It was my privilege to be the co-author of this article (published in the October 2012 edition of IMPACT, the Private Practice Magazine of the APTA) with Stacy Mentz, PT, DPT, PCS.
Therapists opening a pediatric practice or transitioning from adults to pediatrics should be aware of the unique challenges and demands unique to this niche market. These include the overlap with other disciplines, the potential for long term care, the maze of funding sources, the inclusion of family in the treatment process, and the physical demands that are placed on the body.
Children are not just little adults, even when treating a straight orthopedic injury. Children seen in pediatric practice have challenges affecting their ability to develop at the same rate and quality as their peers. This may include those with straight orthopedic challenges but usually the majority of the caseload are children that will have a “lifetime” diagnosis such as cerebral palsy, autism or Down Syndrome.
Because this population has more neurologically driven needs, contending simultaneously with changes that occur as any child chronologically ages, and changes that occur as a result of their diagnosis, many children are seen by multiple disciplines. This includes PT, OT and ST.
PT and OT particularly have overlap and blurring of services and treatment approaches. That makes it essential for good documentation to occur justifying the need for both services by differentiating what the focus of each discipline is. Communication is key – it is easy for parents to get confused by the disciplines, and who does what, and you have to factor in time (and this is time consuming) to make sure you talk to all your colleagues if you are sharing in the care of a child. Practices that offers multiple disciplines makes cross-disciplinary communication easier and more efficient.
Children seen, often have challenges that will affect them across the lifespan and are often seen for long periods of time. This allows therapists to develop a relationship with the families that can go beyond what is considered ‘normal’ for a therapy relationship. As a therapist you often become involved in the dynamics of the family relationship. While this can result in improved care for the child, sometimes a therapist can stay too long, leading to burn out. Suggesting a change in therapist may become appropriate; generally children are able to handle this transition easier than their adult family members.A different therapist can provide new eyes into a child, and see possibilities that the previous therapist wasn’t able to see because of the length of time they had worked together. It also gives a child a chance to generalize their skills out. Challenges can be that the child has a great relationship with the therapist and they know how to work together. As one family has said though, ‘the fact that my child can walk can’t be a secret between the two of you forever!’
With regards to pediatric therapy, there are multiple funding sources which any clinician in pediatrics must explore and understand. Therapy funding for children may fall under IDEA parts B and/or C, which provide federal regulations for state funding of services. Each state has different eligibility requirements and criteria that need to be met. In addition because of the potential for overlap of funding sources, many providers will claim to be the ‘payor of last resort’ and/or will deny treatment if other sources are providing treatment due to ‘duplication of services’. With regards to insurance companies, many companies will only provide services for injuries and not ongoing services which can be a challenge for a family that has a child with needs that will span a lifetime. Often insurance companies will fund rehabilitation for an injury and not for an ongoing process. The Affordable Care Act recently upheld by the Supreme Court will now add a new opportunities for coverage for children, especially those with pre-existing conditions and long term conditions. Pediatric therapists need to stay up to speed on this as the new regulations unfold in order to best advocate for the children.
IDEA parts B and C cover funding for children under age 3 for early start services and children ages 3 and older that qualify for educationally based services. Both provisions have their own set of unique challenges; early start services specify that they need to be provided in the natural environment which is generally the home or daycare or out in the community (not in a clinic setting) and educational services need to be provided at the school or educational facility. In addition to potentially having clinic space available for children, you often have to be able to provide home based and school based care as well, which changes your overhead costs and your business model (this can be a positive, and great way to expand services when you are ready to do so). If you are seeing children in your clinic, and you have an adult based population currently, you may want to consider creating a separate area for treatment because the equipment tends to be different (i.e. toys) and the approach to treatment has the potential for more noise (i.e. singing, musical toys) that may be disrupting to your other clients.
While the focus of your treatment is on that child’s specific needs, because they are dependent on their family, you are also spending time and energy educating the family or the primary caregivers of the child. There always needs to be carryover of training and skills because the child spends the majority of its day outside of physical therapy, and consistent repetition is how they learn. Factoring in if, how or when to bill for this time spent with the family can be very perplexing and complicated. If the caregiver is also the parent, we know it is often hard to get a child to do for a parent, what they will easily do for someone else. Time often needs to be spent with the family to figure out strategies for carryover, and in general how to fit in the demands that are added to the household because oftentimes there is ‘homework’ from each service provider. It can also be a challenge because many times parents become dependent on the therapists and weaning off of services or discharging services can be challenging.
Despite the challenges that arise from running a pediatric practice, there is also the opportunity on a professional level to be part of the most rewarding experiences as you unlock the potential in each child, and make a lifelong impact in both the lives of the child and family member.
Iris Kimberg MS PT OTR NYTherapyguide
Stacy Menz PT DPT PSC owner of Starfish
Therapy in San Francisco, California