Day in the Life of a Physical Therapist | Skilled Nursing and Long Term Care Setting

[0:09]Good morning everyone. Happy Tuesday. Welcome to Megan's channel, Sierra and for today's video, Megan and I thought it would be fun to do like a daily vlog, but kind of specifically focused on us working as physical therapist in skilled nursing long-term care. So, for today, it is 5:40. I got 5:40 and then headed to the gym. Typically on Tuesdays, Megan and I, well Megan and I will alternate working out usually in the morning and so Tuesdays are typically my morning workout days and so I've been getting up at like 5:30. Um, I used to get up at 6:00, but I've been getting up earlier so I can get into work earlier, although today is a little bit different. Because I had a doctor's appointment at 7:30, so I'll get into work, not late, but later than I have been.

[1:23]Good morning, guys. Um, for today's video, Sierra and I are doing a day in the life of being a physical therapist, but we're doing it, um, kind of more in-depth than we typically do our day in the videos and it's going to be more focused on PT related things rather than like the rest of our day. Um, so I thought that this morning I would kind of show you guys, or I would talk about maybe common terminology that we might say in this video to share what it means, so hopefully there's less confusion later on. So, first and foremost, Sierra and I, there's different settings that people work in for physical therapy. Um, you can do outpatient, you can do acute care, you can do peds, you can do home health. Um, there's many settings and any physical therapist can work in any setting, you don't have to have any specific, um, certifications. But, Sierra and I both work in skilled nursing/long-term care. They kind of get lumped together because they're both in, um, nursing homes. And so, typically what that means is most of our case load is going to be what are called skilled patients and that just means that these are patients that are coming from the hospital after some sort of injury or infection or illness, um, and they're not back to their baseline where they're safe to go home. So, they are here to get therapy to hopefully get back home. Sometimes it a transition where, okay, they're not going to end up being safe to go back home, so then the plan becomes do they need to move into assisted living, do they need to move into long-term care. So, that's all kind of like discharge planning and stuff like that, also a part of our job. Um, and then beyond that, um, skilled therapy kind of requires certain things for insurance. So, these people need to be seen five days a week, usually that's Monday through Friday, um, but sometimes like you could get PRN coverage on a weekend or if it was holidays, you could shift coverage. Um, but it's supposed to be seen five days a week for insurance purposes. Um, and then you have people who, you also might call those people part A because with Medicare, um, part A Medicare covers inpatient services, which includes skilled therapy. And then part B, you might hear us refer to part B people. That's anyone who is technically outpatient, so that would be someone who is either a long-term care resident, um, and they're being put on therapy for whatever reason. It could be someone where Sierra and I both work on kind of campuses that have also assisted living and independent living. So anyone who wants therapy and wants to do it at the facility, they would also be part B because they're technically just considered outpatient. Um, so we kind of do a mix, we see a variety of people. Like, we mostly, like I said, are seeing skilled patients and long-term care. However, like today, I have four outpatient people. That's going to be like how my day work is treatment. Um, so it just kind of depends on the day. But, um, another kind of aspect in our job, I guess, is that with most, um, people that work in this setting for therapy, your work day kind of depends on how busy your census is, so how many patients you have. Um, and I think that both of our buildings are pretty full right now, so we have like very, pretty full days. Um, but there are times where we maybe don't have as many people on our case load. And since we're both paid hourly and we have productivity standards, then that means that when we're done seeing people and we're done with our documentation, we leave. Doesn't matter what time it is. Doesn't matter if you're not at your eight hours, you're gone for today. So, sometimes it's nice, sometimes, um, since we're paid hourly, then obviously means if there's no work, you're not getting paid. But, I'd say for the most part, like I have been pretty consistently getting like seven, eight hours every single day. So, it's not a huge deal. If anything right now, since our case load's so busy, and I have my outpatient people too, I'm definitely trying to get creative with doing group and or concurrent, which is another terminology I can explain. So, group therapy, it's not ideal. I prefer one-on-one