Transcript view slides - AMSUS Continuing Education

Integrating Physical Therapy
Services in the Patient Centered
Medical Home
PRESENTED BY:
MATTHEW GARBER, PT, DSC, OCS, FAAOMPT
PAULA PARADIS, PT, MS, DPT, MBA, MHA
JON UMLAUF, PT, DPT, CSCS
Disclosures
Presenters have no interest to disclose.
PESG and AMSUS staff have no interest to disclose.
This continuing education activity is managed and
accredited by Professional Education Services Group
in cooperation with AMSUS. PESG, AMSUS, and all
accrediting organization do not support or endorse any
product or service mentioned in this activity.
Learning Objectives
 Discuss the implications on access to care and
quality by incorporating physical therapy services
within the Patient Centered Medical Home (PCMH).
 Discuss the operational procedures of the Fort
Belvoir Community Hospital (FBCH) PCMH
Integrated Physical Therapy Clinic model.
 Discuss the implications on purchased care and
population health by incorporating physical therapy
services in the PCMH.
Outline
 Demand of Musculoskeletal Care
 How to access Physical Therapy (PT) Services
 Benefits of early access to PT Care
 Benefits of Embedding PT Care within a PCMH
 Evolution of the PCMH PT clinic at Fort Belvoir
Community Hospital
 The Way Forward: Direct Access to PT within the
PCMH
Escalating Demand of Musculoskeletal Care
 Large % PCM visits for
musculoskeletal conditions



Encounter rates for musculoskeletal
conditions have doubled in the last 10
years (MSMR, Apr 2013).
5 of the top 10 reasons for seeking
medical care in the military are
musculoskeletal (MSMR, Apr 2013).
#1 Other back problems
25% of Active Duty Soldiers
(~132K) are on temporary or
permanent physical profiles for
MSK conditions
 In FY14, MSK injuries accounted
for 1.5 million ambulatory
encounters and nearly $400M in
direct patient care costs among
active duty Soldiers.
Medical Surveillance Monthly Report, April 2013
Active Duty
Medical Surveillance Monthly Report, April 2015
Active Duty Medical Encounters (FY14)
Medical Surveillance Monthly Report, April 2015
Non-Service Members Medical Encounters (FY14)
Medical Surveillance Monthly Report, April 2015
Opportunity to Re-Capture Outsourced Care
 Non-service members
accounted for over 80
million medical
encounters (FY14).
 89% of these
encounters were
outsourced
 Over 65 capable of
using Medicare to
help offset cost of
outsourced care
Medical Surveillance Monthly Report, April 2015
Non-Service Members (0-17)
Medical Surveillance Monthly Report, April 2015
Non-Service Members (18-45)
Medical Surveillance Monthly Report, April 2015
Non-Service Members (45-65)
Medical Surveillance Monthly Report, April 2015
Non-Service Members (>65)
Medical Surveillance Monthly Report, April 2015
Cost of Increasing MSK Demand on PT Services
Demand > Supply = Network Deferrals/ Purchase Care
Non Active Duty Accounted for 84% of Purchased Care
Over 30% of All PT Referrals from PCMH
Primary Care  PCMH
 Improve access to primary care
 Improve quality
 Deliver more cost effective care
 Improve and standardize the patient experience of
care
 Establish primary care not as a gatekeeper or a
feeder system but as the foundation of a system for
health
Steps Taken To Receive Physical Therapy Care
50 year old with
back pain
He is scheduled
in a routine
appointment
within 7 days
with his PCM
Steps Taken To Receive Physical Therapy Care
Self Management
PCM then
decides next level
of care needed
Orthopedic Consultation
Sports Medicine Consultation
Advanced Imaging
Physical Therapy Consultation
Steps Taken To Receive Physical Therapy Care
If PCM Consults
PT at initial
encounter
7 days for routine + 28 Days for
specialty care
The MTF has met ATC standards if
the patient is seen within 35 days
Benefits of Early Access to PT Services
 Low back pain is the leading reason why patients
seek medical care (MSMR, Apr 2013)


