By Saturday morning, attendees of the APTA’s Combined Sections Meeting (CSM) were moving with a little less pep in their step—and a couple extra shots of espresso in their morning coffee. Still, the educational sessions on the final day of CSM were chock full of eager learners looking to eat up a few more morsels of wisdom before catching their planes home from Indy. Here are some highlights from day three’s informational smorgasbord (check out recaps from the first two days in this post and this post):
Session: Payment Reform: An Innovative Approach to Advance Physical Therapy Practice
Change is tough. For many people, the idea of letting go of the familiar and embracing the unknown is more than just uncomfortable; it’s unfathomable. When it comes to payment reform, though, change is inevitable. Our country’s healthcare system is buckling under the weight of rising costs, and that means something’s got to give. Enter value-based reimbursement models, which seem to be everyone’s answer to the wasteful spending borne of the incumbent fee-for-service structure. At this point, it’s pretty clear that eventually, providers in all disciplines—physical therapy included—will receive payment based on one of these alternative models. It’s up to PTs to decide whether they’ll be proactive in driving that movement in a way that benefits them—or merely sit back and let nature take its course. In this session, APTA staff members Elise Latawiec, PT, MPH, and Lindsay Still, JD, discussed the APTA’s plans for facing payment reform head-on—and ensuring the PT profession is “at the table” where the decisions that impact them are being made.
The Continuum of Value-Based Payment Systems
There is no singular value-based system for health services reimbursement; rather, there’s a spectrum of models ranging from the current fee-for-service structure—which tends to reward the quantity, rather than the quality, of services provided—to a full capitation model, in which whole networks of providers band together and receive single fixed monthly payments for each enrolled patient. Speckled in between these two extremes are other lump-sum structures such as the per diem structure (in which providers receive one lump sum for each episode, regardless of severity) and the episode of care structure (which is similar to per diem but accounts for severity and complexity).
The APTA’s Proposal: A Happy Medium
The APTA’s proposed alternative payment model falls somewhere in the middle of that spectrum. “That way, we’re not over-treating patients, and we’re not under-treating them,” Still explained. Here’s a brief, basic breakdown of the proposal’s features:
- It separates all CPT codes into two categories: evaluation and intervention.
- There are 12 possible evaluation codes—four each for physical therapists, occupational therapists, and athletic trainers—that reflect the complexity of the examination and the associated clinical decision-making.
- There are five collapsing levels of interventions based on the severity of the patient’s condition and the intensity of the associated clinical decision-making, treatment provision, and risk.
- The amount of payment for each intervention would vary depending on the level—something that raised concerns among audience members in this session. “Ones may be a little lower baseline than what you’re used to, but the fives will be more,” Still assured. “This is the APTA—we don’t want you to go out of business. We want you to get paid; we want you to keep your doors open and continue to provide services. But if we stay where we are now, we’re going to get cut no matter what.”
- The APTA is still ironing out some of the kinks—most of which relate to the intervention coding systems—that it discovered while pilot-testing the system last year. However, PTs could see a partial implementation of the system as early as January 2017.
Visions for the PT Profession
By reforming the PT payment system to better align with the triple aim—that is, the nationwide push for better access, lower cost, and improved accountability in health care—PTs will set themselves up for success in an environment where value will dictate the care delivery process. This transition is reflective of the larger opportunity PTs have to step into roles as care coordinators—an opportunity strengthened by a shift to less-restricted access to physical therapy services, the growing trend of outcomes data tracking, and the push to reduce both overutilization and underutilization of therapy. No, a new payment model will not be the magic solution to all of the challenges PTs—and all healthcare providers—are facing in the current landscape. But it is a step in the right direction. After all, as Still put it, “Change is coming…It’s going to happen anyway, and if we don’t get involved, we won’t get a say.”
Session: How Should I Treat This Patient? Evidence at the Point of Care.
To all of the Apple diehards out there, “6S” might sound like the latest iPhone iteration—and if that were the case, my guess is it would be the size of a laptop. In the context of this presentation, however, “6S” refers to a specific approach to researching, finding, and using synthesized evidence as a basis for clinical decisions at the point of care.
But first, a quick review of the five steps to using evidence-based practice:
- Formulate a clinical question.
- Search for related studies and resources.
- Read and analyze evidence.
- Use analysis to develop and enact a plan.
- Assess outcomes to determine the effectiveness of the plan.
