knowledge of anatomy, physiology, biomechanics and pathology of common conditions encountered in a rehab setting.
  2. At least one year experience working in a rehab setting. This may include a physical therapy clinic, a chiropractic office, a hospital or a nursing home setting.
  3. The ability to identify red flags which indicate the client is not ready to participate in a post rehab program; or the exercise intensity is too great or the client is in need of a referral back to his or her physician.
  4. Understand the contraindicated exercise for a medical condition.
  5. Understand the exercise precautions to be taken with medical conditions.
  6. The ability to assess the client’s progress in functional terms, report the progress to the referring medical professional and understand how to progress the client to reach his or her maximum functional potential.
As you can see, the skills required of the post rehab professional are beyond those of the rehab technician. Exercise physiologists, kinesiologists and personal trainers are ideally suited to work in a post rehab setting after the completion of a post rehab training and certification program. The post rehab professional is not trained to replace the physical therapist or chiropractor, but to work with the client to improve function by using exercise after he or she has received the maximum benefit from physical therapy or chiropractic care and is discharged.
A physician or physical therapist must refer all clients entering the post rehab program. All clients must meet a post rehab criteria established for each medical condition. The criteria are a series of “standards” the client must meet to insure he or she is safe to begin the exercise program. These criteria include post operative timetables, guidelines on the severity of swelling, pain, joint range of motion and other parameters which determine if the client is “medically stable” to begin an exercise program. Just because a physician has referred a client to post rehab does not mean the client is ready for the program. Often times a post rehab program may become a dumping ground for those clients that do not progress in a traditional rehab setting or their insurance coverage is exhausted. The post rehab criteria will prevent the “inappropriate client” from entering the program, thereby eliminating the possibility of exacerbating their medical condition.
The complete separation of physical therapy/chiropractic services from the post rehab program is a must when establishing your aftercare program within a physical therapy or chiropractic setting. This will avoid confusion on the part of the patient/client as well as adhering to Medicare and other insurance guidelines. I realize the construction of a separate facility is cost prohibitive but the establishment of a physical boundary (i.e. wall, door or room divider) and separation of paperwork is a must to avoid confusion in the minds of the post rehab clients. In addition to these steps, I recommend the establishment of a separate business entity with a distinct tax ID number, corporate structure, business name and letterhead. When the patient is discharged from physical therapy or chiropractic care and referred to post rehab, a new client chart should be established for the post rehab program and the client should complete a separate demographic information form as well as all the necessary forms and documentation a new client would complete. The chart should be stored in a secure location separate from the physical therapy clinic’s files. The client should read and sign a disclosure form outlining the scope, goals, benefits of the post rehab program, as well as a description of the role of the post rehab professional. During the first session the staff must again explain the nature of the program and their role and function within the program. In summary, a clear explanation must be made to the client that the program is not “physical therapy” but post rehab in nature.
Now that brings us to the next question; whom should be referred to the post rehab program? The typical post rehab client has residual deficits in joint stability, flexibility, coordination, endurance, prorioception, muscle fiber recruitment and strength, but should be “medically stable” to begin an exercise program. The client has sustained major trauma (ligament rupture, disc herniation, fracture and/or surgery) and the condition is chronic in nature (greater than 30 days and not acute). The client has received the maximum benefit from physical therapy or chiropractic care, and it has been established the client would benefit from a “structured supervised conditioning program”. The client is usually a workers’ compensation or motor vehicle accident claimant. The client is referred by a physician for a “functional conditioning” program. The physician, therapist and patient/client are clear on the scope and nature of the post rehab program, as well as the skills, knowledge, and capabilities of the post rehab professional supervising the program.
The post rehab program should begin with a musculoskeletal screening to assure the client is appropriate for the program. The musculoskeletal screening is a simple process to determine if the client is appropriate for the program and has no red flags. Just a note here, the patient has now become a post rehab client. No longer is the term “patient” used. Once the musculoskeletal screening is completed, a full post rehab assessment may be done at the next session. The full assessment looks at the involved area and assesses function, as well as traditional components such as flexibility and strength.
