As some of you may know, the CDC and MDHHS has recently updated recommendations for PPE for all healthcare providers regardless of setting. They recommend that all healthcare providers wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters when working in facilities located in areas with moderate to substantial community transmission based on the following definitions:
- Substantial community transmission: Large scale community transmission, including communal settings (e.g., schools, workplaces)
- Minimal to moderate community transmission: Sustained transmission with high likelihood or confirmed exposure within communal settings and potential for rapid increase in cases
- No to minimal community transmission: Evidence of isolated cases or limited community transmission, case investigations underway; no evidence of exposure in large communal setting
However, terminology for transmission risk is when using the Michigan Safe Start Map (https://www.mistartmap.info/) uses the terms Low, Low-Medium, Medium, Medium-High, High, and Very High. APTA Michigan has received the following clarification from MDHHS: “All of Michigan is either in medium, medium-high, or high risk areas right now (as outlined in the MI Safe Start Map) and considered to have moderate to substantial transmission right now. We are recommending all HCP wear eye protection for patient encounters due to the level of risk of asymptomatic/pre-symptomatic transmission.” There are not specific guidelines for specific types/brands of eye protection (face shield, goggles, safety glasses etc) other than providers should select equipment that minimizes gaps above, below, and on the sides.
Between April 24 and May 11, 2020, APTA surveyed a representative sample of physical therapists and physical therapist assistants to gauge the impact of the COVID-19 pandemic on the physical therapy profession.
This report is based on responses by more than 5,400 PTs and 1,100 PTAs — members and nonmembers, across practice settings and jurisdictions. The survey findings represent a snapshot in time. It is expected that situations for PTs and PTAs will continue to change according to fluctuations in COVID-19 cases and changes in state and federal guidance.
Continuing Education Requirements Temporarily Suspended
Under Executive Order 2020-61 (rescinded and replaced by Executive Order 2020-150 the continuing education requirements for renewing the license are waived at the time of renewal, if the renewal is completed while the state of emergency declaration is in effect. Governor Whitmer issued executive orders declaring a state of emergency - the most recent being Executive Order-186 which extended the state of emergency until October 27.
Thus, those who renewed by July 31 were not expected to complete continuing education requirements. For further information regarding the PDR activities, visit https://mpta.com/continuing-education/ Please note that the requirement for a course in the Identification of Victims of Human Trafficking is a separate requirement not linked to the two-year renewal process and thus must still be completed.
LARA Online Renewal: https://www.michigan.gov/elicense
Additional clarification from LARA: There is a bright-line distinction between those that complete renewal while the emergency declaration is in effect and those that do not. The LARA systems clearly identify the date the renewal was completed online. Licensees who successfully renew while the emergency declaration is in effect will not be asked to submit proof of continuing education.
Excerpt from the Executive Order:
Any law or regulation is temporarily suspended to the extent that it requires for any health care professional, as a condition of licensure, certification, registration, or the renewal of a license, certification, or registration:
- An exam, to the extent that the exam’s administration has been canceled while the emergency declaration is in effect.
- Fingerprinting, to the extent that, in the judgment of the director of the Department of Licensing and Regulatory Affairs, locations to have fingerprints taken are substantially unavailable on account of closures arising from the COVID-19 pandemic.
- Continuing education while the emergency declaration is in effect.
PDR Credit for COVID-19 related activities - No longer in effect
Executive Order 2020-13 was replaced by Executive Order 2020-82 . On June 3, 2020 the Governor rescinded Executive Order 2020-82.
APTA has provided broad guidance for members to consider when deciding whether or not to provide in-person/clinic-based care. http://www.apta.org/Coronavirus/Statement/. APTA President Sharon Dunn also provided further clarification in a letter to members.