Now, here’s how the 6S approach fits into the picture. Basically, the idea is that there are different levels of evidence available. The first level, for example, includes single studies. The second level includes synopses of single studies. Then the pyramid moves up to systematic reviews—or syntheses—of studies; then synopses of syntheses (which actually only exist for medical doctors, not PTs); then summaries (a.k.a. clinical practice guidelines); and finally, systems, which represent the highest level of knowledge translation. An example of a system would be an EMR that features evidence-based prompts and alerts that offer clinical guidelines based on the information the practitioner enters into the patient record. “That’s the highest form, and that’s where we’re hoping to go,” said one presenter in this session.
To illustrate the process of using such evidence to inform clinical decisions, several PTs shared case examples from their own personal practice. In keeping with the five steps listed above, each case began with a question. For example: “For patient with LBP, what is the most appropriate questionnaire to ID yellow flags?” or “What are reliable and valid outcome measures I could use for this patient that are supported by evidence?”
The presenters then described their process of searching for—and vetting—clinical research that provided answers to their questions. Of course, in this day and age, you can find almost anything—including physical therapy research—on the world wide web. But according to the presenters’ accounts of their own experiences, where you look matters. A couple of their suggestions: PubMed and PTNow. Once they found studies that matched the subject matter they were investigating, they narrowed their options based on ratings, endorsements, clinical appraisals, and expert opinions. Basically, they looked for sources that fell into the highest possible levels of the 6S pyramid. Then, in keeping with the five steps above, they designed and implemented their plans and looked at various outcomes measures to evaluate the effectiveness of those plans.
Outcome measures, of course, were a very popular topic of discussion at CSM 2015, and this session highlighted one more reason why it’s critical that physical therapists track outcomes data.
Session: The Power of Data: Achieving Consistent Patient Outcomes
Continuing along the outcomes thread: You’d be hard-pressed to find a physical therapist who would argue against the importance of objective information. After all, it’s the foundation of evidence-based practice. Getting PTs to buy in to the importance of collecting their own patient outcomes data, on the other hand, might prove to be more of an uphill battle. But, as the Cleveland Clinic proved with the implementation of its proprietary, short-term functional outcome tool, 6 Clicks, opening clinicians’ minds to the power of outcomes data could be as simple as offering them a few free slices of pizza.
That’s what 6 Clicks project leaders did to kick off data collection efforts within the Cleveland Clinic. And most providers came away from that initial meeting with a new appreciation for outcomes data and the opportunity it represented—both for themselves and their patients. “Now they see the benefit, because it’s elevating them as professionals in their setting,” explained one of the presenters in this session. “They are happy to collect it…Therapists typically want to do the right thing.” Pro tip: Never underestimate the persuasive properties of a steaming-hot slice of pepperoni.
Named for the six questions contained in each of its two short-form functional questionnaires, the 6 Clicks tool—explained in detail beginning on page 9 of this document—was specifically designed to:
- Fit in with the busy schedules of clinicians.
- Help distribute inpatient rehabilitation resources rationally and efficiently.
- Determine appropriate discharge timing.
- Apply within a variety of care environments and settings.
Since implementing the tool in 2011, the Cleveland Clinic has been able to:
- Decrease the number of inappropriate counsels.
- Ask for—and add—more therapists to the staff.
- Demonstrate the value of rehabilitative therapy to other members of the organization’s medical team.
- Provide patients with data-backed predictions and expectations for treatment.
According to presenters in this session, the data generated by the 6 Clicks program has garnered a lot of interest throughout the healthcare community at large. In response to that, the clinic is working to create a database that could be used for predictive modeling—something that would be valuable on an even greater scale. The key—as we’ve discussed extensively here on the WebPT Blog—is leveraging standardized, universally recognized tools for outcomes data collection efforts. “Everything is about standardization and care path goal,” said one of the speakers in this session. “With that, I think we have an obligation to eliminate some of the variability in our clinic.”
The other key: taking a cue from Nike to “just do it.” For many organizations, the hardest part of collecting outcomes data is simply getting started. That’s why presenters in this session recommended doing whatever you have to do to “make it out of the gate.” After all, the sooner you start your outcomes tracking program, the more time you will have to refine your processes and learn from your mistakes.
Session: What are Your Purple Cows?: Finding Your Differentiator
You don’t want your practice to be a grey cow. Why? Because, as Dennis Bush, PA, MHA, explained in this session, there’s nothing different—nothing special, remarkable, and most importantly, memorable—about a grey cow. But a purple cow—now that’s something special, and most certainly memorable and remarkable.
