Hospitals are bucking conventional wisdom that acute patients are too ill for PT, and integrating it into care earlier and more thoroughly
Economic and clinical forces are transforming the role of physical therapists in hospital inpatient and outpatient settings. These health professionals are seeing acute patients sooner, speeding their movement through the hospital, easing their transition to the next care setting, and working to keep them from coming back unnecessarily.
On the inpatient side, the trend is toward early physical therapy intervention for acute care patients, including those in the intensive care unit. Fueling the change is a growing body of evidence showing that getting these patients up and moving helps them to recover more quickly and decreases the chance that they'll have lingering weaknesses that can last for years, says Jim Smith, president of the American Physical Therapy Association's Acute Care Section.
Early PT also is good for the hospital bottom line because it reduces ICU lengths of stay and overall hospital LOS, experts say. Smith points to research, published in the August 2008 issue of Critical Care Medicine, by the Wake Forest University School of Medicine and North Carolina Baptist Hospital. The study found that use of a mobility protocol on acute respiratory failure patients shaved 1.4 days off their ICU stays and 3.3 days off their overall hospital LOS. The average cost per patient for those receiving the protocol was $41,142, compared with $44,302 for patients receiving usual care. Total direct inpatient costs, including mobility team members' salaries, were $504,789 lower for the group receiving the protocol.
Early intervention has the added benefit of increasing patient satisfaction, says Patric McQuade, director of the rehabilitation service line at North Shore–Long Island Jewish Health System. "The patients are very happy with how much therapy they're getting," he says. "That means they may choose the hospital again. That helps on the financial end."
However, physical therapy is underutilized in acute care at many hospitals. Several barriers contribute to the problem, including limited staff resources, says James Dunleavy, administrative director of rehabilitation services at Trinitas Regional Medical Center in Elizabeth, N.J. Perhaps the biggest obstacle is the conventional wisdom that acute care patients are too ill for active rehabilitation.
"The physician community has to be comfortable with this new way of looking at how to take care of these patients because they have been brought up under a very traditional model of leaving them in bed," Dunleavy says. "So we fight the tradition."
Because physician decision-making is so varied, Dunleavy is working to educate Trinitas doctors about when early PT is needed for acute care patients. "Some feel — understandably so — with the acute care problems of the patient, their musculoskeletal function is way down the list," he says. "I'm putting something together for our residents that explains to them what happens to the patient when they're acutely ill and lying in bed, and how the degeneration of the muscle system and the neuromuscular system can have a profound effect on other types of illnesses they might be treating."
He also plans to offer physicians a decision-making tool they can use to determine when acute care patients are ready for intervention. "It's a matter of getting those referrals more frequently and on more patients so we can have the positive impact," Dunleavy says.
Having therapists participate in interdisciplinary rounds also helps get patients services sooner, notes Courtney Bryan, director of rehabilitative services at Houston Northwest Medical Center. It establishes routine communication with nurses and doctors and presents opportunities to suggest that a patient is ready for early mobilization.
To change the culture, especially in the ICU, physical therapists have to be a familiar face, says Smith, who is associate professor of physical therapy at Utica (N.Y.) College. ICU clinicians "need to know their patient is as safe with you as they are with any other member of the team," he says. "Once the therapist has shown their credibility, the dialogue changes from 'watch out for my patient' to 'when is a good time for you and me to mobilize the patient?' " However, physical therapists in some facilities don't go on rounds because of pressure on their productivity, Smith says.
Often, physical therapists' ability to provide early intervention for acute patients depends on the effectiveness of rehabilitation department leadership. "Those who can make the case to justify their staff have the people in place," Smith says. "Those who haven't been able to end up triaging patients — 'here's all the patients we have today and these are the ones we have to treat so they can get out the door.' " As a result, the priority list is shaved down to orthopedic surgical patients who can be discharged. ICU patients who could benefit from therapy, but for whom discharge wouldn't be affected, get pushed to the back burner.