therapy, but also with how busy our case load is right now, you kind of got to try and do what you got to do. Um, so group therapy is when you're getting, um, it needs to be at least two people, but it could be up to like six people. Um, and you're getting them all together and you're doing the same thing, so that could be seated exercises. You could do more some things, too, depending on how creative you want to get, the sky's the limit. But, it's just when you're getting people and doing therapy with more than one patient at a time. Um, so it helps kind of decrease the amount of time or your treatment time, because you're getting more people done at one time. And then concurrent therapy is when you're seeing two people, you don't even have to do it for like a full session with some with two patients. Um, but let's say I'm finishing up one person's session and I have them on like the new step or something else. It could be anything. Um, but it needs to be two things where you feel like you can adequately supervise both patients at the same time. So, for example, if I'm finishing up one person's session and we end up with doing 10 to 15 minutes on the new step, I could then go get another patient or, like, if another patient's in the therapy gym and they just finished with another therapist, I could see them at the same time and do something else while the other person's on the bike, and that's just another way to try and like get your treatment time done within your work day if you've got a super busy day. So, like I was saying, because our case load's very full right now, I'm trying to think of like people in my head that would be good to try and do that with today. Usually, um, I get to work around 8:00. Um, that's another perk of our setting is you come when you want and then you leave when you're finished for the day. Another thing we can talk about with being a physical therapist is the documentation side and kind of the non-patient care stuff. Um, first of all, when I when I mentioned productivity earlier, um, what that means is obviously, at the end of the day, everything is a business, including health care, including the companies we work for. And we get paid, like physical therapists and the industry get paid based off of the units that they bill. And so, for physical therapy, you build different things like therapeutic exercise, therapeutic activity, neuromuscular re-education. There's different modalities you can build, some of them are time codes and some of them are non-time codes, um, but for the most part, like the time that we're seeing a patient and however that doesn't being, that's going to get billed via units that we document. Um, and so, really we're only being, um, what's the word I'm looking for? We're only being profitable for a company when we're actively seeing patients. So, obviously, they want to see patients for as much of our work day as possible. Um, but you also have other things you have to do, you have documentation that you're not always able to do point of service. Um, and there's just other things in your work day that might come up that it's not directly billable time. So, in our setting, and most inpatient settings, there's a productivity standard that each company kind of sets on their own. Um, and I believe that my company's standard is you're trying to aim for 85% of your day is patient care time. So, that means if you have like 6.8 hours of treatment, then that gets you to a full 8-hour work day to allow you to have the extra time to do any extra documentation or whatever else, whatever else you might do. Now, I don't always meet these productivity standards. And at this point in time, other than like a little slap on the wrist or just encouraging to document point of service, like nothing really has happened from like a like there's been no punishment for me not meeting productivity standards. But, it's just like a goal to work towards and you'll continue to get encouraged to meet your productivity. Um, concurrent and group therapy help you meet your productivity standards if you're like because that means you're seeing more people even if it's at the same time. Does that make sense? So, that's why, like, the productivity, uh, standard is the reason that I'm not able to only have like, let's say if we had a super low case load and I only had like five hours of treatment and I'm done at like six or seven hours of my day, like, I can't just sit there and do nothing to get paid. I'd have to leave. Another perk to working on the inpatient side of things is the dress code. I get to wear scrubs. Honestly, my company and most skilled companies, I feel like the dress code's pretty much like, doesn't matter what you wear. Um, like you could wear business casual if you wanted to, but who wants to do that? So, I always wear scrub pants, sometimes I wear scrub top, sometimes I just wear like, I'm wearing a long sleeve athletic shirt today, got a cozy little vest on, and I just love being cozy, so dress code is definitely a plus.

