What Defines a GOOD Home Health Therapist?
by Ralph Santos, CEO, MBA, OTR/L
Owner: Center for Physical Therapy Services, Inc.
As an occupational therapist with more than 20 years of home health experience, I can say that it’s also helpful to ask this article title’s contrasting question: “What makes up a not-so-good home health therapist?” Looking at the answers to these questions through the home health lens is important for all therapists and all therapy-related settings. Please note that throughout this article, the term therapy will pertain to physical therapists, occupational therapists, speech therapists and social workers in the home-heath setting; the term client will pertain to those who receive care.
The biggest obstacle to understanding good or not-so-good therapy resides in a few variables, starting with the clinician. Does the clinician possess solid clinical reasoning skills necessary for understanding what to do with each client?
I once had a client who had a cerebral vascular accident (CVA or stroke) that left her non-dominant left side with residual weakness. She complained that her middle finger on her right hand had pain and weakness. She had gone to see a hand therapist who gave her some thera-putty and a set of hand exercises. This was fine, but during my evaluation, I asked her about her meaningful ADLs (activities of daily living), and she immediately exclaimed how much she loved to sew. That’s when it all became apparent that sewing in conjunction with her recent stroke revealed that she did not know how to use compensatory techniques, joint protection principles, muscle energy techniques, gentle stretching, avoiding sensitive tissue irritation, or how to recognize and avoid symptoms of overuse in general. This underscores how basic clinical reasoning is crucial to making a meaningful change on our clients’ lives!
Another obstacle to understanding good or not-so-good therapy involves the resources that determine whether or not the clinician will be able to perceive the set of contributing factors that contribute to the client’s ability or inability to perform tasks (such as walking and swallowing food, beverages and medicine—and all other such ADLs). In addition to effective clinical reasoning, the greatest resource worth prioritizing and attaining would be what I call the therapist’s tool bag.
If I were to use the analogy of a contractor, I would state that therapists often get to work with a client who has recently sustained a loss of some sort, whether it is a loss in their ability to walk or a loss in their ability to make a meal for themselves or for their loved ones. We are given the opportunity and the privilege to make some changes in our client’s lives that will help restore some purposeful meaning! Our tool bags are all unique and differ based on who we are, what experiences we have had, what interests us in the therapy world, what mentors have been in our therapy lives, and how much we enjoy what we do as therapists. For example, let’s take a therapist who has worked in the pediatric field for 10 years and has made a consistent effort to attend at least one continuing education seminar on topics related to pediatrics annually. This therapist also attends his/her association’s (both state and national) annual meetings consistently and she has made a solid network of pediatric health care professionals. This therapist would have a tool bag that would be significant to her being able to use her acquired “tricks” and solid empirically-based CLINICAL SKILLS that will get her client to perform at a higher level. Now compare this pediatric therapist with a new therapy graduate with little to no experience besides a college education and clinical rotations. The obvious difference is based on experience and levels of involvement in the respective fields.
I once had a therapist who called me and asked me for ideas on what to do; this therapist understood her limitations and was open to accepting help. The not-so-good thing was that her tool bag was not sufficiently outfitted for that particular client. If this therapist had not sought help, what outcome would have occurred? There are some therapists who run out of ideas and claim that a client has plateaued, wrongly indicating that the client is at the best he or she will ever be physically, mentally and emotionally. This label triggers a negative domino effect. First of all, the therapist leaves the client high, dry and alone with no therapy interventions. Second of all, the client believes that this is the very best that they are ever going to be. Please do not get me wrong—I know that there are illnesses and traumas for which we know certain return of movement or function will be minimal, but for the vast majority, it is not fair to take away their hope of becoming stronger. I learned the hard way that no matter how well-equipped our tool bag is, a patient with no hope will equate to a client for whom we often cannot make a difference. It is a tough pill to swallow when the client believes he or she will not get any better and that they are destined to have a life without meaning, without any goals, and without any hope. Perhaps most tragically, the label of plateau will tell our “friendly” insurance carriers to deny further therapy services in the foreseen future.
Whether or not we are conscious of it, we as therapists carry a well-respected professional opinion. In fact, we fight all of the time to make sure that the health care community understands that we have value and that our findings are anchored on research findings. As we fight for this respect from our colleagues, we should understand that when we label our clients as having plateaued, we are labeling them as no longer being capable of getting better. Using this label is a force of bad habit and/or sheer ignorance. In fact, when I first started my first company, Center for Physical Therapy Services, Inc., we spent years with a check-off box on our discharge summary that stated, “The patient has plateaued,” and I came to realize that we were doing a disservice to our clients. Well, hindsight is 20-20!
Another point that I have come to understand is what I call the therapeutic use of the self. What does this mean? Some people are inherently good people persons while other struggle their whole lives trying to interact with other people—especially with strangers. As a therapist, it is understood that we will interact with clients, their loved ones and the health care team that accompanies every client. The therapeutic use of self would encompass those therapists’ attributes that makes their very presence a healing experience.
Interestingly, the client will often be the judge of whether or not he or she feels that you will make them better. The energy that you give off, the level of confidence that you exude, the compassion that you demonstrate (or the lack thereof) will be transmitted at the initial client-therapist visit. In many cases, the moment that you call your client over the phone, they will begin their evaluation process. This therapeutic use of self is defined over the initial encounter and during every interactionthat occurs until you discharge that client. A client will know immediately the amount of time, effort and care you as a therapist are willing to invest into them.
