PT Practice Settings and ICF/Guide to Practice — Comprehensive Notes

Overview: Diversity and Opportunities in Physical Therapy Practice

• PTs and PTAs have access to a wide variety of practice settings, enabling exposure to many diagnoses and populations.
• Flexibility to work in multiple settings over a career (e.g., split across settings, travel between sites).
• Teaching and sharing knowledge is a common path (example: lecturer now).
• Emphasis on interprofessional education and collaboration across health care teams.

Learning Objectives (week summary)

• Provide examples of activities and techniques PTs/PTAs use to improve movement skills and maximize functional ability.
• Describe the purpose of the American Physical Therapy Association's Guide to Physical Therapist Practice.
• Explain how the International Classification of Functioning, Disability, and Health (ICF) Model is used to individualize patient needs, goals, and interventions.
• Describe typical practice settings for PTs/PTAs.
• Identify common patient diagnoses and interventions across settings; describe PTA roles in various settings and populations.
• List other professions that PTs/PTAs commonly interact with.
• Note: Take notes during lectures; not all information is on slides.

Guide to Physical Therapist Practice (GPTP)

• The GPTP helps define patient care decisions and interventions across settings.
• Key questions addressed:
  • Who are we encountering and how should they be referred to?
  • How do clinicians decide which interventions are most important for each person?
• History and publication: originally published in 1997; revised in $2001$ and $02/2014$; now an online-only document updated frequently for current practice.
• Important distinctions:
  • Differentiates between patients and clients.
  • Describes conditions seen in PT and PTAs and the tests, measures, and interventions used.
• Definitions (from the GPTP, blue box, page 17):
  • Patients: individuals who receive examination, evaluation, diagnosis, prognosis, and interventions for disease/impairment/functional limitations/disability.
  • Clients: individuals who engage PT services for consultation, interventions, health promotion, fitness, wellness, or prevention services; can include businesses, school systems, and others.
• ICF model adoption: In $02/2008$, APTA House of Delegates voted to adopt WHO’s ICF model for patient categorization.
• ICF focus: Health condition is acknowledged, but emphasis is on how the condition impacts activity and participation in society rather than just the disease.

International Classification of Functioning, Disability, and Health (ICF) Model

• Core idea: Functional impact of health conditions; interconnected factors.

• Components (described visually in class and in text; see textbook page 18 for a clearer diagram):

  • Health condition (disease, disorder, or injury).
  • Body function and structure (impairments).
  • Activity (execution of tasks).
  • Participation (in life situations).
  • Environmental factors.
  • Personal factors.

• Interactions: All components influence one another; the health condition affects body functions, which affect activities, then participation, all modulated by environmental and personal factors.

• Example: ACL injury

  • Health condition: ACL tear.
  • Body function/structure: knee joint ruled by ACL; ROM limitations; swelling; decreased strength; altered gait/balance.
  • Activity: limited walking distance and squatting; stair negotiation impaired.
  • Participation: high school athlete unable to participate in sport and social activities.
  • Environmental factors: support systems, access to care, equipment (crutches) availability.
  • Personal factors: age, motivation, prior activity level.

• Practical takeaway: Clinicians tailor goals/interventions to address not only the impairment but also activity, participation, and personal/environmental contexts.

• Prompt for reflection (forward-looking discussion):

  • Identify a health condition addressable by PT.
  • Consider how two people with the same condition may present differently and why differences occur.
  • Example prompt: back surgery in a 40-year-old active person vs an 80-year-old inactive person; consider factors like family support and comorbidities (e.g., COPD, diabetes, stroke history).

Common Practice Settings in Physical Therapy

• Guiding questions across settings:
  • What types of patients and diagnoses are typical?
  • What services are provided?
  • Do PTAs have different responsibilities by setting?
  • Who else works with PTs/PTAs in each setting?