[10:57]All right, I'm officially on my way to work now. It's 7:45. Finished up with the doctor appointment I had. And now we're driving into work. I had a good workout this morning. I, if you know from our recent video, I'm trying to go on a running journey. So, this morning's workout was a run. It was on a treadmill for like 45 minutes. Did some walk running and I got like 3.7 miles, I think.

[11:21]So, not too bad. I did like warm up and cool down for like five minutes within that. Not that I need to defend myself.

[12:11]All right, it is 4:20. I'm done for the day. Busy, busy, busy day. Um, I'll do my debrief probably when I get home. I will talk through patient test I saw today, what they're here for and being seen for and any highlights for fun things we've been working on in therapy.

[12:32]Okay, I am back home from work. Um, I figured I would talk through the patients I saw today. Um, some things that I was working out with him and then if it's applicable, I took some clips this morning of just different things that we have in our therapy gym. Um, that will give you a better idea of like what it is we're actually like using or what I'm talking about. But like just holy cow, busy day. Our census right now is full basically. And then our outpatient's also kind of busy, too, um, so it just was a busy day. I had three people I saw outpatient, lots of skilled patients. Um, so anyways, usually the hardest part of my day is seeing who is ready to go first thing in the morning. Um, cuz sometimes like therapy can be helping someone like get up out of bed and kind of like get situated for the day, but then usually people like to eat their breakfast like before they have therapy. Um, slash like I don't like that to be every single session is like getting someone up out of bed. So, um, you just kind of have to find the best place to start, I guess, for the day, usually. Um, but when I got in, I was in around 7:45. I just like to do kind of a schedule review, get things printed out. I personally am a paper copy gal. Like, I want my schedule printed out. Um, and I write stuff on it. Like I'll write, um, vitals on my paper copy if it's appropriate or needed.

[14:02]I will write, obviously my in and out times because that's how I keep track of what I'm billing for different patients. I'll keep track of co-treat times. I'll keep track of like standing duration sometimes and really probably be the main things, I guess. I'm going to try and like go through this in a way where it's interesting and not just like exhaustive. So, started my day with someone that was a new admin yesterday, so this was my first actual treatment session with him. Um, and he had still been in bed when I decided to go in and work with him, but he was at least agreeable to do his full treatment session with me and then do breakfast. So, sometimes I like to do that so I don't have to like circle back, cuz I if I can avoid it, I hate splitting up treatment times with people. It's just not ideal. Um, so in bed mobility was one of the things he needed to work on anyways. He had been in the hospital for an acute kidney injury, so there's no major things going on. He's just generally weaker and has, um, less strength than prior to his admission. Um, so the good thing is we're just kind of working on general strengthening and endurance and trying to progress that, so we did some short distance walking with the walker. We did some standing tolerance, we did bed mobility, um, things of that nature. Next person on my schedule was here because they were admitted for a COPD exacerbation. He is pretty much contact guard to standby for all mobility, but he just gets fatigued and worn out very easily, and I'm monitoring his oxygen and vitals to make sure that those are going okay. Providing cues for purse lip breathing. I also worked on some standing balance with him as well and doing unsupported standing, um, just to make him safer with mobility and his ADLs. ADLs are activities of daily living, so anything that people have to do throughout their day, so like getting ready in the morning in front of the bathroom or preparing meals, things of that nature. Um, usually that's like a term we use just to like say, we're doing XYZ thing to facilitate safety and balance for in ADLs or what have you to tie it over to the functional reason we're doing what we're doing. Another patient we're seeing, he kind of is a little bit more complicated. So, he has a history of left side, left-sided stroke, but he came to us because he had a fall, and then he broke his left femur and also left humerus, so he's non-weight bearing on that side. And then hemiplegic on that left side as well as fracture. He is weight-bearing tolerated, though, so that's good. Um, he's come a long way. His transfer status was staff, is he uses what's called a disc pivot transfer, and I hadn't seen this at any of my clinical sites or my prior place that I worked. Um, but these things are pretty nifty for the right patient. I actually really like them. Um, you basically do a pull to stand, and then the disc, like, they're on just pivots so that they can turn and transfer into like their wheelchair or something else. Um, and he's been doing well with that. We have to help with like positioning