APTA Michigan President Michael Shoemaker provides updates and calls for feedback from members regarding several topics
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.
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
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
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
Executive Order 2020-30 - Replaced April 26 by Executive Order 2020-61 - Continuing Education Requirements Temporarily Suspended
Under Executive Orders 2020-30 and 2020-61, 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 Order 2020-99 on May 22 which extended the state of emergency until June 19. If the declared emergency ends before you complete your renewal online, you must meet all of the continuing education requirements under the administrative rules for physical therapy. 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.
MPTA sent a letter to the Governor on March 20 requesting relief in many of the areas outlined below.
Download file
On March 30, MPTA sent a second letter to Governor Whitmer, to again request mandated coverage of telehealth services.Download file
On April 3, MPTA also sent a letter to the Department of Insurance and Financial Services to request mandated coverage of telehealth services. Download file
Michigan Unemployment benefits expanded by $600 per week
Gov. Whitmer signed an agreement with the U.S. Department of Labor to expand unemployment benefits by $600 per week and to extend benefits to residents who do not qualify for traditional state unemployment assistance. Residents who don't traditionally qualify include people who are self-employed, seasonal workers and others who can no longer work because of the pandemic. You also should be aware that you can backdate your claim to reflect the day you were laid off or let go due to COVID-19. Once your claim is approved and processed, you will receive unemployment assistance dating back to this date.
You can find a full, step-by-step guide for applying by clicking here.
Additional Federal Support: Families First Coronavirus Response Act: Employer Paid Leave Requirements
Relief for small business owners is evolving at a rapid pace at both the federal and state levels.
At the state level, MPTA has been working with the Director of the Department of Labor and Economic Opportunity to share the concerns of owners of PT practices of varying sizes. There is no one-size-fits-all solution, but resources that may be helpful include:
Michigan Small Business Relief Fund:
Michigan Guidance Regarding Layoffs:
https://www.michigan.gov/coronavirus/0,9753,7-406-98163-522113--,00.html
Contact the Office of Employer Ombudsman on-line through your MiWAM account or at 855-484-2636
At the Federal Level, the Cares Act was signed into law on March 27. This legislation includes many provisions that will help small business owners. Two resources are found below:
- Small Business Owner's Guide to the Care Act (US Senate Committee on Small Business): https://www.sbc.senate.gov/public/_cache/files/2/9/29fc1ae7-879a-4de0-97d5-ab0a0cb558c8/1BC9E5AB74965E686FC6EBC019EC358F.the-small-business-owner-s-guide-to-the-cares-act-final-.pdf
- General Summary from DC Law Firm: https://www.venable.com/insights/publications/2020/03/breakdown-of-covid-19-relief-bill-passed-senate
- Paycheck Protection Program Loan Information: https://www.sba.gov/funding-programs/loans/coronavirus-relief-options/paycheck-protection-program-ppp
Department of Licensing and Regulatory Affairs Guidance for Students Graduating in 2020
Graduating physical therapy students are eligible for issuance of a license with the exam waived during Michigan’s State of Emergency. Executive Order 2020-61 provides temporary relief from certain restrictions and requirements governing the provision of medical services. Specifically, part 9 states:
“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:
(a) An exam, to the extent that the exam’s administration has been canceled while the emergency declaration is in effect.
(b) 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.
(c) Continuing education while the emergency declaration is in effect.”
Students should apply for their full license. See below for additional information.
- Bureau of Professional Licensing (BPL): www.michigan.gov/bpl
- Select: Health Professional Licensing
- Select: Physical Therapy
- Select: Physical Therapy and Relicensure Form under Licensing Applications and Forms on the right side of the page
- For questions and additional assistance email bplhelp@michigan.gov.NOTE: For the subject line reference as Physical Therapy Licensure
- Schools will need to submit a certification of completion for each student at BPLData@michigan.gov, subject line should be: Physical Therapy Licensure Student Certification. Once the transcripts are available schools will need to update their submission to include permanent transcripts at BPLData@michigan.gov. Students cannot be issued a license if the certification is not submitted by their educational program.
There are currently sufficient locations open for fingerprinting and once the students submit their completed application, they will receive a customer service number to take with them to schedule to have fingerprinting done at one of the available locations. Once the application process is completed, the student will receive the license with a notice that the testing was waived under EO 2020-30 and post COVID-19, see sample notification:
TEMPORARY EMERGENCY LICENSE NOTIFICATION
Dear Licensee:
Your license was issued under Executive Order 2020-30 which allowed for the waiving of certain requirements for licensure on a temporary basis. Be advised that the waiver of requirements only applies to those requirements that cannot be met due to cancellation, unavailability, etc., and that you are responsible to meet any requirements for licensure if you have the ability to do so now or at any time in the future.
This communication is to notify you that licenses issued under this order are only valid for 6 months from the date the state the emergency declaration expires or is terminated by the Governor of Michigan. Failure to meet all the licensure requirements outlined in state law or rules pertaining to your license by the end of this time period will result with your license being deemed null and void.
If you have any questions contact the Bureau of Professional Licensing at BPLHelp@michigan.gov.
Students will need to communicate directly with BPL via the email above to process their applications and answer any licensing specific questions.
Student Loan Relief:
Effective March 20, all borrowers with federally held student loans will automatically have their interest rates set to 0% for a period of at least 60 days. In addition, each of these borrowers will have the option to suspend their payments for at least two months to allow them greater flexibility during the national emergency. This will allow borrowers to temporarily stop their payments without worrying about accruing interest.https://www.ed.gov/news/press-releases/delivering-president-trumps-promise-secretary-devos-suspends-federal-student-loan-payments-waives-interest-during-national-emergency
COVID-19 Stimulus Package: Federal student loan borrowers will be able to defer payments, and employers can offer repayment benefits tax-free.
Payments on federal student loans can be deferred through September 30, 2020, with no accrual of interest during that period. Additionally, the stimulus allows employers to contribute up to $5,250 annually toward an employee's student loans without the benefit being taxed as employee income. The employer provision applies to any employer payments made between now and January 1, 2021.
Additional Student Resources are found here: https://studentaid.gov/announcements-events/coronavirus
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)