Acute Care (Hospital-based PT)

• Setting: hospital PT department or bedside care in patient rooms; focus on acute, sudden-onset conditions.
• Typical patients: post-surgery, falls-related injuries (elderly), COPD exacerbations, pneumonia, UTI, other acute illnesses.
• Goals: improve strength, endurance, and tolerance for bed mobility; progression to more advanced functional activities; discharge home or to a lesser care setting.
• PTA role: assist with mobility training, gait training (walker/cane), ADLs, educate on precautions and safety.
• Specialized areas within acute care:
  • Cardiac rehabilitation: monitored exercise for cardiac patients.
  • Inpatient rehabilitation: for significant neuromuscular events (e.g., stroke); multi-disciplinary rehab (PT/OT/SLP) with mobility focus; goal to return home or progress to another unit.
  • Wound care: WCS (Wound Care Specialist) in PT; debridement, wound cleansing, wound dressings.
  • Emergency room PT: typically PT evaluates to determine disposition (home vs admission) and may train safety devices before discharge; less common for PTAs in ER.
• Key takeaway: Acute care emphasizes rapid assessment and safe transfer principles and often serves as the entry point to inpatient rehab pathways.

Outpatient and Private Practice

• Setting: most commonly envisioned PT; can be private practice or part of a hospital outpatient facility.
• Characteristics: patients come from home; range of ages; broad spectrum of musculoskeletal conditions.
• PTA role: prescribe and supervise therapeutic exercises; enhance strength, flexibility, balance; educate on home exercise programs; implement modalities (heat, ice, e-stim, ultrasound); manual therapy; traction; patient education.
• Specialties commonly found:
  • Sports medicine
  • Women’s health (pelvic floor, postpartum considerations)
  • Aquatic therapy
  • Industrial/occupational medicine (ergonomics, on-the-job adaptations)
  • Performing arts therapy (dance, theater, circus performers)
• Patient diagnoses commonly treated: back pain (including bulging discs, radiculopathy), shoulder issues, tendinopathies, post-operative rehab, etc.
• Setting-specific notes: outpatient clinicians must tailor plans to diverse age ranges; acuity is generally lower than acute inpatient settings but requires strong critical thinking and protocol adherence.

Skilled Nursing Facility (SNF), Extended Care, Transitional Care Unit (TCU), Subacute Rehab

• Organization umbrella: SNF (skilled nursing facility), extended care facility, transitional care unit, subacute rehab (often collectively referenced as SNF/TCU/subacute continuum).
• Target population: older adults with chronic medical needs or those requiring ongoing rehab before returning to independent living.
• SNF: 24-hour medical care; mobility assistance; residents vs patients (respectful terminology within long-term care).
• TCU: transitional stage after hospitalization; common goal to return home or move to SNF afterwards; often require multidisciplinary therapy (PT/OT/SLP).
• Subacute rehab: intensive rehab (often 3 hours of therapy per day across disciplines) with a plan to discharge to home or alternate living arrangement.
• PTA role: maximize resident mobility; independence in bed transfers and ambulation with assistive devices; evidence-based regimens to support transition back to home.
• Example pathways: stroke → subacute rehab (PT/OT/SLP) → home or alternate care setting; discharge decisions depend on progress and home support.

Home Care (Home Health)

• Setting: PTs/PTAs visit patients in their homes; services delivered in patient’s residence.
• Rationale: patients with mobility deficits who cannot easily travel; home environment established as therapy setting.
• PTA role: work on functional tasks in home context (transfers, chair-to-bed, stairs, thresholds); provide caregiver education and home exercise programs; bring equipment as needed.
• Complexity and supervision: high; patient independence in home health often requires prior clinical experience; not typically a first-job setting for new grads due to safety and decision-making demands.

Hospice

• Setting: for terminal illnesses (e.g., cancer) with prognosis often < $6$ months; services may be delivered at home, SNFs, assisted living, hospice facilities, or hospital units.
• Rationale for PT: improve or maintain activity, reduce pain, maximize remaining function, and improve quality of life; promote independence to lessen caregiver burden.
• Ethical/practical implications: focus on quality of life and patient-centered goals; balancing comfort with functional gains; emotional and relational considerations with families.
• PTA considerations: hospice is more complex emotionally and logistically; experience valuable but may be less common for new graduates due to complexity.

