Important note: The OSHA Emergency Temporary Standard (ETS) referenced below MAY or MAY NOT apply to non-hospital healthcare settings. Please review this flow chart to determine whether or not the ETS applies to your setting.
If the ETS does not apply all should keep current MDHHS recommendations in consideration.
OSHA Emergency Temporary Rule: June 22, 2021: Masks and other precautions are still necessary in healthcare settings. August update continues to recommend special consideration for certain health care settings.
Under the latest version of the MIOSHA Emergency Rules, the state’s Workplace Safety Rules are in line with the OSHA Standards. Specifically, MIOSHA’s Emergency Rules are adopted from Subpart U in the OSHA Standards. Subpart U is the COVID-19 Emergency Temporary Standard and provides standards that healthcare settings must follow. Under the latest rules, only healthcare settings have certain protocols and standards to follow. All other sectors and workplaces are encouraged to follow CDC and OSHA guidelines. The updated rules are effective today and are set to expire on December 22, 2021.
View the OHSA requirements here: https://www.osha.gov/coronavirus/ets APTA additional guidance: https://www.apta.org/news/2021/06/14/osha-covid-rules
MDHHS updated guidance effective June 22 which states: Healthcare Facilities, such as hospitals, ambulatory care settings and surgical centers - As of now CDC healthcare guidance remains unchanged. Facilities should continue to follow CDC guidance. https://www.michigan.gov/documents/coronavirus/MDHHS_Face_Mask_Recommendations_5.20.21_725941_7.pdf
CDC Guidance from February 2021 remains in effect for health care settings: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html
Implement Telehealth and Nurse-Directed Triage Protocols
Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19
Although screening for symptoms will not identify asymptomatic or pre-symptomatic individuals with SARS-CoV-2 infection, symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented.
Re-evaluate admitted patients for signs and symptoms of COVID-19
Screening for fever and symptoms should also be incorporated into daily assessments of all admitted patients. All fevers and symptoms consistent with COVID-19 among admitted patients should be properly managed and evaluated (e.g., place any patient with unexplained fever or symptoms of COVID-19 on appropriate Transmission-Based Precautions and evaluate).
Source control refers to use of well-fitting cloth masks, facemasks, or respirators to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. In addition to providing source control, these devices also offer varying levels of protection for the wearer against exposure to infectious droplets and particles produced by infected people. Ensuring a proper fit is important to optimize both the source control and protection offered. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19.
Encourage Physical Distancing
Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission.
Examples of how physical distancing can be implemented for patients include:
For HCP, the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions. Transmission can also occur through unprotected exposures to asymptomatic or pre-symptomatic co-workers in breakrooms or co-workers or visitors in other common areas. Examples of how physical distancing can be implemented for HCP include:
Transmission from asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection can occur in healthcare settings, particularly in areas with moderate to substantial community transmission.
The fit of the medical device used to cover the wearer’s mouth and nose is a critical factor in the level of source control (preventing exposure of others) and level of the wearer’s exposure to infectious particles. Respirators offer the highest level of both source control and protection against inhalation of infectious particles in the air. Facemasks that conform to the wearer’s face so that more air moves through the material of the facemask rather than through gaps at the edges are more effective for source control than facemasks with gaps and can also reduce the wearer’s exposure to particles in the air. Improving how a facemask fits can increase the facemask’s effectiveness for decreasing particles emitted from the wearer and to which the wearer is exposed.
PPE recommended for the care of patients with suspected or confirmed SARS-CoV-2 infection is described in Section 2.
HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history):
HCP working in areas with minimal to no community transmission, should continue to adhere to Standard and Transmission-Based Precautions based on anticipated exposures and suspected or confirmed diagnoses. This might include use of eye protection, an N95 or equivalent or higher-level respirator, as well as other personal protective equipment (PPE). In addition, universal use of a well-fitting facemask for source control is recommended for HCP if not otherwise wearing a respirator.
