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Challenges for Physical Therapists in Critical Access Hospitals

Physical therapists (PTs) are often front and center at critical access hospitals (CAH). In these rural settings, PTs must have expansive knowledge and a vast skill set to best meet the needs of patients and caregivers. A PT must know how to function in nearly every setting at a CAH: outpatient, acute, subacute, nursing home, home health, acute rehab facility, inpatient and outpatient psychiatric, emergency rooms, and more while addressing the needs of individuals across the life span.
Many physical therapists and physical therapist assistants (PTAs) practice in rural areas. APTA’s Senior Payment Specialist Alice Bell, board-certified specialist in geriatric physical therapy, and APTA members Carmen Oguz and Brendon Larsen, discuss important issues facing CAHs today.
What are the unique issues patients and providers in rural settings face as they relate to access to the right care, from the right provider, at the right time?
AB: Rural providers are seeing some of the negative sequelae of bundled payment demonstration projects with a reduction in access to necessary services for some patients, and a potential for rural providers being carved out of provider pools. There is, however, opportunity to form stronger alliances around common challenges and leverage access to legislators. A study by the Office of Health and Human Services estimates that half of the adults living in rural areas suffer from a chronic health condition. The link between chronic health conditions and poor functional performance has been well established. Individuals living with chronic health conditions can benefit from physical therapy to restore function, manage disease processes, mitigate risk for further decline and complications, and, in some cases, reverse the effects of chronic disease.
BL: One of the biggest challenges we face is a shortage of available health care providers -- 85% of rural communities are currently classified as Health Professional Shortage Areas. Therapists working in these settings must wear multiple hats working with a diverse population. Highlighting the advantages of working in rural settings will ultimately help us create a workforce for this patient population.
AB: Access to physical therapist services in rural communities often depends on the availability of PTs and PTAs. Payment decisions that limit the provision of services by PTAs are even more detrimental in rural health care. Physical therapists and PTAs often work as a team to ensure early and uninterrupted access to care. A physical therapist evaluates the patient, develops the plan of care and treatment goals in collaboration with the patient and family, and may engage a PTA to deliver some of the necessary interventions. This team approach is even more critical in rural areas where a PT may need to cover a larger geography. Working together with a PTA, the PT can ensure that the patient’s care is not interrupted when the physical therapist needs to evaluate and/or update the plan of care for a patient in another location. APTA has been working for some time on the restriction of PTAs as recognized providers by TRICARE. With nearly 40% of American veterans living in rural areas, this restriction may prohibit veterans from receiving timely and appropriate physical therapist services. Rural health communities and providers can engage in discussions with payers and local representatives to encourage expansion of the coverage of telehealth services.
CO: Telehealth can be a useful tool to extend the reach of providers and deal with the excessive burden of travel on patients and caregivers. Rural health providers and patients would be better served if the use of telehealth services was expanded to include PTs. The use of telehealth to provide care that is needed in a timely manner can alleviate the barriers associated with burdensome travel. Telehealth can often reduce the overall cost of care by preventing an avoidable decline in the patient’s condition.
What is most important for policymakers or health care leaders to understand about rural health care or access to rural health care?

BL: Policymakers need to know that 90 million Americans currently rely on rural hospitals and that their funding is essential. Since these hospitals suffer from low staffing, high demand, and low repayment, any proposed cuts to Medicare reimbursement would negatively affect their ability to operate. Policymakers should also be made aware that restricting a PTs scope of practice, or independence, will negatively affect the many families who rely on us as health care professionals.
CO: The most important thing to understand is that CAHs can’t be managed like other hospitals. CAHs have a smaller voice. Despite advocacy efforts, there are a number of barriers to receiving high-quality care, including transportation, insurance policies, recruitment, reimbursement, and separate payment methods. The development of additional policies or availability of knowledgeable human resources to improve access and to educate health care leaders and the communities in these areas are necessary.
AB: As stated earlier, patients in rural settings are known to have a higher incidence of chronic disease. For patients and caregivers who are attempting to manage the impact of chronic disease and prevent the need for high-care, high-cost episodes, access to a variety of health care providers is critical. Rural settings have consistently faced challenges in terms of numbers of providers as well as number of available provider hours, due to disparate geography and a larger amount of time spent by providers traveling to locations to provide care. APTA has recently submitted a letter of support for NRHA's Save Rural Hospitals Act (H.R. 2957) to ensure that all rural Americans have access to the health care services they need.  Traditional care-delivery models do not always work in rural settings and critical access hospitals. The need for innovation in these settings is great, and it is important that burdensome policies do not undermine the ability for PTs to create models of care delivery that best meet the needs of the patient and community population.

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