Additional APTA resource: Physical Therapist Management of Patients with Diagnosed or Suspected COVID-19
Workplace Toolkit provided by the Department of Licensing and Regulatory Affairs - excerpt below:
To further protect workers and the community, Gov. Gretchen Whitmer’s Executive Order 2020-147 reiterates that businesses who are open to the public must refuse entry and service to individuals who fail to comply with wearing a face covering. The Dept. of Labor and Economic Opportunity (LEO) stands at the ready to provide the tools necessary for businesses to protect their workers and remain safely open.
Under the governor’s order, businesses must post signs at all entrances instructing customers of their legal obligation to wear a face covering while inside – to assist employers with this requirement, a print-ready poster is available online. LEO and the Michigan Occupational Safety and Health Administration (MIOSHA) have a set of online resources at Michigan.gov/COVIDWorkplaceSafety that provides guidelines, posters for employees and customers, factsheets, educational videos and a reopening checklist to keep workplaces safe.
May 21 - Executive Order 2020-97 - Expanded Workplace standards to include provisions specific to outpatient health care facilities effective May 29. Governor Whitmer issued Executive Order 2020-97, updating a prior rule on workplace safety. Per the amended order, outpatient health care facilities, including clinics, primary care physician offices, and dental offices, will have to adopt strict protocols to prevent infection. The Executive Order contains a number of requirements for all employers, as well additional requirements for health care operations. Be sure to carefully read Executive Order 2020-97 and implement these requirements in your practice, in addition to other regulatory guidance that remains in effect. Current guiding documents include:
LARA Frequently Asked Questions for Outpatient Facilities
Encouragement to use telehealth when available and appropriate (Executive Order 2020-86)
Protections against employer retaliations for workers who stay home (Executive Order 2020-36)
Best practices for screening procedures which are the foundation of all in-person clinic operations for patients and employees can be found in the CDC guidelines for Risk Assessment
Regulations regarding the re-opening of economy are changing rapidly. On Friday June 5, Executive Order (EO) 2020-114 was issued. EO 2020-114 replaces the recently issued EO2020-97 which applied to all businesses, and contained specific guidance for health care operations. EO 2020-114 has several important changes additions, and you should review this EO carefully to ensure you are in compliance. Several changes in EO 2020-114 compared to EO 2020-97 include:
1.k. When an employee is identified with a confirmed case of COVID-19: (1) Immediately notify the local public health department, and (2) Within 24 hours, notify any co-workers, contractors, or suppliers who may have come into contact with the person with a confirmed case of COVID-19. (l) An employer will allow employees with a confirmed or suspected case of COVID19 to return to the workplace only after they are no longer infectious according to the latest guidelines from the Centers for Disease Control and Prevention (“CDC”) and they are released from any quarantine or isolation by the local public health department
1.l. An employer will allow employees with a confirmed or suspected case of COVID-19 to return to the workplace only after they are no longer infectious according to the latest guidelines from the Centers for Disease Control and Prevention (“CDC”) and they are released from any quarantine or isolation by the local public health department.
10. All businesses or operations that provide in-home services, including cleaners, repair persons, painters, and the like, must:
a. Require their employees (or, if a sole-owned business, the business owner) to perform a daily health screening prior to going to the job site.
b. Maintain accurate appointment record, including date and time of service, name of client, and contact information, to aid with contact tracing.
c. Limit direct interaction with customers by using electronic means of communication whenever possible.
d. Prior to entering the home, inquire with the customer whether anyone in the household has been diagnosed with COVID-19, is experiencing symptoms of COVID-19, or has had close contact with someone who has been diagnosed with COVID-19. If so, the business or operation must reschedule for a different time.
e. Limit the number of employees inside a home to the minimum number necessary to perform the work in a timely fashion.
f. Gloves should be worn when practical and disposed of in accordance with guidance from the CDC.
