PTs are playing an important role in reducing patient readmissions to hospitals. They could play an even a bigger one. Here’s how.
By Eric Ries
In the pages of Physical Therapy last November,1 a physical therapist (PT) and a clinical psychiatrist asked the question, “Physical Therapy Information: Could It Reduce Hospital 30-Day Readmissions?” Their response was an emphatic “yes.””Physical therapy provides a unique information-bearing relationship in the hospital setting,” observed Jennifer Kreppein, PT, and Thomas Stewart, MD. “It involves hands-on, personal treatment often delivered by the same individual or team, which is an increasingly rare component in fragmented, technology-driven health care delivery.”
In addition to providing such relevant information as mobility and balance observations, “Of paramount importance,” Kreppein and Stewart wrote, is that patients tend to share with PTs pertinent personal details “that could inform discharge planning and re-admission risk.”
“Who knows their risk,” the authors observed, “better than the patients themselves?” Such self-assessment “is not big data,” they acknowledged, “but it is personal and actionable information.”
Physical therapy, Kreppein and Stewart noted, “contributes to patient education and discharge planning, and can contribute to reducing readmission risk through narrative [information], plus quantitative data such as mobility and balance.”
In a response letter to Physical Therapy this February,2 Jim Smith, PT, DPT, MA, and Anita Bemis-Dougherty, PT, DPT, MAS, endorsed Kreppein and Stewart’s view. They wrote that the role of PTs in reducing hospital readmissions is “timely and important,” given the existence since 2013 of the federal Hospital Readmissions Reduction Program. That program imposes payment reductions on hospitals considered to have excessive readmission rates for Medicare patients. The program was created in response to the fact that, as noted on APTA’s Hospital Readmissions webpage (www.apta.org/HospitalReadmissions/), nearly 1 in 5 Medicare patients—2.6 million senior citizens—discharged from hospitals are readmitted within 30 days, at a cost of more than $26 billion annually.3
Smith, a past president of APTA’s Acute Care Section, and Bemis-Dougherty, the association’s vice president of practice, cited as a “strong endorsement” of their views a 2011 acute care study4 that concluded, “Holding all other variables constant, a patient was more likely to be readmitted when the therapist discharge recommendation was not implemented and services were lacking,” compared with instances in which PT-recommended steps were taken.
In their letter, Smith and Bemis-Dougherty expressed concern that “the voice of the physical therapist too often is missing in the discharge planning process”—for reasons that may include staffing reductions that decrease physical therapist services among some inpatient populations and instances in which PTs’ discharge plan recommendations are not accepted or followed by other members of the health care team. (One recent study of discharge orders at a large academic hospital5 strongly suggests that such concern is valid.)
“Our personal recommendation,” Smith and Bemis-Dougherty wrote, “is that advocacy by physical therapists practicing in hospitals is needed to raise the therapist’s profile in the discharge planning process.”
In fact, in a variety of care settings across the United States, PTs are answering that call to action—ensuring that their voices are heard and that physical therapy plays a key role in decreasing the personal and economic costs of preventable rehospitalization.
Pauline Flesch, PT, MPS, is the executive director for rehabilitation services at Indiana University Health. A couple of years ago, there was “kind of an ‘aha moment,'” she says, when the health care system’s wound care-specialist PTs and wound ostomy nurses realized that a flaw in the physician referral mechanism was causing needless delays, with negative implications for optimal patient care.
“What we discovered on the inpatient side of patient care was that we were duplicating some efforts and delaying service because physicians weren’t always sure who was the right provider at the right time when it came to these 2 groups,” Flesch recounts. “So, for example, if a referral went to the wound ostomy team but the patient didn’t have an ostomy or fistula but, rather, a type of wound that should have gone to our PT wound team, the referral might not make it to the PTs until 24 or 48 hours later.”
When the 2 groups sat down together, “everyone recognized the benefit to the patient of working in unison to triage all wound referrals,” Flesch says. “Now, all patients requiring wound care come to 1 place. We’ve decreased duplication by at least 25%, and we also know quickly which patients need the services of both teams. This collaboration has had a great impact.”
