8- FOXcast PT: Greg Hartley at CSM 2018

Jimmy: Welcome to FOXcast PT, a podcast for clinician’s made by clinician’s. It’s brought to you by FOX Rehabilitation. Find out more at foxrehab.org.

Welcome to FOXcast Physical Therapy. We are at CSM 2018 here in New Orleans and we’ve got our next guest on the show, an assistant professor of physical therapy at the University of Miami where he was also a graduate, Hurricanes, The “U.” He has held numerous leadership positions within the Academy of Geriatric Physical Therapy and he’s right now the academy’s president-elect, taking office later on tonight. He’s the founder of the first geriatric PT residency in the U.S. and former director of rehabilitation for a large post-acute care provider, Dr. Greg Hartley. Dr. Greg Hartley, welcome to the show.

Greg: Thank you. Happy to be here.

Jimmy: We appreciate you coming out. You’re taking control of the section. That’s a big deal.

Greg: It is.

Jimmy: How are you handling that role so far?

Greg: Well, I’ve only been in office for 12 hours.

Jimmy: But I bet you it started before that.

Greg: Yeah it did, So there’s a lot of a big learning curve, but I’m really looking forward to what I anticipate can be some really interesting and rewarding challenges that we face but also some interesting ideas about how we can increase our membership and engage our members a little bit more, particularly with the membership issue.

There are two big populations that I think we should target. One is those individuals who may be members of other sections that don’t necessarily think that they work in geriatrics. Although data from APTA’s research department that I just got my hands on last week actually tells us that, in 2017, physical therapists in private practice as well as physical therapists and hospital-based outpatient centers – so, that’s really the two big outpatient areas –  31 percent of their time is spent treating adults over the age of 65.

Jimmy: I was with one of my colleagues at FOX Rehabilitation here and we were at a PT school, giving a presentation on geriatrics and working with older adults.

The responses were what you would assume in terms of, “I don’t know if I want to do that and I want to work on an outpatient ortho.” And, Heather just put it pretty succinctly and said, “You’re going to be working in geriatrics, working with older adults, humans with older humans. So, you’re gonna need to have a wide skill set because you think you’re going to do all high jumpers and athletes or just anything, but you’re going to be dealing with human beings who need to move. We need to make sure you know how to treat those humans who need to move.”

Greg: Right. So, in an outpatient environment when one out of every three patients that you lay your hands on is over the age of 65, how can you say, “I don’t treat geriatrics?”

So orthopedics or sports or whatever might be your primary interest, certainly the Academy of geriatrics should have something to offer you. You should stay informed about the aging adult. You should get the journal. Know what the research says about mobility and people who are 77 years old because that’s going to be a part of your patient population.

So hopefully, we can engage people that perhaps are not members of the academy now because they don’t identify with the Academy of Geriatrics. I would like to sort of change that a little bit and help them identify with that aging adult population.

Jimmy: Where do you go if you wanted to start with orthopedics? Do you go to the ortho section president or do you, like, where do you what do you think your sessions will start?

Greg: For example, yesterday, we did a session on this very topic: the growing needs of aging adults.

We did it for the ortho section. It was programming for them, so it was in a huge room. We had it near capacity, full of folks, mostly orthopedic section members. So, we got to sort of send the message of: here’s the demographics of the aging population in the United States, and, this is the fastest growing population in the United States.

I shared the data: one out of every three patients you treat is going to be over the age of 65. So if you don’t think you’re working geriatrics, you might want to rethink.

Jimmy: I got news for you, I got data for you.

Greg: So hopefully we got some people engaged yesterday in that session and hopefully we’ll continue that. So, I think we can target larger sections and maybe get some crossover, not to take membership away from ortho because that’s certainly where they identify and are primarily but also hopefully encourage them. That’s one group of people that I think we have potential to grow.

The other is the early professional and the student. So, I think we really have to engage the early professionals. Geriatrics kind of has an image issue that I think we need to work on part of it is the same messages. “These are the patients you’re going to be treating. You need to engage in a section and an academy that’s going to give you some resources to help you deal with that.”

Jimmy: The other thing I want to want to point out is specifically for students or new professionals. You can 100 percent be a part of two different sections of the APTA. You can be a member of all of them. So by all means you know treated as a part of continuing education as jumping into the section for a little while.

Greg: I’m a member of four sections.

Jimmy: What sections are you in?

Greg: Education, health policy and administration, and neurology.

Jimmy: So you’re not pigeonholed by just going into one particular section. You’re saying, “Hey, this is where my skill set lies. And I would like to improve in these areas. How do I do that? Get around some of the people who are like minded right.”