In some facilities, physical therapists have created processes that help nurses and doctors think about therapy at the beginning of a patient's hospitalization. One example: Therapists developed a functional screen conducted as part of the initial nursing assessment on every patient so that patients in need of therapy are identified immediately.
At Houston Northwest Medical Center, the functional screen includes questions about mobility needs, activities of daily living and self-feeding, Bryan says. If a patient fails the screen, it triggers the nurse to talk to the physician about writing physical therapy orders.
Ideally, the assessment also should identify when a patient has pre-existing functional problems that would not benefit from therapy, Dunleavy says.
An emerging trend is PT order sets for certain patient types. North Shore–Long Island Jewish has sped access to physical therapy by using prepackaged order sets for patients having total joint replacement and those who've had a stroke. If a joint replacement patient has the operation on Monday, he or she automatically will be seen by a therapist on Tuesday, McQuade explains. The stroke patient order set includes an automatic assessment by the rehabilitation team. "It minimizes the time delay in getting the physician to write the order and then sending the order."
The list of patients who are served by physical therapists has expanded over the past 10 years, Bryan notes. It includes patients with pneumonia, congestive heart failure and chronic obstructive pulmonary disease. For example, pneumonia patients are going to be deconditioned, which puts them at risk for falls. The patient isn't going to need a PT visit every day, but should be assessed by a physical therapist who can check his or her risk of falls and then work to correct any weaknesses.
As pressure to prevent readmissions grows, so does the importance of physical therapists' role, Bryan says. Not only do they provide care in the hospital, but they teach the patient and family about the disease process and disease management, prescribe home exercise programs, offer safety tips, and do anything else that might decrease the likelihood of an unnecessary readmission, she says.
Physical therapists are instrumental in helping to create a safe discharge plan, Bryan adds. They help determine the appropriate discharge destination for the patient. They go over the home environment with the patient and family to figure out what support and equipment the patient might need. "A lot of things the patient or the doctor doesn't think about are really important to us — mobility, feeding, positioning, prevention of falls, medications that make you dizzy," Bryan says.
Beyond the inpatient side of care, many hospitals are in the outpatient physical therapy business. This service line is getting renewed attention as hospitals prepare for the coming Medicare penalties for "excess" 30-day readmissions established under health reform, and as they evaluate whether they want to become accountable care organizations.
As is the case with inpatient care, the types of patients physical therapists can serve in the outpatient arena go beyond the orthopedic and stroke recovery realms that usually pop to mind. They include patients who have diabetes, lymphedema, vestibular disorders and those who need continuing wound care, Bryan notes.
The idea is that offering outpatient physical therapy as part of the hospital's care continuum helps to avoid readmissions and offers continuity to patients. When patients select the hospital's outpatient PT program, it has the added benefit of keeping that downstream revenue in the system, McQuade notes.
Meanwhile, hospital physical therapy directors are evaluating how an ACO model would affect delivery of physical therapy services as part of a larger episode of care. "It really puts the onus on the provider and the facility to provide the care as quickly and efficiently as possible," Dunleavy says. For example, for joint replacement patients, he's looking at how to create a seamless delivery structure from pre-op services, to surgery, to recovery, to outpatient rehab. "So there would be no delay," he says. "The barriers that make it difficult to follow through that way would not be there."
In communities where most physical therapists are in private practice, the push toward ACOs could create some new opportunities for partnership, Dunleavy says. "The guys in the private offices are talking to me because they're concerned that these ACO structures are going to lock them out of the patients." These practitioners might be interested in partnering with facilities or facility-based practices in some way.
In the past few years, physical therapists at some hospitals have become a presence in another care setting — the emergency department. Two big reasons for the emerging trend are hospitals' desire to prevent avoidable admissions and the potential to improve ED efficiency.