13. Gymnasiums, fitness centers, recreation centers, sports facilities, exercise facilities, exercise studios, and like facilities must:
a. Post sign(s) outside of entrance(s) informing individuals not to enter if they are or have recently been sick.
b. Maintain accurate records, including date and time of event, name of attendee(s), and contact information, to aid with contact tracing.
c. To the extent feasible, configure workout stations or implement protocols to enable ten feet of distance between individuals during exercise sessions (or six feet of distance with barriers).
d. Reduce class sizes, as necessary, to enable at least six feet of separation between individuals.
e. Provide equipment cleaning products throughout the gym or exercise facility for use on equipment.
f. Make hand sanitizer, disinfecting wipes, soap and water, or similar disinfectant readily available.
g. Regularly disinfect exercise equipment, including immediately after use. If patrons are expected to disinfect, post signs encouraging patrons to disinfect equipment.
h. Ensure that ventilation systems operate properly.
i. Increase introduction and circulation of outdoor air as much as possible by opening windows and doors, using fans, or other methods.
j. Regularly clean and disinfect public areas, locker rooms, and restrooms.
k. Close steam rooms and saunas.
Regarding item 9.o., guidance for facility cleaning can be found on the CDC website https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html
Regarding item 9.f, minimum items to be contained in screening procedures are outlined in Executive Order 2020-60 https://www.michigan.gov/whitmer/0,9309,7-387-90499_90705-527059--,00.html:
The screening procedures must include the following questions:
A. Do you have any of the following symptoms?
i. Fever of 100.4 degrees or higher (as measured by a touchless thermometer if available, but a verbal confirmation of lack of fever is sufficient if a touchless thermometer is not available);
ii. Cough (excluding chronic cough due to a known medical reason other than COVID-19);
iii. Shortness of breath;
iv. Sore throat; or
v. Diarrhea (excluding diarrhea due to a known medical reason other than COVID-19).
The Chart found HERE is a complete, up to date listing of payer policies.
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:
- BCBSM Telemedicine Services - note that this policy went into effect before May 1 due to COVID-19
- Telehealth services covered at no cost to the beneficiary
- PTOT benefit extension
- Covid-19:Determining members telehealth benefits
- Telehealth Procedure Codes for services provided at no cost for patients
Legislative Action:
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 is offering a number of free courses related to COVID-19 in the Learning Center: https://learningcenter.apta.org/student/Catalogue/CatalogueCategory.aspx?id=dcbae4dc-1a13-42ff-b9da-7ba7a62162e9
The Cardiovascular and Pulmonary Section has free webinars posted on YouTube here: https://www.youtube.com/channel/UCJR0p2186h3OYPfnavgjfHQ as part of the PACER Project: Post-Acute COVID Exercise & Rehabilitation
- Cardiovascular and Pulmonary Examination by Morgan Johanson
- Pediatric Considerations Post-Acute COVID-19 By Ashley Parish
- Vital Signs, Oxygen, & Exercise Prescription. How are these impacted by COVID-19
- Anatomy, Histology, and Pathophysiology of COVID 19
MPTA Western District Webinar recorded April 28: CLICK HERE to view
Expecations in Physical Therapy during COVID-19: Cardiopulmonary Concepts Applicable for All Settings - Presented by Dr. Kaelee Brockway PT, DPT
Topic: Dr. Brockway discussed preparation and management strategies from a cardiopulmonary perspective that is applicable to patients amidst this pandemic. These concepts are utilized across all settings and will help our profession serve its role in combating COVID-19.
FAQs
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:
333.16283 Definitions.
Sec. 16283.
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://mpta.com/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.
Additional Resources
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APTA Information
- Physical Therapist Management of Patients With Diagnosed or Suspected COVID-19 - Includes information for outpatient facilities, inpatient facilities, and home health.
- Telehealth and E-visits - APTA guidance for providing telehealth services and e-visits amid COVID-19.
- APTA Coronavirus (COVID-19) Updates - APTA has provided multiple updates chronicling the rapid evolution of COVID-19 guidance and related regulations. (April 14, 2020)