Bush formed this bovine metaphor based on a personal experience in Saint Thomas, where he and his wife made countless car excursions to and from the beach. On the way, they passed all kinds of cattle pastures, where they would stop and take pictures of the cows. They grew so enamored with these animals that they even went to far as to name them. Of course, they didn’t stop for just any ol’ cow. To warrant a picture—and a name—the cows had to stand out; they had to have interesting markings or shapes. One day, the couple stopped at a dairy farm that had actual purple cows—as well as an ice cream stand called Udder Delight that sold alcoholic milkshakes, something that no one else offered in those days. Those cold, creamy—and yes, boozy—treats were truly something to remember. And for Udder Delight, they were a purple cow.
What Bush wants to know is: Where are the purple cows of the PT industry? At the beginning of the session, he scrolled through dozens of screenshots from PT clinic websites across the country. His point: they were all eerily similar. “None of you are interesting,” he said. “None of you are doing anything that’s different from anyone else in your area. You’re all a bunch of rehab cows that look, smell, and act the same.”
To break free of the monochromatic pack, Bush suggested taking a page from the marketing geniuses at Disney and “creating memorable moments.” How? By offering differentiators that spark emotional reactions. Because at the end of the day, those are the things that foster patient loyalty. “You can all treat; you’re all physical therapists,” Bush said. “The rest is customer service.” To emphasize this point, Bush described the way the character cast at Disney World carries out the company’s goal of creating memorable, vacation album-worthy moments. “They get down on one knee, so they’re at the child’s level,” he said. “They use face-to-face contact.”
While most PTs already interact with their patients in a face-to-face capacity, Bush offered several examples of how they can take that concept further: by sending handwritten holiday and birthday cards, for example. But the real meat of Bush’s argument centered on using the five senses—sight, sound, smell, taste, and touch—to turn patients’ experiences into something remarkable. He urged PTs to keep in mind that, to a patient or any other consumer, perception is reality. That is, whatever they experience is what they believe. Here are a few of the examples of potential differentiators for each category of sense:
- The exterior of you clinic—including your signage—is important, because it’s where patients form their very first impressions of you as a therapist. “Take a look at the outside of you clinic like it’s the first time you’re seeing it,” he said.
- Introduce details that could serve as the basis for stories later on. What’s something that’s worth talking about? In addition to making sure your clinic is always neat and clean, Bush suggested, among other ideas, rotating office furniture and decor based on the season, putting a unique fixture in the bathroom, and trading magazines for picture books—especially ones suited to your specific patient population.
- Put your signature—or, as Bush referred to it, “autograph”—on any knickknacks or pieces of therapy equipment (e.g., therapy bands) that you issue to your patients. Bonus points for including a personal note.
- Make towel animals with the towels you provide to patients during their visits. (Or train your therapy techs to do it.)
- When you conduct ultrasound, make a smiley face with the gel.
- Make sure the music you play during treatment aligns with your setting, your patients, and the experience you are trying to create. For example, if you’re a sports-type clinic, you might want to use a workout playlist. If you treat mostly Medicare patients, stick to oldies. Seeing a lot of middle-aged workers? Classic rock might be the ticket.
- Use the appropriate tone of voice with your patients. This is especially important for your front office staff—or, as Bush likes to call them, your “welcoming staff.” Address patients by name and in a warm, inviting, and friendly manner.
- Host “discharge celebrations” in which the patient who has completed therapy rings a bell or a gong.
- Smell is strongly tied to memory, so the last thing you want is for your clinic to smell like rubbing alcohol—or worse, body odor. According to Bush, two of the scents most strongly linked to pleasant memories are citrus and vanilla—so if you use air fragrance, stick to those varieties.
- Pop popcorn, bake cookies, or make other treats that have scents that evoke positive memories.
- If you work with a lot of older patients, wear a baby powder fragrance. According to Bush, this particular scent has a soothing effect for that age demographic.
- Provide holiday-inspired treats to patients. For example: This time of year, you could purchase a bunch of Valentine’s Day mugs at Goodwill and fill them with candy.
- Give small treats to patients who are adhering to their exercise plans and making good progress.
- For older patients, provide snacks and treats that evoke fond memories from childhood.
- Body contact already is part of physical therapy, so PTs have a built-in avenue to develop relationships and personal connections using this tactic.
- You could take this a step further in your clinic by training your techs to provide head and shoulder massages to relax patients at the beginning or end of their treatment sessions—as long as your practice act allows it.