and weight bearing through that left side. Today we mostly focused on those transfers and then standing unsupported in the parallel bars. Um, I'm providing like a knee block to that left side to help with weight shifting and because it's not as strong. And then we also did some unsupported standing, um, just to help him encourage putting weight to that side and then I was doing a co-treat with OT where they helped kind of work on reaching and then he's kind of a heavy assist sometimes doing the pull to stand, so we needed a second person for that, too. Didn't do this today, but I also got a video of one of our outpatient pieces of equipment called an omnicycle. Um, and so, this is handy because it doesn't have a chair, so people in wheelchairs you can just wheel them right up to it, and you can use it as like an arm bike or leg bike. You can use it for there's different programs. So, if someone has more of like an ortho problem and you just want them to do it for resistance on their legs, you can do that. But, it also has a neuro program, um, which I've been doing with him since he has a history of stroke, um, because it'll just have the pedals go a set distance, but like the person can also try and activate their muscles, and it has like a little feedback thing on screen to tell you what percentage you're doing with what, um, muscles. So, it's also good just for maintaining range of motion, if someone can't move their leg, um, but the more they're able to kick in and help, then they can also get some resistance and stuff. So, he has been improving that because his percentage, I've been monitoring what I had been prior and what it was most recently, and his percentage on the left side's going up, so that is good. One of my outpatient people, um, is someone in assisted living. We are actually just working on transfers with her and trying to make sure they're safe. We've kind of been exploring both stand pivot transfers and slide boards just to see what would be the safest for the patient and the staff that help do her transfers. Um, so that was what we did with her. One of my patients on my schedule was actually out in the hospital, so I did not see them today. I actually had to do a discharge for them cuz usually when people are admitted to the hospital, we have to discharge them. One of my other outpatient people, um, I actually discharged her today cuz she met all her goals, but I was seeing her for chronic low back pain and just, um, decreased balance. But she met all her goals, so we discharged today. One person had been here skilled and then they were in the hospital for a little bit and then they came back because they had a GI bleed and just some abdominal stuff going on. So, they're still quite weak right now. We're trying to just work on building strength up again, working bed mobility, transfers, walking cuz he's just overall very, very fatigued right now. But I got him to participate more than more today than I had been in the past couple days, so that's good. Um, another one of my patients, I actually can't remember exactly what brought him to the hospital. It might have been a fall, but no like major injuries. Um, we've been seeing him because he obviously needs to be safe enough to go back home. But he has been, um, a little bit tricky just because he also has like vertigo or dizziness of some kind going on. And we did do a Dix-Hallpike assessment on him, but he hasn't had any nystagmus and it's not really reproducible in the ways that typical BPPV is. Um, so I think it could be something else that's kind of contributing to that and I'm not really sure entirely what I need to do to address it. He's been taking meclizine to help with the dizziness. Of course, today the facility ran out, so his dizziness was a little bit worse today. Um, generally he's doing the walking with a walker and he has a full flight of stairs he's been able to do that like contact guard, but his dizziness was just a little bit worse today. So, I, um, opted to keep him in the parallel bars just because that way he has a little bit more feedback by keeping both hands on the parallel bars and work just safer. So, that was what I did with him. Another one of my patients is here skilled after having a pretty complicated back surgery, so they have to wear a TLSO. I hate those things. Like it does not fit her well, but I hate those braces so much with a passion. But they basically have to be on all the time after back surgery and our job as a therapist is no matter how annoying precautions or restrictions are, it's our job to try and enforce them. So, she is also, she had a recent fall on top of this and she is also non-weight-bearing in one of her arms and is supposed to have in a sling. Um, so we got her into the parallel bars today for the first time and we're able to help work on standing. So, we did multiple bouts of that. Gets fatigued easily cuz she hasn't done a lot of standing, um, but it was good to try and boost her confidence a little bit. Another patient, he actually had been here when I first started working here, then went home, and is now back because he had a fall. And so he has a pubic fracture, um, and that typically is not something that they're going to treat surgically, so he's weight-bearing tolerated.

