Joint guidelines for therapy co-treatment under Medicare

The American Occupational Therapy Association (AOTA)

The American Physical Therapy Association (APTA)

The American Speech-Language-Hearing Association (ASHA)

Overview

Co-treatment may be appropriate when practitioners from different professional disciplines can effectively address their treatment goals while the patient is engaged in a single therapy session. For example, a patient may address cognitive goals for sequencing as part of a speech-language pathology (SLP) treatment session while the physical therapist (PT) is training the patient to use a wheelchair. Or a patient may address ADL goals for increasing independence as part of an occupational therapy (OT) treatment session while the PT addresses balance retraining with the patient to increase independence with mobility.

• Co-treatment is appropriate when coordination between the two disciplines will benefit the patient, not simply for scheduling convenience.
• Documentation should clearly indicate the rationale for co-treatment and state the goals that will be addressed through this method of intervention.
• Co-treatment sessions should be documented as such by each practitioner, stating which goals were addressed and the progress made.
• Co-treatment should be limited to two disciplines providing interventions during one treatment session.

Clinical examples

1. An 86-year-old male with history of high blood pressure and cholesterol, and who has a pacemaker, fell down the stairs at his home and sustained a subdural hematoma. The fall resulted in moderate right side hemiparesis with difficulty swallowing and expressive aphasia. He was transferred to a skilled nursing facility with goals to include balance and motor retraining exercises, strengthening exercises, transfer training and wheelchair management skills, maximizing independence in ADLs, and improved functional comprehension and swallowing function with vital signs monitored during activity. The PT and SLP perform co-treatments that include the following:

The SLP provides strategies to help the patient with following multi-step directions to perform exercises, while the PT works with the patient on motor sequencing and motor activity. The PT adapts seating for the patient, taking into consideration best positioning to optimize facilitation of swallowing interventions by the SLP.

2. A 66-year-old female status post ischemic stroke with resulting severe hemiparesis on the left side was admitted to an inpatient rehabilitation facility 3 days earlier from the acute care hospital. She had hypertension and diabetes, and was obese. She was previously independent in all activities and was working part time outside of the home. She lived alone in a single-level house. The patient is being seen by PT and OT. Her many rehabilitation goals include: increase sitting balance to perform self-care, independence in transfers from bed to wheelchair to toilet, and ambulation with assistive devices. The PT and OT perform co-treatments that include the following:

The PT facilitates weight shift and balance training in a sitting position while the OT works on upper extremity dressing strategies and techniques, which require trunk stability. The PT works on bed mobility from supine to sitting, and on transfer from the bed to the wheelchair and to the toilet. The OT works on toilet training using adaptive devices and compensatory techniques as well as on dressing and hygiene management skills, while the PT facilitates lower extremity weight shift and standing from the toilet. The PT facilitates balance and weight shifting while standing as the OT works on bilateral fine and gross motor IADL tasks as components of simple meal preparation in the kitchen.

3. A 72-year-old male sustained a traumatic brain injury when he skidded on an icy road and collided with a tree while driving home from the grocery store. Prior to the accident, the patient was retired and living in a retirement community with his spouse of 50 years, both functioning independently with all ADLS and IADLs intact. The patient and his wife expressed a desire for him to return home with environmental adaptations and support services as needed. The patient had a history of mild COPD and a prior right knee replacement. He also had some residual right-sided paresis and gait disturbance, and some difficulty with executive function, including self-organization skills and mild memory impairment. He gets short of breath with moderate exertion. The OT and PT provide co-treatment in a ADL kitchen that include the following:

The PT provides verbal and tactile cuing with gait training to facilitate safe functional mobility in and around kitchen, while the OT works on cognitive and executive function skills needed to gather items for a food preparation task, such as attention to task, remembering items needed, locating items in the cupboard and refrigerator, and the sequencing steps involved in preparing the snack or meal.