Whatever you do to differentiate yourself, remember that it’s only a matter of time before your clinic’s purple cow fades into just another grey cow. Because once your competitors catch wind of what you’re doing, there’s a good chance they’re going to replicate it. To stay ahead of the curve, you’ve got to keep the creative juices—and the innovation—flowing.
Session: What PTs Need to Know to Avoid a Lawsuit
Liability. Malpractice. Risk control. These are scary words for any healthcare provider—PTs included. In fact, presenters in this session revealed that, overall, the number of legal claims against physical therapists is on the rise—with the most common allegation being that the provider in question failed to appropriately supervise or monitor patient therapy sessions. And while, in some cases, you might not be able to avoid a lawsuit completely, you absolutely can arm yourself to fight any litigation that comes your way. (Hint: defensible documentation is your best weapon.)
How? Well, the devil, as always, is in the details—or, for the example cases presented during this session, the lack thereof. Here are a couple of the scenarios discussed during this presentation:
1. Case background: A PT developed a post-total-knee-replacement care plan for a 70-year-old female patient based on her physician’s orders. The orders specified that the patient should wear a T-Rom brace at all times. However, the PT’s care plan did not designate which brace the patient needed to wear, so the treating PTA did not change the patient’s brace when she came to therapy wearing a knee immobilizer instead of a T-Rom brace. At one point, the patient lost her balance and experienced pain. She saw another PTA on five separate occasions over the next 10 days with no record of pain during any of those visits. Three months later, the patient received a diagnosis of re-rupture of the patella alta—a condition that required additional surgery. Following the surgery, the patient developed an aggressive wound infection, eventually leading to amputation above the knee.
Results: The patient and the PT practice’s insurance provider reached a settlement of $550,000 indemnity payment and $69,000 expense payment.
Takeaway: Always thoroughly review physician’s orders prior to treatment, and prepare a detailed care plan based on the orders. Furthermore, if you deviate from those orders, discuss it with the patient and obtain written confirmation of that discussion from the patient. It’s also important to have a clear incident/accident reporting procedure in place.
2. Case background: A morbidly obese 49-year-old woman entered a rehabilitation facility following a hit-and-run motorcycle accident that resulted in a 95-day hospitalization. Upon beginning therapy, she could only ambulate using a rolling walker due to muscle tightness, weakness, and sensory deficit in the lower extremities. The PT developed a care plan based on the patient’s limitations. Five months into therapy, while performing an exercise she had done successfully many times before, the patient became weak and had to sit on the non-moving chair the therapist had positioned behind her. As she sat, she shifted weight very heavily onto her standing leg, which resulted in metatarsal bone fractures. She continued with therapy for five weeks, after which she was discharged. The patient claimed that the therapist had created a hazardous environment by using parallel bars of different heights and that the therapist should have been positioned behind—rather than in front of—the patient during the exercise. During legal proceedings, the PT was evasive and untruthful, particularly regarding his policies and procedures manuals. He also admitted to going against self-exercise regulations and could not meaningfully explain how the patient was performing the exercise.
Results: The jury ordered indemnity payment of $175,000 and expense payment of $17,000.
Takeaway: Thoroughly know—and always practice within—your state’s scope of practice, and adhere to the designated standard of care. Furthermore, ensure the safety of the physical environment with respect to patients’ individual needs, and stop any treatment that may present a safety risk. Finally, immediately report and document any fall, injury, or accident and seek appropriate medical assistance.
On the topic of incident reports, PTs must be vigilant about filing these documents when necessary. Remember, these reports are confidential, and divulging any information is on a need-to-know basis. Examples of reportable incidents include falls, treatment-related injuries, and patient complaints about care quality, inappropriate PT or PTA behavior, or unusual pain or discomfort. Incident reports should:
- Objectively explain what happened.
- Provide only facts—not conclusions.
- Not judge the patient’s feelings or reactions.
While PTs should not include incident reports within the patient record, the SOAP notes themselves are equally important from a legal standpoint. After all, medical records are legal documents that can help prove your innocence to a judge or jury. Your documentation is not just the patient’s story—it’s yours, too. And in the event of a lawsuit, you’ll want that story to be well-rounded, complete, and in compliance with all state and federal standards and laws. Basically, your documentation might just be—quite literally—your “Get Out of Jail Free” card.
I don’t know about you, but I’m stuffed full of rich, delicious knowledge—and like most CSM 2015 attendees, I’ll be digesting all that informational goodness for weeks to come. Got a question about something covered here? Post it in the comments section below. Were you lucky enough to join in the fun in Indy? What was your favorite session? What insights did you come away with? Share your thoughts below.