Based on the findings of the assessment, the post rehab program is established using the standard post rehab protocols for the client’s condition. Modifications are made to the protocol based on the client’s needs and with input from the client’s physician and therapist. The final program is forwarded to the client’s physician for review and approval. Program goals, duration and frequency must be included. Use as many exercise diagrams and pictures as possible when forwarding the post rehab program to the physician for approval. The physician may not be familiar with exercise jargon and therefore not comfortable giving his or her approval. Remember to make it easy for the physician to understand the post rehab program. A picture is worth a thousand phone calls and dozens of post rehab program approvals.
Once the post rehab program is established, the insurance carrier may be contacted to obtain pre-authorization for insurance reimbursement. Let’s make it clear. Medicare, Medicaid and many HMO’s will not pay for post rehab services. Currently there is no list of insurance carriers that reimburse for post rehab services. Claims covered by workers’ compensation and motor vehicle insurance carriers are most likely to reimburse for post rehab services. When making the initial contact with the insurance carrier, the post rehab professional or facility should follow the guidelines below to improve the chances of pre-authorization and reimbursement:
  1. Gather the following information from the client: full name, mailing address, social security number, date of birth, and insurance claim number. Also obtain the insurance carrier’s phone number and the name of the claims adjuster from the client.
  2. Make sure you have the post rehab program in hand with the physician’s signature of approval.
  3. Call the claims adjuster before 9:00 am.
  4. Once you contact the client’s claims adjuster provide the client’s name, social security number, date of injury, diagnosis and claim number.
  5. Explain to the claims adjuster your role as a post rehab professional. Indicate you have a signed referral from the physician, as well as an approved post rehab program from the physician. Describe the post rehab conditioning program, as well as the benefits and the program goals. Establishing a script to read from may be a great help in clearly describing the program.
  6. Ask for pre-authorization for your program for the specified number of weeks or sessions. Provide the cost of the program and reiterate the goals of the program. Make sure the goals are functional in nature.
  7. You may receive pre-authorization during the conversation or you may receive it after the claim is reviewed. The key is providing as much information as possible to the claims adjuster. This gives the claims adjuster a clear picture of your program.
  8. Make sure to follow up within 2-3 days if pre-authorization is not obtained during the initial conversation.
  9. Once pre-authorization is obtained, the billing process begins. Send your invoice and post rehab session logs for each session to the claims adjuster every two weeks. Follow up on the invoice within 5-7 days to insure its receipt and no additional documents are needed. Also, if a re-assessment is completed during the 2-week period it should also be forwarded to the claims adjuster.
  10. Post rehab services are billed 25% above the regional rate for personal training services. The reimbursement may be a percentage of the billed rate and usually takes 6-8 weeks to receive payment. In some instances, the client may be reimbursed for the services, so take care to check with the insurance carrier periodically. Also, the insurance carrier may use one of three options we commonly see with post rehab imbursement. The three options are:
    1. Medical Membership – this is a monthly fee the carrier pays for the client to utilize the facility over a 30-day period. The facility must assess client at the beginning and the end of the 30-day period. The assessment should be sent to the insurance carrier along with the monthly invoice. Documentation of progress is important for the insurance carrier to determine if the program is beneficial. The monthly fee is usually $50-$100 per month.
    2. Post rehab sessions – the insurance carrier may opt to pay for individual post rehab sessions completed one on one with a post rehab professional. Each of these sessions should be documented and the session logs forwarded to the carrier with the invoice.
    3. Client reimbursement – with this scenario the client pays for the post rehab session at the time of service and the insurance carrier reimburses the client. The post rehab facility may provide the client with the session logs and documentation he or she needs to send to the insurance carrier or the facility may submit the documentation on behalf of the client.
One important point to understand is each post rehab insurance claim is judged individually. Again, there is no insurance carrier at this point that pays for post rehab services as company policy or based on the post rehab professional holding a specific post rehab certification. Each case is reviewed and reimbursement based on a number of factors. The key is clearly explaining your program to the claims adjuster and its benefits for the client. Remember, post rehab is not a substitute for physical therapy or chiropractic services. As you can see, there are a number of steps required to establish your post rehab program appropriately. When you think of the number of patients discharged daily from physical therapy or chiropractic care, the opportunities and benefits are tremendous. Post rehab is here to stay. The question is will you take the steps to establish your program and take advantage of this huge opportunity.
Mark your calendar for January 19, 2006. We are hosting our first teleseminar entitled “Establishing a Profitable and Effective Post Rehab Program.” This 90-minute teleseminar will walk you step by step through the establishment of a safe, effective and profitable post rehab program in a physical therapy, health club or personal training studio. This program is for physical therapists, personal trainers and health club managers/owners. Click here for more information.
 
