“A Plan of Care is defined as a personalized treatment strategy that sets measurable goals and ensures that all stakeholders in healthcare remain aligned throughout the therapy process.”
A well-structured Plan of Care (POC) in physical therapy is important for guiding patients toward a successful recovery. It is reported that 68% - 72% of patients experience significant improvement in their condition following a solid POC.
With that in mind, let’s explore how to establish a Plan of Care, as well as the common challenges and solutions to ensure its success.
A plan of care, or treatment plan, is customized and created by a physical or occupational therapist to provide a clear strategy addressing a patient’s unique health needs and treatment goals. This plan specifies the interventions, exercises, and techniques that will be implemented to enhance the patient’s condition.
So, what should you consider to add in your plan of care? The plan of care should contain the following core components in Physical Therapy:
Although understanding a plan of care is essential, it is equally important to establish a plan for your patients, ensuring that interventions are targeted, effective, and matched to their specific needs.
When establishing a plan of care, it is important to ensure it is created by a qualified professional, such as a qualified physical therapist. Also, the plan of care must be finalized before any therapy treatments can begin, ensuring a structured and compliant approach to patient care.
Here are some of the points to remember when writing a plan of care:
A certified plan of care ensures compliance and effective treatment in your services. When it comes to Medicare patients, certification is an official validation, not just a course. Requiring a physician’s or NPP’s signature to confirm medical necessity. Let’s understand this better.
If you're treating Medicare patients, you must understand how to navigate Medicare's certification and re-certification requirements for plans of care. The following are the requirements that must be met:
While the physical therapist personalizes and writes the POC, it must be reviewed and certified by a physician or NPP to ensure compliance and approval for treatment.
The physician or NPP must provide a signature, which can be either electronic or handwritten but not a stamp, to validate the plan. Medicare does not require the certifying physician to have personally seen the patient; however, some physicians may have policies that mandate a patient visit prior to certification.
Certification should occur within 30 days of the patient’s initial therapy treatment to ensure compliance and avoid delays. The signed and dated Plan of Care authorizes the physical therapist to proceed with treatment as outlined in the plan.
Furthermore, if the physician or NPP provides verbal certification, then it must be followed-up with a signed document within 14 days of giving the verbal approval.
Although the certification remains valid until the treatment duration specified in the plan ends, the patient’s condition changes significantly (necessitating a revision of goals) or 90 days after the initial treatment—whichever comes first. If further care is needed beyond this point, a new Plan of Care must be submitted for recertification, following the same process.
Delayed certification is permitted if a physician or NPP provides the required certification at a later date. To satisfy delayed certification requirements:
Once the Plan of Care is certified by an NPP, you can proceed with developing and implementing the treatment plan while ensuring it aligns with the established goals. This includes carrying out the prescribed interventions and tracking patient progress to ensure effective outcomes.
Implementing a Plan of Care in physical therapy is a systematic process that requires continuous assessment and modification to ensure optimal outcomes. Let’s take a look below at how, as a Physical therapist, you must remain flexible and responsive to patient needs.
During the first therapy visit, you must conduct an examination and evaluation to establish a diagnosis and prognosis before beginning treatment. The evaluation focuses on identifying risk factors, cognitive or environmental barriers, and opportunities for health promotion.
During the visit, you will evaluate the following:
According to the Standards of Practice for Physical Therapy by the American Physical Therapy Association (APTA), adapting the Plan of Care based on patient progress and evolving therapy needs is an integral responsibility of physical therapists. This process ensures that treatment remains patient-centered and outcome-driven.
Modifications to the POC may include:
You might like reading about Understanding and complying with the change in policy implemented on Jan. 1, 2025, under the 2025 fee schedule.
The plan of care can provide a clear direction throughout the treatment process, but establishing one may pose some challenges.
As a physical therapist, you face various challenges when managing Plans of Care. Here’s a clear breakdown of challenges and solutions to address them effectively:
Challenge 1: Incomplete or Missing Documentation
You may encounter issues where certifications, progress notes, or evaluations are incomplete or missing, which can lead to claim denials.
Solution: Ensure all documentation is thorough and accurate. Use standardized templates to streamline record-keeping and minimize the risk of omissions.
Challenge 2: Lack of Specificity in Treatment Plans
Plan of Care documents that lack detailed information about diagnoses, goals, or treatment specifics may fail to meet compliance requirements.
Solution: Create detailed POCs that clearly outline diagnoses, measurable goals, and the type, amount, frequency, and duration of therapy. Practice management tools like
Spry PT can simplify the process and ensure compliance.
Challenge 3: Delayed Certifications and Recertifications
Delays in obtaining certifications from physicians or NPPs can disrupt patient care and reimbursement.
Solution: Use a tracking system to monitor certification timelines and send timely reminders. Automate alerts for upcoming deadlines to avoid delays.
Challenge 4: Failure to Update Plans of Care
Significant changes in a patient’s condition may require updates to their POC, and failing to document these changes can lead to compliance issues and penalties.
Solution: Regularly review and update POCs as needed. Use software solutions to flag when updates are required, ensuring patient care aligns with their evolving needs.
Challenge 5: Patient Non-Compliance with Plan of Care
Patients not adhering to their treatment plans can hinder progress and outcomes.
Solution: Foster better adherence by clearly communicating treatment plans and setting realistic expectations. Educate patients on the importance of following their plans and provide reminders for home exercise programs and appointments using patient engagement tools. Build strong relationships with patients to encourage commitment to their recovery.
A well-constructed and routinely reviewed Plan of Care not only guides effective treatment but also serves as an educational and motivational tool for patients. Sharing and discussing the plan regularly helps establish medical necessity and demonstrates the value of your services.
By ensuring your POC is comprehensive, compliant, and patient-focused, you can achieve better outcomes, improve engagement, and streamline therapy processes, leaving little room for inefficiencies or scrutiny.
SPRYPT offers features such as automated documentation, customizable templates, and integrated billing, which will assist you in maintaining accurate records, setting measurable goals, and ensuring timely certifications. Get a Free Demo Today!
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