Pediatrics (Pediatrics Physical Therapy)

• Setting: hospital pediatrics, school-based, or outpatient clinics dedicated to children.
• Key characteristics: children have developmental or neuromuscular disorders, birth defects, or genetic conditions (e.g., cerebral palsy, Down syndrome, muscular dystrophy, cystic fibrosis).
• PTA role: integrate therapy into play; address motor control, functional mobility, strength, balance; adapt activities to child’s interests and energy levels; involve parents and caregivers.
• Challenges: children can end sessions abruptly; treatment often requires quick adaptation and creativity; parental involvement is central; school-based therapy necessitates coordination with educators.
• Typical environments: pediatric hospital settings, schools, outpatient pediatric clinics.

Schools and Educational Settings

• Settings: school-based PT in K-12 environments; collaboration with teachers, school nurses, and families.
• Focus: support participation in school activities, mobility within classroom and playground, and safe accessibility for students with disabilities.

Floating/Traveling PTAs

• Concept: independent projects with short-term contracts across settings (acute, inpatient, subacute, outpatient).
• Pros: travel experiences, exposure to diverse settings, networking opportunities.
• Cons: must adapt quickly to new facilities and processes; typically require demonstrated experience before assignment; not ideal for new graduates due to supervision and learning curve.

Academia

• Role: teaching at PT programs; if licensed and/or advanced degrees held, PTA can become program director or faculty.
• Focus: educate future PTs/PTAs, develop evidence-based curricula, and mentor students.

Interprofessional Education (IPE)

• Core idea: PTs and PTAs work with a broad team of healthcare professionals to provide comprehensive patient care.
• Why it matters: enhances patient outcomes; ensures appropriate expertise is brought to each case; improves communication and collaboration.
• Common collaborators:
  • Core rehab providers: physicians, nurses, pharmacists, occupational therapists, speech-language pathologists, athletic trainers, chiropractors, massage therapists.
  • Other professionals who interact with patients one-time or infrequently: respiratory therapists, prosthetists, phlebotomists.
  • Non hands-on roles: social workers, chaplains, health information managers, dietitians.
• How IPE is learned: case-based tutorials and interdisciplinary case scenarios (e.g., PT/OT collaboration on pediatric case; case conferences with multiple disciplines).
• Real-world example: inpatient rehab conferences with PT, OT, SLP, physician, case manager, nursing leadership, and sometimes mental health professionals.

Practical Implications Across Settings

• Each setting presents different patient diagnoses, levels of severity, age ranges, and interprofessional interactions.
• Early career exploration is encouraged: volunteer work, internships, or shadowing help identify preferred settings.
• Some settings require more advanced experience due to complexity (e.g., home care, hospice, pediatrics, floating/operational responsibilities).
• A strong foundation in core competencies (examination, intervention, documentation, and clinical reasoning) is crucial across all settings.

Additional Resources and Guidance

• Viewing recommended videos can provide a visual understanding of how interventions look across settings (pediatrics, inpatient, outpatient, etc.).
• Interprofessional case-based learning is emphasized in many programs to prepare students for real-world collaboration.

Key Terms to Remember

• PLOF: Prior Level of Function
• ADLs: Activities of Daily Living
• ICF: International Classification of Functioning, Disability, and Health
• WCS: Wound Care Specialist
• SLP: Speech-Language Pathologist
• CPT: Current Procedural Terminology (not explicitly stated, but commonly used in documentation across settings)

Quick Reference: Publication and Model Dates (memory aids)

• GPTP publication history: $1997, 2001, 02/2014$ (online, easily updated)
• ICF model adoption by APTA: $02/2008$

Final Thoughts for Exam Preparation

• Expect questions about how the ICF model guides patient-specific goals and how environmental/personal factors influence outcomes.
• Be able to describe roles of PTs and PTAs in at least three settings (e.g., outpatient, acute care, and SNF/TCU).
• Understand which settings typically require more experience and why (home care, hospice, pediatrics, traveling PTAs).
• Know the concept of interprofessional education and be able to name common collaborators and the value of case conferences.