 
Total Hip Replacement Post Rehab Guidelines
By Michael K. Jones, PhD, PT
The total hip replacement is fast becoming the most common orthopedic surgical procedure performed in North America. Hundreds of thousands hip replacements are performed every year to restore function following hip fracture, arthritis or other hip disorders. Total hip replacements are usually performed on clients 55 years or older. With the improvements in prosthetic design, the durability of the total hip implants is incredible. The improved durability means the total hip replacement client is able to function at a much higher level, as well as seeking a more active lifestyle. This lifestyle requires the client complete physical therapy, as well as an ongoing post rehab program. This article will summarize the exercise guidelines and precautions for the total hip replacement client.
The total hip replacement prosthesis is usually made of a titanium alloy with a life expectancy of 10-12 years. The total hip replacement is seldom performed on younger clients except when there is a cancerous lesion or a major trauma. The trauma results in a fracture of the neck of the femur. This fracture cuts off the blood flow to the femur head hence causing the development of avascular necrosis. Avascular necrosis is the death of tissue due to lack of blood supply. In seniors, this is a serious condition and may lead to the more serious condition of osteomyelitis, a systemic bone infection that may become fatal. To avoid further complications, the fractured hip is replaced as quickly as possible.
The total hip replacement surgical procedure requires the resection of the superficial and deep hip muscles, the removal of the femoral head, the boring out of the acetabulum and the removal of a portion of the femoral neck. The new prosthesis is implanted into the femoral shaft using cement or a method whereby the bone surrounding the prosthesis grows into pores crafted on to the surface of the prosthesis. The cemented procedure allows the patient to start moving and ambulating within 24-28 hours of surgery. The porous implant is most stable several weeks after surgery. The porous implant is far more stable over the long run.
The key concerns with the total hip replacement develop after surgery. The surgical procedure requires the removal of the ligamentous structures surrounding the hip joint and supporting/stabilizing the joint itself. Loss of these ligaments makes the hip unstable in certain positions and certain movements. Hip flexion beyond 90 degrees, hip adduction across the midline of the body and hip internal rotation may cause dislocation of the surgical repaired hip. These three movements together are found in activities such as sleeping on one side at night with the hips and knees flexed, getting in and out of a low chair, and getting on and off the toilet. These three activities should be permanently avoided after hip replacement. The THR client is usually discharged from the hospital with assistive devices and aids to avoiding these positions and activities they may cause hip dislocation.
The functional outcomes following total hip replacement are usually very good. Most clients are referred to physical therapy following the surgery and benefit from a post rehab program to improve balance, strength, flexibility, endurance, proprioception, joint stability and more. Once out of physical therapy, the post rehab emphasis is on improvement of overall leg strength. Overall leg strength is the ability to control the weight of the body for stair climbing, stepping off curbs, and getting out of chairs. High impact activities such as jogging, tennis, etc. must be performed in moderation to avoid excessive wear and tear on the implant. High impact activities may reduce the life expectancy of the implant. High impact activities should only be added to the post rehab program after obtaining clearance from the client’s orthopedic surgeon.
Our total hip replacement post rehab protocol is available by clicking here. The post rehab protocol will note program goals, precautions, anatomy/pathology concepts as well as a flowchart indicating the progression of exercise. As mentioned earlier, the key is the improvement of overall leg strength. Activities such as hip abduction, hip extension, hip bridging, leg press, leg extension, standing terminal knee extension and hip adduction (not crossing midline) are exercises you will note in the protocol.
Stretching the hip following total hip replacement is contraindicated. Due to the surgical procedure and loss of ligaments, the hip is somewhat unstable after surgery. Clients with the sensation of tightness or myofascial pain symptoms should be referred to a massage therapist for deep tissue massage and/or myofascial release techniques. The use of stretching techniques may actually cause the dislocation of the hip.
The Tinetti Gait and Balance Assessment must be used to assess the client’s ambulatory capacity. The assessment should be completed during the first or second session. The Hip Harris Scale may also be completed but the Tinetti Scale is vital to establishing a functional baseline for balance and walking. The Tinetti should be performed every 2-4 weeks to judge the client’s progress with the post rehab program. A copy of the Tinetti Gait and Balance Scale is available by clicking here.
Every post rehab professional should become familiar with the basics of the total hip replacement post rehab protocol. This is the most often used protocol in our PREPS set. The number of total hip replacements will continue to grow as the baby boomers age but continue with their zest for life and activity. Please take a moment to print the THR protocol as well as the Tinetti Scale. I guarantee, one day in the near future you will encounter a total hip replacement client.
 
