Therapy Co-Treatment Scenarios and Documentation

This week’s Harmony Healthcare International (HHI) compliance reviews spurred discussion surrounding therapy documentation and the clinical indicators surrounding co-treatments as a therapy delivery method.  When two therapists of different disciplines are involved in a combined treatment session, documentation must illustrate the necessity of both disciplines.  This is best conveyed by describing discipline specific tasks addressed during the treatment session.  

The RAI Manual defines co-treatment as the following: 

“When two clinicians (therapists or therapy assistants), each from a different discipline, treat one resident at the same time with different treatments, both disciplines may code the treatment session in full. All policies regarding mode, modalities and student supervision must be followed as well as all other federal, state, practice and facility policies.

For example, if two therapists (from different disciplines) were conducting a group treatment session, the group must be comprised of four participants who were doing the same or similar activities in each discipline. The decision to co-treat should be made on a case by case basis and the need for co-treatment should be well documented for each patient. Because co-treatment is appropriate for specific clinical circumstances and would not be suitable for all residents, its use should be limited.”

Harmony Healthcare International (HHI) hopes to offer clarity through examples of supportive documentation on the delivery of this treatment technique.  However, first, let’s discuss some co-treatment combinations.

PT and OT appear to be a natural pairing because of the treatment crossover in neuromuscular and orthopedic deficit remediation.  However, patients also benefit from co-treatments with SLP and OT, for interventions such as self feeding.  During these types of therapeutic collaborations, OT can address postural alignment, positioning, adaptive equipment, and the motor sequence of self feeding, while the SLP addresses bolus size, rate of presentation, and any specific strategies identified to reduce the risk of aspiration; such as chin tuck swallow, or multiple swallows per bolus. 

On occasion, one can see SLP and PT combinations.  This is commonly delivered with a patient who is significantly impaired receptively or cognitively. The SLP may co-treat with PT to assist the patient with comprehension and processing of cueing during ambulation, or transfers by actually training staff how to best facilitate the patient’s ability to follow cues, and by modeling the best approach to elicit patients’ cooperation. Documentation of goals to establish the medical necessity of this treatment modality is essential.

Examples of appropriate goals in support of co-treatment follow:

• Patient will demonstrate self feeding skills with setup assistance x 4/5 consecutive sessions x 14 days, while applying swallow safety strategies with minimal verbal cueing.
• Patient will demonstrate lower body dressing skills with minimum assist while maintaining standing balance in order to complete the task safely in preparation for return to ALF.
• Patient will operate motorized wheelchair at reduced speed from Rehab gym to the dining room while maintaining trunk alignment at midline x 4/5 sessions x 14 days to promote functional mobility in preparation for community mobility.
• Patient will complete homemaking tasks at standing level while demonstrating appropriate dynamic standing balance and safety x 15 minutes x 4/5 sessions x 7 days in preparation for return to home.

In order to support this unique form of therapy delivery, Harmony Healthcare International (HHI) recommends including documentation in the daily treatment encounter notes describing each discipline’s specific goal of the treatment session and the rationale for two therapists.  

Example #1 of a clinically appropriate co-treatment session PT and OT: 

• Patient with poor trunk stability seated on the mat table in the therapy gym.
• The physical therapist is working on manual techniques to initiate muscle contraction in the trunk to increase trunk strength and stability.
• At the same time, the occupational therapist is working on weight bearing through the upper extremities to maintain edge of bed sitting while incorporating PNF patterns to elicit tone and stability.
• This treatment includes the skills, knowledge and judgment of both disciplines to allow patient to receive optimal benefit from skilled therapy intervention. 

Example #2 of a clinically appropriate co-treatment session PT and OT: 

• Bed mobility activity involving occupational and physical therapy.
• The physical therapist is providing vibration stimulation to invoke contraction in the trunk to assist patient in initiating reaching across midline in supine.
• Simultaneously, the patient is supported by the occupational therapist in reaching across to weight bear through hemi-arm when reaching for edge of mat.
• Patient completes supine to sit with maximum tactile cues by occupational therapist and physical therapist to get to the edge of bed with maximum assist of 2.
• (This example of clinically appropriate treatment could not be performed by a rehabilitation technician due to the complexity of the skills required by both disciplines involved). 

Harmony Healthcare International (HHI) recommends that staff therapists receive ongoing education and caseload review in order to enhance working knowledge of co-treatment usage combined with the practical application in the Post Acute Setting.  In addition, Harmony Healthcare International (HHI) suggests ongoing audits to verify that each discipline consistently and accurately documents the medical necessity and rationale for all co-treatment sessions. 

If you have questions about Therapy Co-Treatment, please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413.