One area in which therapists can have a big impact is handling patients with musculoskeletal complaints, says Anita Bemis-Dougherty, associate director of the American Physical Therapy Association 's department of practice. Some hospitals have a physical therapist in the ED full time who evaluates these patients, does physical exams, and determines whether they need to see the emergency physician or if their problems can be effecitvely managed on an outpatient basis. When it comes to patients who ultimately don't need emergency care, "you're keeping them out of the hospital, you're keeping them out of the ED, and you're making sure they get follow-up care."
Staffing the ED with a physical therapist can increase patient satisfaction, decrease wait times and ease emergency physicians' workloads, she adds.
North Shore–Long Island Jewish is exploring the creation of such a program for people arriving in the ED with back problems, McQuade says. "This is an opportunity for us to both prevent unnecessary hospitalizations and to potentially capture that patient for rehab down the line."
Hospitals considering this route must determine whether physical therapy services would be provided as part of the ED visit with no separate charge or billed as outpatient care. "My discussions first of all would be with administration — this is what an ED intervention program can do. This is what it will cost. What is the benefit?" says Bryan. "You might have ED patients who could not pay for physical therapy services, so are you offering them in a consultative role to the physician?"
North Shore–Long Island Jewish hasn't decided how it will handle billing,but is leaning toward not charging separately for PT, McQuade says. "If you can prevent an unnecessary admission, you minimize denials," he says. "Then if you can capture the downstream revenue, it's more than worth the investment." A financial analysis will be conducted to help make the final decision on how to bill.
Houston Northwest is utilizing physical therapists in caring not only for ED patients with musculoskeletal pain, but also patients who need wound care or who have poorly controlled chronic conditions, Bryan says. One example is diabetic patients. A lot of diabetics don't look at their feet everyday and wind up in the emergency department because they get wounds, she says. Many also have balance problems because they can't feel the bottom of their feet. Physical therapists in the ED address the problem, educate the patient and make sure they get proper follow-up care.
As in the acute care setting, physical therapists in the ED must make strong connections with the nurses and physicians to succeed, Bemis-Dougherty says. "They need to exhibit interprofessional collaboration and bring something valuable to the team. You can't just say, 'I can see everybody.'"
Geri Aston is an H&HN contributing editor.
Recent advancements in physical therapists' education and training support their growing role in various hospital settings. In the past decade, physical therapy has shifted to a doctoral-level degree. The trend is driven, in part, by the growing complexity of care and state laws that give physical therapists varied levels of direct access to patients, says Jody Frost, American Physical Therapy Association director of academic/clinical education affairs.
Direct access means physical therapists must be able to determine which patients they can treat and which to refer right away, and they must have knowledge and skills in patient evaluation, diagnostics, radiology and imaging, oncology, pharmacology and evidence-based practice and prescription drugs. All of these subjects are part of the physical therapy doctorate curriculum, Frost says. Of the 212 accredited physical therapist programs, 207 are at the doctoral level, and the remaining five will be by 2015, as mandated by the Commission on Accreditation in Physical Therapy Education.
Physical therapists increasingly are seeking postdoctoral training via residency and fellowships that culminate in board certification to specialize in a particular area, Frost notes. Physical therapist residencies and board certification are available in cardiovascular and pulmonary, clinical electrophysiology, geriatrics, neurology, orthopedics, pediatrics, sports and women's health. Oncology and acute care physical therapy also are working toward recognition as specialties.
A growing number of hospital-based physical therapists are becoming specialists so they can focus on one area of hospital care and to better serve their patients, Frost says. Specialization typically doesn't lead to higher salaries, although in markets where a particular physical therapy specialty is in high demand, hospitals may offer bonuses or debt relief.
Therapists with specialty training are more common in larger hospitals where patient volume in the various clinical areas is high enough to warrant it, says Patric McQuade, director of the rehabilitation service line at North Shore–Long Island Jewish Health System. "If you have a large population of patients who are getting joint replacements, for instance, you really need somebody who can coordinate care, who can really start moving these patients, and who the physicians identify as experts."