[21:16]He had a little bit more pain when he got here. Obviously, he's also here because he's unsteady at home and we need to work on balance and safety awareness. Um, increasing compliance with his walker because we discharged him with a walker, and he was walking around without it. So, we're trying to work on that as well. Um, did some stairs with him for the first time. He's generally like a contact guard to min assist type of person. Just taking more time because of pain, decreased endurance, um, but we're trying to work on building that all back up. Okay, I think this is my last person to talk about. Um, I had one other outpatient person today. Usually the PTA, um, sees this person, but I had to do both a progress note and a recertification today because sometimes just with how the dates of when different documents are due, um, you sometimes have to do both. And so that's what I had to do today. Um, and so, she's being seen for, um, she had a previous compression fracture, but that's healed and now she just has, um, like left low back pain. Um, she also has history of scoliosis, so that's probably also contributing as well. Um, but I was just trying to work with her on like some general postural stretches, did some manual therapy on her as well to try and decrease some of those, uh, like tender trigger points and was instructing her on different things she could do at home, different stretches, some core strengthening. But with my outpatient, I usually like to spend at least part of our session in that like back room area we have on the mat table, whether it is for manual treatment or I just feel like it's an easier and more private spots to like talk about goals, discuss if they're wanting to change any, anything regarding plan of care. So this person we bumped down, um, since they've been on therapy for a while, now is an opportunity to decrease frequency and see if we could manage that prior to discharge, so we bumped down to just once a week. Other things, too, since I got a video, I didn't have this person on my schedule today, but we also have someone who's on our case load who has a stroke that we've been working on walking. So, I took a video of myself using a hemiwalker cuz that's been the assistive device we've been training him with. Um, we had been using a large base quad cane initially, um, which he was doing okay with that, but when he did have a loss of balance, it sometimes would require like min assist from myself to correct. And we're really trying to optimize like independence, even if it means we have to compensate in some ways. So, we switched over recently to using the hemiwalker and he's more steady and stable with that. So, I gave a little demo of how you use one of those cuz I feel like a lot of people probably haven't seen those before unless they've seen or worked with stroke patients. 5:00. I'm sitting in my car. I'm still on my work parking lot, but I figured I would talk you through some of my key patients today in order to the best of my memory. So, I came in, I think I had like just under seven hours of treatment time. Um, and I had two EVS, two progress reports, and then I was supposed to do a group of three. And so, like with that group of three, um, they were each scheduled for 45 minutes. That doesn't count towards my total treatment time. I mean, like it does when I do billing and stuff, but like my projected time in facility is based on that group of three, essentially, it's treated like time-wise as like one 45-minute patient. Um, so, I start off with my two EVS because I just wanted to, one was skilled, and then one was a part B Eval. The skilled I'd like to see, like pretty much as early as I can just to update staff on like if they like what their transfer status is and things like that. So, typically with the skilled Eval, I start with a chart review, look at why they went to the hospital. This person had a fall at home and then they had A-Fib noted when they were in the hospital. Um, key things to note are they had any precautions. She did not. Because she was in A-Fib, I did take her vitals, um, and like keep track of that during the session. Her vitals were fine during the session, which was good. And then we're basically just looking at, um, education, figuring out the home environment is, figuring out their prior level of function, and then, um, I kind of do this little spiel of like, today day one is just us kind of figuring out how much help you need if any to do X, Y, and Z. Typically that includes getting in and out of bed, getting in and out of chairs, how far can you walk, um, what does your walking look like, what does your balance look like, what does your strength look like. We do a whole assessment and then I give nursing staff recommendations for how I would say to transfer this patient, whether