For patients and PTs, that impact has extended beyond inpatient care, Flesch notes, with significant implications for decreased readmissions.
“It absolutely has heightened awareness throughout IU Health of the important role of wound management PTs,” she says. “The long-term goal now is to achieve the same standard of care throughout all our facilities by modeling similar collaboration between our CWS [certified wound specialist] PTs and WOCNs [wound ostomy certified nurses]. This collaboration started with the inpatient population, and we recently integrated a WOCN into the physical therapy outpatient clinic to treat appropriate patients.”
In fact, in what Flesch calls “recognition of the great work being done by physical therapists who are certified wound specialists,” IU Health spent about $1 million to double the size of the outpatient physical therapy wound program. “We’ve carved out a space and time during the week in 1 of our clinic rooms where ostomy nurses can join our outpatient team and assist patients who will benefit from their services,” she noted.
The result, Flesch says, is that, “If a patient still has a complicated wound upon discharge from the hospital, we’re staying on top of that.”
The data bear that out. “We’re keeping track of patients who we believe have avoided hospital readmission as a result of these outpatient efforts,” she says, “One recent month, the outpatient wound team performed 56 new patient evaluations. We determined that 35 of those patients might have been rehospitalized or required an emergency room visit if not for the efforts of the outpatient wound team.”
At Providence Health Systems in Oregon, meanwhile, a number of steps are taken to ensure that PTs are optimally engaged in ensuring patient safety and guarding against unnecessary hospitalization, says Cathy Zarosinski, the health care provider’s director of regional rehab operations. These steps begin at the hospital and continue through transitional settings and home care.
She cites as an example Providence patients who have undergone total knee replacements. “We were finding that the overall readmission rates for those individuals was rising slightly, with a number of patients being readmitted about 2 weeks after discharge,” Zarosinski says. “We looked into it, and we found that the primary reason people were being readmitted was that they were falling at home.” Providence accordingly stepped up efforts to get patients who’ve undergone total knee replacements into outpatient therapy after discharge, “to improve their range of motion and make sure their balance is where it needs to be.”
Some physicians may be reluctant to order post-discharge physical therapy, Zarosinski acknowledges, but both hospital and home care PTs educate patients and families on the risks, “empowering them to insist on outpatient physical therapy—particularly if the person who’s had the knee replacement is at all fearful of falling. Because,” she says, “the patient who is scared of falling will fall. It’s inevitable.”
This complements other, longstanding initiatives at Providence to limit falls risk. “We have built into our medical record a question that’s asked of every patient on every physical therapy evaluation: ‘Have you had any falls in the past year?’ A ‘yes’ response triggers a complete falls-risk assessment,” Zarosinski notes.
PTs meet before discharge with all patients who’ve had joint replacements. “We train the patient and the caregiver on all aspects of safety—safe transfer, safe and proper use of assistive devices,” Zarosinski says. “We work hard to instill in patients confidence that they can do everything we need them to do. It’s paramount that we make sure the patient and the caregiver understand the exercises we’re prescribing. We demonstrate proper transfer and ambulation techniques to caregivers to make certain those are understood, as well.”
Those things happen at the hospital. Providence is equally committed to ensuring that no nuance is lost in the patient’s transition from hospital to home. “Our home care therapy department gets the notes from the patient’s treatment sessions with the PT at the hospital, and the PT’s contact information,” Zarosinski says. “So, the home care PT is aware from the start of any particular concerns.”
Home-health PTs, furthermore, conduct a safety check to guard against potential hazards, such as throw rugs or ill-placed furniture. They also “reinforce how frequently patients should be getting up, show patients how to use shower benches, ensure that the tub is set up properly, and can call in an occupational therapist for help with a particular matter, if needed,” Zarosinski says. “It’s all about reducing falls risk—keeping patients safe and out of the hospital.”
Theresa Gates, PT, COS-C, emphatically stated her position on the role of home-health PTs in reducing hospital readmissions when she named her presentation at APTA’s 2014 Combined Sections Meeting (CSM) “We CAN Keep Our Patients At Home!”
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