The College has received quite a few questions over the years regarding how physiotherapists could properly provide services that differ from “typical” or “standard” physiotherapy. Often the questions were coupled around whether the physiotherapist could provide these services as physiotherapy and if it would be within the physiotherapy profession’s scope of practice to do so. To further explain what constitutes physiotherapy services, you can access a good practice article which went in-depth into what makes physiotherapy, physiotherapy here.
If you have realized that a niche area of care or a broader application of past skill sets do not constitute physiotherapy, but you still wish to pursue this business stream then what do you do? Well, if you have decided to offer services that are not within the scope of practice of physiotherapy, they would be considered non-physiotherapy services and, therefore, must be dealt with separately so as not to confuse or mislead (intentionally or otherwise) the public, potential clients, or funders.
Physiotherapists have a professional responsibility to work within the established legislation, Standards of Practice, and Code of Ethical Conduct. Although the College of Physiotherapists of Alberta has no role in how you manage your business outside of physiotherapy, any non-physiotherapy services must be provided in a way that doesn’t impair the physiotherapist’s ability to fulfill their professional responsibilities. This article will explore how physiotherapists are expected to manage non-physiotherapy business streams without confusing or misleading patients or the public as to what service they are receiving or paying for. Due to the increased frequency of this issue the latest draft Standards of Practice includes a standard related to Dual Practice. Although the Standard is not yet in force, this article will provide guidance on how physiotherapists would engage in dual practice in a way that will help them fulfill the College’s expectations when they do so.
Preparation is Key
It is imperative to take the time to ensure that you have the structures in place to properly separate your non-physiotherapy business streams from your physiotherapy practice as transitioning patients from one stream to another poses risks. The larger the separation between the two services, the easier it is for the patient to understand. It is important to recognize that there are risks to providing non-physiotherapy services within your practice setting and being better prepared to provide physiotherapy and non-physiotherapy services as distinct business offerings will drastically reduce the risk of any issues occurring.
Location: Are you planning to offer non-PT services at the same place you practice physiotherapy or are you planning to have a separate space? It seems obvious that a separate space would lead to an easier understanding that the non-physiotherapy services provided differ from the ones that occur at the physiotherapy clinic, but it may not always be an option. If you have completed your yoga instructor course and choose to work as a yoga instructor out of a yoga studio there is little risk of the public being confused. However, offering one-on-one yoga instruction within the physiotherapy clinic where you practice as a physiotherapist can create false impressions that your yoga instruction is physiotherapy. This would be similar to providing personal training sessions with someone in your physiotherapy clinic’s gym vs. meeting them at the local gym down the street. The atmosphere at a clinic will often differ from the atmosphere you encounter at the studio or gym so location can matter quite a bit.
Another scenario which has increased in frequency in recent years is that of physiotherapists who work within training facilities, gyms, or studios. As mentioned above, the location that services are provided in can lead to an increased risk of patients misunderstanding the services they are receiving - physiotherapy or personal training. If a physiotherapist working in a gym environment was providing personal training in addition to physiotherapy services in that environment, the risk of misunderstanding increases considerably.
Advertising and Promotion: This is an area where physiotherapists need to be explicit and transparent about what are physiotherapy vs. non-physiotherapy services. Non-physiotherapy services should be advertised separately from your physiotherapy services.
When advertising non-physiotherapy services you must not use your title Physiotherapist, PT or Physical Therapist as you are not working as a physiotherapist, and these are protected titles. Although having a shared website or social media platform for both physiotherapy and non-physiotherapy services may make sense from a business perspective, the College’s focus is on the public interest and the risk is that combined promotion can lead to confusion and misrepresentation.
If you choose to house both physiotherapy and non-physiotherapy services on one website you must be very clear and transparent on the separation of the services. Spend time explaining why patients would not be able to claim non-PT services for reimbursement as physiotherapy. You can also take the time to provide clarity on the process a potential client would take if they wished to pursue either physiotherapy or non-physiotherapy services. In the online world there is ample data and space to explain all these concepts thoroughly as you no longer need to squeeze the pertinent information onto a business card or pamphlet.