Greg: I mean, I’m an educator so I would be remiss if I didn’t be a member of the education section. And, my interests are in neurology as well as geriatrics so of course I’m a member there. So, there’s plenty of opportunity for people to be members in multiple academies and sections. I would encourage that. So that’s a huge market for us I think to grow as an academy and hopefully expand our message the early professional and other target population. I think we really have to increase our social media presence. That’s one of my strategies as the incoming president is to try to engage the early professional student in a much more interactive way and the way that they will actually engage.

 

Jimmy: I love that. So here’s a crazy idea: podcasts!

Greg: Right. So that’s kind of where I see us growing.

Jimmy: Well, you’re just you’re just getting going. I’m excited for it. Going back to it more on a clinical topic, some of you are passionate about the provision of skilled care.

Greg: Yeah, so this is a chronic issue I think that we have had in certain settings and part of it I think is based on inherent ageism. We talk about ageism in society we talk about ageism in policy and discrimination issues related to age. But I think we have to self-reflect because I think physical therapists are ageist.

Jimmy: Are we guilty of that ourselves?

Greg: Absolutely. 100 percent.

So we under-dose our aging adult patients because we may look at that patient and say, “he’s too old to make improvement,” or, “there’s no potential,” or “he’s maxed out,” or, “I got him back to prior level of function, so that’s good enough for me.”

We don’t think about what chronic conditions that individual was living with before he ended up in your practice and how you might not only deal with the primary issue that he was referred for but also the underlying chronic issues and maybe get that person better than they were when they came to you.

That’s one of the issues is that I think we tend to under-dose: strength training. I mean how many times have we been in a facility, whether it be an outpatient clinic or a skilled nursing facility or a hospital, and we see a therapist or a physical therapist assistant put a two pound ankle weight on a patient, put them over a bolster and say, “Do this you know short our quad three sets of 10 and then come back a few minutes later and say, ‘Mr. Jones, did you get those three sets of ten?”

“Yeah.”

Find what you want me to do. Now move on to the next exercise that doesn’t necessarily challenge ration either. And then at the end of the day we call that skill therapy. We call that strength training. That was the goal. So I would challenge the physical therapist and PTAs out there that, that’s not skilled therapy and in fact it’s likely malpractice sure to practice.

Jimmy: Yeah, I want to repeat what you just said because we’ve got an audience of people online on the podcast and walking by: If you’re not challenging a patient, that’s tantamount to malpractice.

Greg: Absolutely. 100 percent. So if you’re not using your degree and your license at the top of your license to dose exercise appropriately, if your goal is strength training your resistance that you provide to your patients less than 60 percent, then you’re not strength training.

So how you establish that target zone for strength training is super important. And, I just don’t see that happening in a lot of places, at least not routinely. And the same it’s true when you put them on a restorator for five minutes or 10 minutes and you come back and say that’s skilled therapy when you never even checked their heart rate or their response to the activity.

Jimmy: Listen to 1 rep max and how to strengthen a muscle that works no matter what they do no matter what you do. You’re one rep max might be a little bit different right. But we got to hit 60, 80 percent. Greg: Exactly. There’s easy ways to do that, to estimate the amount of resistances necessary so you know there’s a paper on that from Dale Avers and I believe Rosemary Black. It’s a white paper on strength training age and it also would encourage people to look out for that. It actually talks about these issues and goes through the steps of how to estimate a 1 rep max.

Jimmy: You want to talk about that say great we talk about that a lot here at FOX Rehab. Tim Fox is you know you sound a lot like Tim. He’s got a little longer hair than you little different accent. Yeah that’s what we want to hammer home. You know, if you’re call and skilled and someone comes in and questions you yet are you going to stand behind that. Absolutely you wouldn’t do that front of an audience.

Greg: And your documentation has to support that as well. I mean, that’s where you’re going to be gauged on whether or not you’re going to be receiving payment for service. So, that documentation has to reflect the skill the skill needs to demonstrate the decision making that went into why you chose that much weight or why you chose that many reps or why they did that aerobic activity for X number of minutes, whatever it is it doesn’t really matter, balance change or whatever.

Jimmy: It goes back to math and in sixth grade.I was terrible math, especially in sixth grade. It was like, “Give me the answer or explain how you did it. Can you stand behind this? Can you explain why you did that? Someone get a question. If so are you sound in that?”

Greg: You know, the documentation of just writing down an exercise and how many reps and how much said somebody did that doesn’t reflect skill. The clinical decision making that went behind it why you chose that, that’s the skill.

Jimmy: So you’re in an interesting role clinician, educator and now leading a section. So you’re very passionate about advocating and policy.

Greg: We had elimination of the hard cap. After 21 years of fighting for that in physical therapy, we actually had a permanent repeal of the cap on Part B. Now what it does is essentially make permanent the exceptions process. So we still have the KX we still have the process of what we had before but now we never have to fight this battle again after 21 years. That’s a huge win.