it's one person helping with a walker, um, a mechanical lift if they need it, um, two people helping, things like that. Um, all in all, a pretty easy Eval, good start to my day. Um, then I had a part B Eval that basically means a resident who lives out of facility. And it was an easy Eval, his Eval was actually also easy because typically part B Eval are for like a fall or a decline in function. His was, um, like a quarterly review and we were picking him back up for restorative therapy. We have a restorative program at my facility where we have two aids that can do like exercise or balance programs or whatever programs we want with residents. He had previously been on one and like he time-wise can be due for being on it again. Um, so basically my Eval today was just making sure he's independent in facility with his walker. Reassessed all that, make sure that looks good. Did like a quick balance assessment to see how his balance was. Mild balance deficit, so we'll probably work on that a little bit. And then we'll re-establish his restorative program. Um, he's mostly doing like the new step bike, um, I think for that, maybe walking also. So, his Eval was also very easy. Then I did my group. Uh, we did an exercise group. I had three people, um, working on, we do like a little warm-up, we get our legs moving, run through like seated exercises. And then we end with like having everyone do some sit to stands as like a functional task related to doing lower body strengthening, why it's important to them. And then, um, do a little cool down stretching. And then I think I saw one more person, yes, I saw one more person before lunch. Um, it was just another part B working on safety awareness. She has dimension, so she tends to lean for walker behind, requires lots of cues to like position her walker appropriately. So that's what we're working on. And I had my lunch break. And then, um, afternoon, not like uneventful, but just like, I had one guy I saw. Um, we're doing mostly walking with him. Uh, try and work on coordinating cuz he has Parkinson's and tries like he also had a hip fracture. He brings his feet very close together and it's basically like kind of tripping on himself and he gets tired. So, working on, um, making sure his coordination doesn't break down as we walk those longer distances.

[28:13]He did pretty well today. Um, someone, I had a work comp person. I've been seeing her kind of on and off. This is her first visit after a little bit of time off. Um, she's got what I think is like some hip and dominant pain. That's what I'm trying to work on with her. It was kind of like a partial reassessment today when I saw her since it's been a hot minute. Um, I saw her for about an hour. I did some like body mechanics training and stuff for like lifting, um, heavier loads. Yeah, I just, I think I, the rest of my people were also skilled. So, like basically everyone who's skilled, we're working on strengthening, endurance, functional tasks, um, kind of per what they can tolerate. So, that was my day. It was a pretty full day, honestly. I think I was just over 8 hours. So, yeah, now that the work day is done, I'm going to head home. I'm just getting ready to get changed in my work clothes, but I did want to say that one of my favorite things about being a PT, and this could, I'm sure, work for other healthcare professions as well, but when I leave work, like, I'm not thinking about work. I leave work and I basically don't have to do anything work-related. Um, the only thing is sometimes, like, sometimes patients just like stick around in my mind, or I'm trying to come up with like better ideas, so if anything, it's more so like sometimes just bouncing ideas back and forth between myself and Sierra to see if she has any ideas. And or like, um, continuing edits that I have to do outside of work. Usually, um, and then also, you know, I might look stuff up myself just if I'm trying to again get ideas, or if one specific patient is kind of making me have to think a little bit harder, or things to try. Um, and then also having to do a little bit more outpatient-related stuff, which has been a little bit since I've done a lot of that in school, and I'm just kind of getting used to that again. Um, sometimes, like, I have an outpatient work comp Eval I'm doing tomorrow for back pain. Um, which I'm pretty sure it's mostly just a strain because they got injured while they were transferring someone. Um, but I might just kind of review if there's any specific tests. Can you stop, Vegas? I might just kind of think through in my head a little bit of like, what do I want that Eval to look like? What things do I want to take a look at? Um, and kind of like a starting place for treatments that I might do, but other than that, like I get home from work and out of sight, out of mind.