Often you will hear stories where clients no longer want any more therapy visits, or where we as therapists label certain clients as “difficult,” “non-compliant” or with some other negative label. The problem does not stop at the fact that we have not developed a therapeutic use of self or that the client has been labeled erroneously by us. The real problem is that the client now believes that all therapists are incompetent, uncaring or just plainly do not care. Such negative cycles unfortunately can begin with us and end with a discontented client. To add insult to injury, this cycle usually will escalate. The client has his or her own social circle and this now becomes a contagion that spreads faster than any virus. And these clients’ friends all have their own social circles and their own health care team. As you can deduce, the vicious circle from one discontented client can become a nightmare. This will impact the therapist in many not-so-good ways, including a tarnished reputation, the negativity of the entire therapy community instigated by defined social circles, the lack of trust by payer sources, the potential exclusion in health care reform and so on. When we care, our clients know it, and when they know it, they will not only get better but it will help to bring to light the efficacy of all of us as therapists!
Remember that we are one part of a larger group of health care professionals and paraprofessionals that provide a service or a product to our clients. It is important for therapists to understand that our roles are defined by our Scope of Practice and that this dictates what we legally can and cannot do. As a therapist, knowing what and where to refer our clients is essential. Oftentimes, a therapist may or may not see those red flags that come out in a normal therapy visit, which should raise your eyebrows and should elicit some therapeutic action. I like to use a sports analogy when referring to these red flags. If you think of almost any team sport, especially one that involves a ball, a strategy and a goal, you can imagine that our role on the health care team is essentially the same. Let me elaborate. When we see our clients, we listen to them, we evaluate them, we read their past medical history and we look at their current medications and so forth. We eventually create a plan of care that includes what we are going to do with the problems that have been identified and what the future for these clients might be; then steps are made to achieving therapeutic goals. That is the game plan!
The plan of care is our game plan in health care. I imagine the ball itself to be what actions are necessary in the competent care of our clients. For example, let’s say that your client is complaining of frequent falling episodes and you render a set of visual perceptual evaluations and a series of deficits are discovered that can or should be addressed by either one or more health care professionals. You might recommend an optometrist to assess the client’s vision and you may recommend a neurologist to address suspected neurological involvement, and you may recommend an occupational therapist for visual perception retraining and perhaps consult their primary care physician to talk about a specific medication that could be affecting the client’s vision; perhaps a social worker will need to be contacted to address the lack of a consistent caregiver, etc. My point is simple: take that ball and pass it to the relevant professionals, and please do not forget to document in your notes that the referral was made and to state the clinical reasoning for such a referral.
Once these therapeutic actions have taken place, we have moved from clinical reasoning to having a therapy tool bag. We also practiced the therapeutic use of self and broadened of our understanding of our role on the health care team. Can this list get any longer? I would like to list just one more concept before closing which I feel is just as important as the concepts above. This is a vital point that is often overlooked.
Consistency and accountability involves staying true to who you are and also building a trusting relationship. As health care providers, we do not have the luxury of turning off our consistency and accountability when it comes to client care. When we are not consistent, our clients know it and they can build up resentment to our lack thereof. In my opinion, being consistent means keeping true to who you are and also building a trusting relationship. One of my many mantras in life, especially in my business life, is trust. Our company, the Center for Physical Therapy Services, Inc., provides physical therapy, occupational therapy, speech therapy and social work services to home health agencies and to hospice agencies in the greater Los Angeles County. I vividly recall an agency texting me to let me know how much they love working with us! Now, this was an anomaly; most often an agency will call or text me to complain about a therapist for one or more of the reasons mentioned in this article. I took the opportunity to text back to the agency and I wrote: “Thank you for having the trust in us to take care of your clients.” I acknowledged that even though our patients are and should be the primary focus on our care, our referring agencies are also clients. Clients are our patients, our referral sources, our home health agencies, our hospice agencies, our patient’s family members, our patient’s doctor(s), the entire health care team on the case, and the insurance company, and I am sure that there are others that I have not mentioned. The bottom line is that with consistency comes accountability, and therapists need to know that we are held to certain standards. If you tell a patient that you are going to order them a walker, or simply that you are going to call them on Friday to see how they are doing, it is vital that you do in fact make this call or action happen. Nothing is more disconcerting to a client than a flaky clinician. It is a big responsibility and therapists need to understand that we must prove to ourselves, to our accrediting bodies, and to our universities that we have the competency, the knowledge and the desire to help others via our respective therapy services. Once you have your license, once you put on that white lab coat with a badge labeling you as a health care professional, you are now part of this incredible living and breathing environment called health care! Realize that the dynamics of health care often go way out of the arena of health and frequently touch on topics such as reimbursement, lobbying, human resource concerns and even issues created in Washington by legislators, and in our case, Sacramento legislators.
Finally, let me state that my list of what makes for a GOOD therapist versus a not-so-good therapist is not all inclusive. I am certain that other variables that will arise, but at least this will set the foundation to make you a GREAT clinician. The concepts listed above do not work in isolation! Our clinical reasoning skills, our clinical skills (the tool bag), our therapeutic use of self, our understanding of the clinical team, and our consistency and accountability are variables that work together to determine whether we become GOOD therapists or the not-so-good therapists. I hope that we all strive to use this information to become those GOOD or GREAT therapists that our clients recognize and love!
Ralph Santos, CEO, MBA, OTR/L,is the owner of the Center for Physical Therapy Services, Inc. located at 1650 E. Walnut Street, #B, Pasadena, CA 91106. Their office number is: (626) 683-9959. The Center for Physical Therapy Services, Inc., specializes in the training and guidance of PT, OT, ST and MSWs in the home health care setting. The company’s website is: www.Center4PT.com. The Center for Physical Therapy Services, Inc., also provides home health agencies and hospices with in-office training, lectures to senior centers, training to caregivers, and is able to help clients with choosing a home health care or hospice agency.
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