And, who does it impact more than members of the Academy of geriatric physical therapy? Because that’s our patient population our patient population is a Medicare population. And so if this doesn’t impact you and you’re treating older adults then I’m not sure who else it would impact rather than more than us.

So I’m very passionate about advocacy. The next big thing for us, I don’t know what that’s going to be but we will have the next big thing. We will need to deal with the payment parity for telehealth. We need to deal with payment parity for PT versus PTA because that was one in the legislation that came out. So we’ve got a lot of battles before us. The other big battle coming before us is going to be in post-acute care so we’ve got big payment reform initiatives coming for skilled nursing we’ve got a huge payment reform issues coming for home health. So trying to deal with the political aspect of making sure that our patients get the care they need and then obviously that we get the payment that we deserve.

Greg: Those are big important issues that I think people don’t understand the connection between the importance of participating in a political action committee giving even if it’s just a dollar giving anything to the PAC so that we can have some influence on Capitol Hill because like it or not that is how things get done in this country. And it’s interesting to note that only about 6 percent of the members of APTA actually give to the PAC. And if every member of the APTA gave 20 dollars we would be the largest healthcare PAC in the country. How powerful would we be and how much influence should we have on Capitol Hill.

Jimmy: One thing that I’ve been doing you know podcasting and reporting and talking with people in this field for going on five years. I just found out today that none of your dues as an APTA member can legally and do not go to the PAC. It has to be a donation by a member. I just found out today I just assumed part of my dues went to the political action committee.

 

Greg: No that’s for legal reasons sure like you described that can’t happen. So PAC donations are separate. We have people that can make large donations, but seriously, one dollar, two dollars, skip a cup of coffee one day and give three bucks to two of the PAC.

Jimmy: I heard a great line.

“What is the political action committee?”

“How does it work?”

So if the APTA is a big old Harley, the political action committees the cool side car with the dog with a tail wagging at the side. That’s how we talk to Washington D.C. where all the decisions are made. We’ve got to be there that you know you brought the the cap repeal but that just happened overnight. Right? Of course not. Do you want to go one year 21 years just counting them.

Greg: If that’s overnight.

Jimmy: Right yes. So you could stop all the work with the political action committee right now. You would not notice today. You’re not going to notice tomorrow. Six months, a year from now you’re going to notice and to get that momentum again. Not a chance.

Greg: I’m passionate about it because I care about our profession. I’m passionate about it because I care about patients. I’m passionate about it because I care about health care in the country. But I think for the member of the Academy of Geriatric Physical Therapy these Medicare issues in particular affect us more than any other academy or section in the APTA.

And so, I would really encourage and challenge members of the AGPT to give, just give something even if it’s a dollar or two dollars, 10 dollars, 15, whatever you can afford but also: Put a value on how important you think political action is and if you think that’s an important cause if you think that it’s a win for PTAs to be able to participate in the tricare system, if you think that those things are important to your practice.

Jimmy: Then make a donation just as a show. We have a tradition here of a show it’s called the FOXtale comes at the end. Why did you choose to work with older adults and why do you continue to work with older adults?

Greg: It sort of happened by accident. My grandma was involved in an accident and you know a lot of people have a similar story. So I was exposed to physical therapy that way. Her accident was pretty significant. And I saw what tremendous change and her overall quality of life physical therapy made it enabled her to stay home longer and enabled her to live a higher quality of life almost right up until the very end.

So, That got me interested in physical therapy. When I went to PT school I wasn’t sure what area I would go into. Is it going to be orthopedics, sports or geriatrics. I had no idea. And but once I graduated I started working mostly I was at the VA for a while but I started working mostly with aging adults. And I found that the changes that were happening in physical therapy were so. Even when they were small changes they were so meaningful that they were so they enable people to have huge changes in their overall quality of life.

So it wasn’t about getting one grade stronger in strength it wasn’t about gaining 10 degrees of range of motion. It was about, “Can I stay home rather than go to an institution?”

That’s a big change. It’s huge.

So I started realizing that those small changes had been even when they were small had huge life changing sort of outcomes. And I just felt like that that was the best way I could contribute to this individual’s life. So that’s that’s why I keep doing it. The outcomes are so worth it.

Jimmy: I love that. So is it Dr. President Hartley, or President Dr. Hartley, congratulations on taking over the section of big things and I appreciate you taking the time out for FOXcast.

Jimmy: Thanks for listening to FOXcast PT, a clinically excellent podcast. It’s brought to you by FOX Rehabilitation. Listen to other episodes or read articles and position papers at foxrehab.org.