Administrative Actions: Although the Dual Practice Standard of Practice is not yet in force, in the future there will be a performance expectation and currently it is strongly encouraged that if you are providing non-PT services at your current physiotherapy practice location, you conduct non-physiotherapy business activities on separate days or times from which you provide PT services. This can help when advising your patient as to what days you provide non-physiotherapy services and creates another level of separation from your physiotherapy practice. Setting up different booking and billing portals for patients to follow will also create separation. Online booking or having an admin flow chart for when patients call can streamline the process and potentially decrease the risk of confusion for patients navigating the system.
Communication and Consent: Some of the most common issues the College sees when physiotherapists provide non-PT services is when there is a communication breakdown. The bulk of the responsibility will fall on the physiotherapist as you will be guiding patients and gaining their consent for services. You should also realize that ongoing informed consent is a key part of this. Patients may start out at your physiotherapy practice for an injury and receive conventional physiotherapy services at the beginning. As they are transitioning out of your care as a physiotherapy patient, they may choose to continue with care that is considered a non-physiotherapy service. When doing so, clear communication of the plan, rationale, and implications of that decision must occur.
Booking and Billing: When it comes to risk, booking and billing is a significant area of concern. Either the administrative structure, physiotherapist, or patient error can lead to a misunderstanding around how to book or bill for a session which can in turn lead to conflict or unmet expectations. One example is the patient who booked a service thinking it was covered by their extended health benefits only to get a call from their insurer denying the claim. Or a physiotherapist may find out that the patient submitted a receipt for reimbursement from their benefit plan as a physiotherapy appointment when it was not a physiotherapy service. Miscommunications occur but the more structure you have within your administrative systems, the less likely that the miscommunication will happen or lead to a larger issue.
To illustrate how communication consent, booking, and billing can be intertwined and create challenges when providing non-physiotherapy services, consider the scenario of a patient who has been in physiotherapy for several weeks or months rehabilitating from a back injury. Over the course of their recovery, they have become quite sedentary. The patient reports their life is quite hectic and they approach you after their discharge from physiotherapy to provide them with personal training services.
If you choose to do so, you must communicate the following regarding their change in their care plan. The patient must be informed of what the transition to non-PT services may mean to their potential funding as well as any other implications the change in services may have on their goals of care. Upon the transition, the patient and you must both understand that the services can no longer be billed as physiotherapy using your registration number. Prior to any changes being made the physiotherapist must obtain consent. The key through all of this is ongoing clear, transparent communication with the patient to avoid any confusion or misrepresentation.
Charting: This also means your charting for physiotherapy services needs to be separate from any charting you complete for other non-PT services. You may decide to have two separate charting systems in place to further distinguish between the various services you provide. In the proposed draft Standards, the minimum is to have either separate notes and clearly document which service you are providing at any appointment.
Self-referral: Conflict of interest occurs when there is a potential financial gain from steering the patient back to you to provide them with the non-physiotherapy service. For example, you are seeing a patient as a physiotherapist, and you are in the process of discharging them but feel that an overall fitness program or continuation in a yoga class would be beneficial to their overall health. You also provide this service and are confident in your ability to continue to assist this patient. Would you refer them to yourself in your capacity as a strength coach or yoga instructor?
As with managing other potential conflicts of interest related to self-referral leading to financial gain, in this case you should provide a list of trainers or yoga instructors that they can access, and you can include your name among them, but you must give the patient options and you must do so in a way that is free of pressure or coercion. They may still choose you, but it is of their own accord.
Summary
The draft Dual Practice Standard of Practice outlines many ways in which physiotherapists must manage the various roles they may occupy in the delivery of physiotherapy and non-physiotherapy services. Physiotherapists must adhere to the expectations within the Standards and must also ensure that they are operating within the Code of Ethical Conduct.
The public and patients can become misinformed or can misunderstand the nature of the services being provided when physiotherapy and non-physiotherapy business offerings are not offered as distinct services. It is up to the physiotherapist to create the necessary separation between physiotherapy and non-physiotherapy services.
Previous articles have discussed what makes a service billable as physiotherapy and this article has provided information for the practitioner seeking to provide non-physiotherapy services in addition to physiotherapy while adhering to the Standards of Practice and Code of Ethical Conduct. If you are considering a dual practice situation and have questions about how to do so in a manner consistent with professional expectations, you can also contact professionalpractice@cpta.ab.ca to discuss your situation.
Sean FitzGerald, PT, Practice Advisor