Consider Performing Targeted SARS-CoV-2 Testing of Patients Without Signs or Symptoms of COVID-19
In addition to the use of universal PPE and source control in healthcare settings, targeted SARS-CoV-2 testing of patients without signs or symptoms of COVID-19 might be used to identify those with asymptomatic or pre-symptomatic SARS-CoV-2 infection and further reduce risk for exposures in some healthcare settings. Depending on guidance from local and state health departments, testing availability, and how rapidly results are available, facilities can consider implementing pre-admission or pre-procedure screening testing with authorized nucleic acid or antigen detection assays for SARS-CoV-2.
Testing results might inform decisions about rescheduling elective procedures or about the need for additional Transmission-Based Precautions when caring for the patient. Limitations of using this testing strategy include obtaining negative results in patients during their incubation period who later become infectious and false negative test results, depending on the test method used.
The Chart found HERE is a complete, up to date listing of payer policies. Last update: 1/11/21
April 30 Update - Telehealth Services now covered for Medicare Beneficiaries - see additional information in the Chart. https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf
Additional BCBSM Resources:
Senate Bill 898 to amend the insurance code (1956 PA 218) requiring that a service provided through telemedicine will provide the same coverage and reimbursement as if the service involved face-to-face contact was introduced by Senator Adam Hollier on April 29, 2020 and was referred to the Health Policy Committee. This bill would also require insurers to continue to provide the same reimbursement for physical therapy provided via telehealth beyond the COVID-19 pandemic.
APTA Policy is clear that telehealth can be an appropriate model of care delivery of physical therapy services. http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/TelehealthHODPolicy.pdf#search=%22telehealth%22
Further, the FSBPT has a resource paper on important considerations for physical therapists utilizing telehealth https://www.fsbpt.org/Portals/0/documents/free-resources/TelehealthInPhysicalTherapy2015.pdf
Regulatory scope of practice is almost always more limiting than professional scope of practice, but there are also many instances of the Physical Therapy Section of the Public Health Code being silent on specific issues. When you look at the Public Health Code, there is nothing in the Physical Therapy section that specifically permits or prohibits telehealth. However, a quick search of the General Provisions, which apply to all licensed health professionals, reveals that telehealth is permitted to be provided by licensed health professionals in Michigan: http://www.legislature.mi.gov/(S(0dsbzvzpxu4lawibsw5ym4q2))/mileg.aspx?page=GetMclDocument&objectname=mcl-368-1978-15-161
From a state regulatory scope of practice perspective, telehealth is permitted by physical therapists:
As used in this section and sections 16284 to 16288:
(a) "Health professional" means an individual who is engaging in the practice of a health profession.
(b) "Prescriber" means that term as defined in section 17708.
(c) "Telehealth" means the use of electronic information and telecommunication technologies to support or promote long-distance clinical health care, patient and professional health-related education, public health, or health administration. Telehealth may include, but is not limited to, telemedicine. As used in this subdivision, "telemedicine" means that term as defined in section 3476 of the insurance code of 1956, 1956 PA 218, MCL 500.3476.
(d) "Telehealth service" means a health care service that is provided through telehealth.
Further, the Insurance Code (MCL 500.3476) offers additional guidance:
(1) An insurer that delivers, issues for delivery, or renews in this state a health insurance policy shall not require face-to-face contact between a health care professional and a patient for services appropriately provided through telemedicine, as determined by the insurer. Telemedicine services must be provided by a health care professional who is licensed, registered, or otherwise authorized to engage in his or her health care profession in the state where the patient is located. Telemedicine services are subject to all terms and conditions of the health insurance policy agreed upon between the policy holder and the insurer, including, but not limited to, required copayments, coinsurances, deductibles, and approved amounts.
(2) As used in this section:
(a) After December 31, 2017, "insurer" includes a nonprofit dental care corporation operating under 1963 PA 125, MCL 550.351 to 550.373.
(b) "Telemedicine" means the use of an electronic media to link patients with health care professionals in different locations. To be considered telemedicine under this section, the health care professional must be able to examine the patient via a real-time, interactive audio or video, or both, telecommunications system and the patient must be able to interact with the off-site health care professional at the time the services are provided.
Further information regarding "scope of practice."