 
Quadriceps
 Leg Press
Leg Extension
Standing Terminal Knee Extension
Gluteals Leg Press
Hip Abduction
Hip Extension
Hip Adduction
(Do not cross midline)
 
Mark your calendars for January 19, 2006. We are hosting our first teleseminar entitled “Establishing a Profitable and Effective Post Rehab Program.” This 90-minute teleseminar will walk you step by step through the establishment of a safe, effective and profitable post rehab program in a physical therapy, health club or personal training studio. This program is for physical therapists, personal trainers and health club managers/owners. Click here for more information.
 
 
Ask Dr. Mike

Question: Are more physical therapy clinics developing post rehab programs for the patients after discharge?
Dr. Mike,

I am a physical therapist in New Jersey and I want to work with a few post rehab clients in the local health club. Is this a growing trend? Are more physical therapy clinics developing post rehab programs for the patients after discharge?

Gordon (physical therapist)
New Jersey
Gordon,
That is a great question as this month’s issue is dedicated to helping physical therapists and chiropractors develop post rehab programs in rehab settings. We all hear of the major changes taking place in the physical therapy arena. We hear stories of physical therapists being laid off or taking major salary cuts. There is even some research that indicates there may be a surplus of physical therapists within this decade. Well, all of these reports are true.
We are seeing more physical therapists leaving the rapid pace of the physical therapy clinic seeking the calm one-on-one setting of health clubs and fitness studios. Many therapists have developed niches in pre and post natal training, spinal stabilization and/or Pilates, along with many other areas.
I receive many calls from physical therapists fed up with the paperwork, long hours and unmotivated patients. Many therapists contact me asking what personal training is all about. Many are fitness enthusiasts and have advanced degrees in exercise physiology in addition to their physical therapy degree. They are looking for a slower pace, less stress and motivated clients. Personal training offers that and more!!!
Many of these “potential” trainers wonder, “Should I make the transition?”. Many have made the transition and are doing quite well. Contrary to what some personal trainers may feel, physical therapists have a vast knowledge of muscle physiology and exercise program design. After gaining experience developing fitness programs, taking additional courses in marketing and nutrition, you have a highly qualified, well-educated and credentialed personal trainer with direct connections to the medical community.
Five years ago, I predicted the major competition for personal trainers would come from physical therapists transitioning from traditional medical settings to the health club. Well its happening and will continue to increase. The health care systems in North America, as well as the huge reductions in insurance reimbursement are pushing this wave. The health club setting, with it multitude of clients is heaven compared to the physical therapy clinic that averages 15 to 20 patients per day.
I urge personal trainers to obtain more education, establish solid relationships with insurance carriers, physicians and other medical professionals in your community now!! One day you may look up and see your referral source training a client next to you in the fitness club.
Best in Fitness,
Michael K. Jones, PhD, PT
President
 
 

For more information visit:
www.postrehab.com/postrehabworks.htm
 
 
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Ideal Candidate Qualifications:
- Degree in Exercise related field, or science related education (Biology, Physics, etc)
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have a medically oriented background
- Excellent sales, communication and customer service skills
 
Email resume to: info@njpostrehab.com. References will be sent upon request.
 



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Mark your calendars for January 19, 2006. We are hosting our first teleseminar entitled “Establishing a Profitable and Effective Post Rehab Program.” This 90-minute teleseminar will walk you step by step through the establishment of a safe, effective and profitable post rehab program in a physical therapy, health club or personal training studio. This program is for physical therapists, personal trainers and health club managers/owners. Click here for more information.
 
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