Joint Guidelines for Therapy Co-Treatment Under Medicare

The following guidelines were developed by the American Speech-Language-Hearing Association (ASHA), American Occupational Therapy Association (AOTA), and American Physical Therapy Association (APTA).

Co-treatment may be appropriate when practitioners from different professional disciplines can effectively address their treatment goals while the patient is engaged in a single therapy session. For example, a patient may address cognitive goals for sequencing as part of a speech-language pathology (SLP) treatment session while the physical therapist (PT) is training the patient to use a wheelchair, or a patient may address ADL goals for increasing independence as part of an occupational therapist (OT) treatment session while the PT addresses balance retraining with the patient to increase independence with mobility.

• Co-treatment is appropriate when coordination between the two disciplines will benefit the patient, not simply for scheduling convenience.
• Documentation should clearly indicate the rationale for co-treatment and state the goals that will be addressed through this method of intervention.
• Co-treatment sessions should be documented as such by each practitioner, stating which goals were addressed and the progress made.
• Co-treatment should be limited to two disciplines providing interventions during one treatment session.

Clinical Examples

1. An 86 year-old male with history of high blood pressure and cholesterol, and pacemaker, fell down the stairs at his home and sustained a subdural hematoma. The fall resulted in moderate right sided hemiparesis with difficulty swallowing and expressive aphasia. He was transferred to a skilled nursing facility with goals to include balance and motor retraining exercises, strengthening exercises, transfer training and wheelchair management skills, maximizing independence in ADLs, and improved functional comprehension and swallowing function with vital signs monitored during activity. The PT and SLP perform co-treatments that include the following:
   
   The SLP provides strategies to help the patient with following multi step directions to perform exercises while the PT works with the patient on motor sequencing and motor activity. The PT adapts seating for the patient taking into consideration best positioning to optimize facilitation of swallowing interventions by the SLP.
2. A 66 year old female status post ischemic stroke with resulting severe hemiparesis on the left side was admitted to an inpatient rehabilitation facility 3 days ago from the acute care hospital. She has hypertension, diabetes and is obese. She was previously independent in all activities and working part time outside of the home. She lives alone in a single level house. The patient is being seen by PT and OT. Among her many rehabilitation goals are: to increase sitting balance to perform self care, independence in transfers from bed to wheelchair to toilet, and ambulation with assistive devices. The PT and OT perform co-treatments that include the following:
   
   PT facilitates weight shift and balance training in a sitting position while the OT works on upper extremity dressing strategies and techniques which require trunk stability. PT works on bed mobility from supine to sitting and transfer from the bed to the wheelchair and to the toilet. The OT works on toilet training using adaptive devices and compensatory techniques as well as on dressing and hygiene management skills while the PT facilitates lower extremity weight shift and standing from the toilet.
   
   The PT facilitates balance and weight shifting while standing as the OT works on bilateral fine and gross motor IADL tasks as components of simple meal preparation in the kitchen.
3. A 72 year old male sustained a traumatic brain injury when he skidded on an icy road and collided with a tree while driving home from the grocery store. Prior to the accident, the patient was retired and living in a retirement community with his spouse of 50 years, both functioning independently with all ADLS and IADLs intact. The patient and his wife have expressed a desire for him to return home with environmental adaptations and support services as needed. The patient has a history of mild COPD and a prior right knee replacement. The patient has some residual right-sided paresis and gait disturbance and some difficulty with executive function including self-organization skills and mild memory impairment. He gets short of breath with moderate exertion.
   
   OT and PT provide co-treatment in a ADL kitchen with PT providing verbal and tactile cuing with gait training to facilitate safe functional mobility in and around kitchen, while OT works on cognitive/executive function skills needed to gather items for a food preparation task, such as attention to task, remembering items needed, locating items in cupboard, refrigerator, and sequencing steps involved in preparing the snack or meal.