Expanding your professional boundaries is the epitome of professional practice because a good clinician is always learning. As you consider the directions in which you would like to grow, you also need to understand the legal/regulatory constraints that may impact your decision.
"Scope of Practice" is a broad term that includes: 1) professional scope of practice as defined by CAPTE entry-level education standards, APTA positions and policies, and FSBPT resource papers, 2) regulatory scope of practice as defined by state law, and 3) personal scope of practice as defined by your individual experiences and professional development. Other factors that affect your practice include third party payer regulations and facility policies.
All of the resources for determining professional scope of practice can be found at: http://www.apta.org/ScopeOfPractice/. Among the numerous links available is the link to the APTA Policies related to practice http://www.apta.org/Policies/Practice/
Resources related to regulatory scope of practice in MI can be found at: https://www.michigan.gov/lara/0,4601,7-154-72600_72603_27529_27549---,00.html
Especially important are the links to the Physical Therapy section of the Public Health Code, the General Provisions of the Public Health Code, the Administrative Rules, and the FAQs. Licensing and Regulatory Affairs (LARA), in consultation with the MI Board of Physical Therapy (aka the PT Licensure Board), promulgate the administrative rules and the FAQs which are an interpretation/application/operationalization of the Public Health Code, and have the force of law. Navigating the legalese of regulatory scope of practice can be challenging, but APTA Michigan is here to help. One of the many member benefits is the ability to ask APTA Michigan leaders questions about practice. Although the APTA Michigan cannot offer legal advice, it can provide highly informed guidance.
Even during a pandemic, you must follow all applicable laws and regulations for practice as a physical therapist/physical therapist assistant, including meeting all applicable professional practice standards for patient management and documentation, as well applicable laws regarding scope of practice, direct access (e.g. the 10 visit/21 day limit), PTA supervision/delegation, etc. The only direct/explicit regulatory/scope of practice change was Executive Order 2020-30 allowing physical therapists to work as respiratory therapist extenders. If you are redeployed in another role (working as a nursing tech, helping in a triage tent, working on a mobility team, etc) it is important to recognize that you might not practicing as a physical therapist/physical therapist assistant in that capacity. Rather, you might be functioning as an unlicensed individual under another provider's license (e.g. physician etc) who is delegating acts, tasks, and functions to you. In these instances, you should not represent yourself or your services as a physical therapist/physical therapist assistant/physical therapy, and you should be sure that roles and responsibilities as clearly outlined. The breadth and depth of the knowledge and skills possessed by a PT/PTA are what make PTs/PTAs so versatile during crises such as the present COVID-19 crisis which allow us to be redeployed in creative and useful ways and allow PTs/PTAs to provide an wide array of acts, tasks, and functions delegated by other health care providers. You just want to be clear on when you are truly providing physical therapy as a physical therapist/physical therapist assistant and follow all laws and regulations.
There are no regulatory restrictions on delegation of services provided via telehealth, and the requirement for general supervision of the PTA (i.e. available via telecommunications) still applies. However, all of the other requirements for delegation to and supervision of a PTA also still apply. Therefore, the PT should only delegate provision of telehealth to a PTA when it is appropriate to do so based on the individual patient and the PTA to whom services are being delegated. The Administrative Rules regarding PTA supervision and delegation are detailed in R 338.7138 and can be found in the Board of Physical Therapy General Rules found here: https://aptami.org/practice/. The APTA Michigan is not aware of any payer-specific prohibitions on delegation of telehealth services to PTAs.
Statute and the PT rules do not provide any details regarding application of the direct access provisions in this circumstance. The APTA Michigan believes that the statutory intent of direct access was for an initial encounter/start of a new plan of care for a new problem or for a recurring problem that was previously resolved/adequately treated. Therefore, as your clinic resumes operations and if you are resuming a plan of care established before the COVID-19 crisis, the APTA Michigan believes that it would be inappropriate to do so under the direct access provisions and that you would need to update/revise the initial prescription. However, please know that APTA Michigan is exploring temporary remedies and options to help eliminate this issue as clinics restart operations.