Physical therapist management of patients who are acutely ill is receiving increased attention. This year, 2 observational and descriptive studies were published that report on the utilization of physical therapy in the acute care setting.1,2 This attention is timely as health care reform is debated and changes are proposed to current care delivery. As Jette et al2 state, the advent of bundled payments, or reimbursement based on the entire episode of care, will test not only the profession of physical therapy, but every profession providing care in the acute care setting and on through all care settings, including the home. All health care professions will have to adequately describe and quantify current practice, establish more robust outcome measures, and perform research to understand optimal or preferred practice as it relates to patient outcome.
Physical therapists have a long history of treating people in acute care settings, and there is evidence that physical therapy intervention can make a positive difference. For example, a landmark study in 1954 defined the abnormality (postoperative pulmonary complications), divided a relatively large patient cohort (172 patients who had undergone upper-abdominal surgery) into 3 intervention groups, and measured significant decreases in the complication rate with one preferred physical therapy approach.3 Those patients who received both preoperative and postoperative pulmonary physical therapy had a 12% incidence of pulmonary complications, compared with those who received only postoperative pulmonary physical therapy (27% incidence of pulmonary complications) and those who received usual care (42% incidence of pulmonary complications).
Postoperative complications for patients who had undergone upper-abdominal surgery were a major cause of morbidity and mortality in the 1950s. The reasons for that were many, including longer and less-sophisticated use of anesthesia, more-invasive procedures for abdominal surgery, and the philosophy of keeping a patient in bed for extended periods of time postsurgery. These “reasons” share a common theme—they are functions of the settings in which the patient received care and in which the team delivered care. Today, the amount and type of care required to minimize postoperative complications are quite different, reflecting the changes in care settings during the past half century as well as a greater focus on the needs of the individual patient.
Some studies have examined early intervention as compared to delayed care. In 1982, for instance, Cope and Hall4 documented that early intervention for individuals with head injuries, as compared with later intervention, achieved the same level of function but with half the total number of treatments and an estimated savings per patient of $40,000. With the availability of this evidence, our challenge is to determine whether the approach is currently used, and, if so, whether it has the same or different effect today. Anecdotal reports indicate that some believe the physical therapist should simply evaluate for discharge in the acute care setting and not provide intervention. Is there evidence to support this approach? How can we best address care for the patient in the acute care setting that indeed maximizes function while providing the most efficient delivery of care?
Jette et al2 collected data at 3 academic medical centers regarding the practice of physical therapy in the acute care setting. The researchers make an important statement that the first step in reducing variation in practice is to describe practice and the variability of practice from setting to setting. They acknowledge that variations of practice observed in the 3 centers likely included factors related to the practice setting and that previous research has shown that choice of interventions are affected by factors such as caseload or reimbursement. They cited a model described by O'Neill and Kuder5 that suggests
a “baseline heuristic” that reflects the practitioner's education, experience, and professional style. This heuristic is adapted to the practice environment and then further modified to reflect the specific situations of individual patients in decision making. Any of these sets of factors could result in different decisions about how to manage patients with similar conditions; these differences result in variations in practice across practitioners and practice settings….
Applying the conclusions of the aforementioned studies to physical therapy in the acute care setting, it might be speculated that decisions about patient management could be related to physical therapists’ education and experience, the environment and resources of the facility, and the general characteristics of the patients treated at the facility.2(p1159)
These examples from acute care are emblematic of all of physical therapy. Whether we are academicians who prepare practitioners, clinicians who practice within a particular health care system or a particular setting, or investigators who conduct research—we rarely, if ever, understand (let alone validate) the impact of these systems or settings on our own practice or on patient response. Perhaps it is time to challenge the status quo and look more closely at these influences on the patients and clients we treat. Our understanding of these influences is critical if the physical therapy profession is to engage in the national health care debate and determine the role of physical therapists in the care delivery system.
Earlier this year I had the privilege of chairing the Physical Therapy and Society Summit (PASS), which was sponsored by the American Physical Therapy Association (APTA). PASS occurred in response to an APTA House of Delegates motion that the association should convene a group of thought leaders to envision how physical therapists can address current, evolving, and future health care needs. The summit was attended by more than 100 individuals, including 30 thought leaders in policy, technology, and innovation outside the physical therapy profession. The group addressed issues from health care access, to health care systems and funding, to practice models. One striking paradigm shift was thematic throughout the event, encompassing all of the factors that have an impact on patient care—and we will need to absorb it into our professional souls as we help to reframe how care is delivered.
The usual paradigm of care from the perspective of the physical therapist involves the patient and the physical therapist (Fig. 1). Jette et al2 allude to this tangentially, as their survey revealed that only 70% of visits included communication with other health care team members. There was no mention of how the physical therapy intervention fit or was accomplished collaboratively with other professionals or how the physical therapy intervention assisted or added to the positive outcome of the individual returning to his or her own life—an important consideration that extends beyond the simple patient–physical therapist paradigm.
The paradigm of the future as envisioned by PASS (Fig. 2) places the patient/client—the health care consumer—in the center, surrounded by a team of health care providers that includes the physical therapist. The members of the health care team collaborate with one another to share data and communicate outcomes as they provide care to each individual, with recognition of and attention to the community (availability of support, level of function needed to be independent) and the society (responsibility of providing services, ability to cover services) within which the patient lives. Each level in the paradigm—the individual health care consumer, the health care team, the community, and society—affects the outcomes of care, including the physical therapist's essential focus on functional outcomes.
What would our education and practice look like if we used this paradigm in a more intentional manner? The notion that the physical therapist operates as one entity among many in a multilevel system challenges us to think differently, practice differently, teach differently, and conduct research from a larger perspective. For example, research would require complex designs, involve multiple centers and multiple disciplines, and follow a cohort of patients with a given disability throughout their entire episode of care—from acute care, to rehabilitation, to home. Adoption of the PASS model would stimulate researchers to explore factors related to the setting of care, services provided by the health care team, characteristics of the reimbursement and health care system, as well as resources provided by the community and society to fully explain physical therapy outcomes, practice, and practice variation. This type of systems approach will advance the role of physical therapy to better address the needs of society.
- © 2009 American Physical Therapy Association