Low back pain (LBP) patients receiving early physical therapy
are less likely to receive advanced imaging, additional
physician visits, major surgery, lumbar spine
injections and opioid medications (Fritz 2012, Childs 2015)
When LBP patients receive early physical therapy care
(<14 days), total medical costs per patient is 60% lower (Fritz
2012, Childs 2015)
Potential Benefits of Embedding a PT within
PCMH
 Improve access to care to PT services
 Ability to prioritize Acute/Sub-acute patients
 Improve relationship between PCMs and PTs
 Information Sharing between services
 Participation in Huddles
 Patient Handoffs
 Bilateral Training Opportunities
Fort Belvoir Pilot: PCHM PT Clinic
 Started in Family Medicine (SEP 2013)
 Personnel = 1 PT, 1 PTA
 Services available to all enrollees
 Template change
 Mostly new encounters
 Consult review
 Acute/sub-acute prioritized into PCMH PT Clinic
 Chronic patients were seen in the main PT Clinic
 PCM Education
 Consults to include patient status (Acute, sub-acute, chronic)
PT Embedded Pilot Cost Outcomes
One PT embedded in PCMH Sep 2013
No increase in personnel (same FTE equivalent)
Over 35% decrease in network deferrals and associated cost
FY13
PT Purchased Care
PT Network Deferrals
FY14
$ 2,521,971 $ 1,556,999
2632
1706
Reduction Percentage
$ 964,972
926
38%
35%
Concerns
 1 PT for entire family medicine clinic (25,000 enrollees)
 Heavy demand = provider burnout
 PT had to be rotated out every 4-6 months
 Not entirely patient centered
 Patients were still required to call for appointment with PT
 Location of care confusion
 Inability to provide same-day/acute appointments
 Limited ability to provide follow-up/hands-on
treatment

Concerns on the quality of care that was being delivered
Change 1
 Added more PTs to Family Practice PCMH Clinic
(DEC 2015)


Due to space limitations, providers rotated within FM PCMH Clinic
Goals: prevent provider burnout, increase quality of care
 1 PT imbedded within the Internal Medicine Clinic
(JUN 2014)
 Template change – added treatment/follow-up
appointments to increased quality of care delivered
 Add Walk-in/acute appointments to provide care within
72 hours
 Allow patients to book with PT the same day at PCM
encounter

Patient hand-carried slip
Total Consults Written & Deferred FY15
PHYSICAL THERAPY MTF FBCH
Trending for FY15 – 1084 Consults Deferred
Additional 36% reduction from FY14
Total AD Consults Written & Deferred FY15
PHYSICAL THERAPY MTF FBCH
No Leaked AD Prime due to capacity for 7 months
Voice of the Customer:
 Black Belt Project “Voice of the Customer” surveys:
 Likert Scale (1-5) questions on access/environment, PT
experience, imaging experience
 “Overall Experience” question - Net Promoter Score
 179 surveys completed from main PT clinic, Family
Medicine and Internal Medicine PCMH clinics with
embedded PTs over three months
Survey Results: Net Promoter Score (NPS)
Replicates the NPS methodology described in the 2003
Harvard Business Review
 Used widely in business based on its researchsubstantiated correlation between high NPS scores,
company growth and customer loyalty





Results based on score received on the 1-10 scale:
Promoters: Scores 9 or 10
Passively Satisfied: Scores 7 or 8
Detractors: Scores 6 and below
 Industry Average: 16%


Exceptional companies: USAA, E-Bay: 75-80%
Anything above 0% considered good
PT Survey Results: Net Promoter Score
(NPS)
 179 patients surveyed (Apr-Jun15) in PCMH-based PT and main PT
locations
 NPS Question:
 “How would you rate your overall experience today with
your provider on a scale of 1 to 10 with ‘1’ being the worst
experience, to ’10’ being the best experience ever.”
 Both locations exceed industry standards for exceptional customer
experience
Patient Surveys - 179 total: Net Promotor Scores
Clinics
Total Surveyed
Answered
NPS
PCMH
72
38
(30)
78%
(8)
Main PT Clinic
107
75
(66)
88%
(9)
Promotors
Passively
Satisfied
Detractors
NPS*
22%
(0)
0%
78%
12%
(0)
0%
88%
*NPS Industry Average 16%
Additional Survey Results
 ALL patients responded to the following statements with a
4 or 5 rating:
(Scale of 1-5, with “1” being “not at all” and “5” being “absolutely”)





Confidence in PT’s knowledge
Explanation by PT on current condition
Interest and concern shown by PT
Overall satisfaction with PT
Preference to see a PT first for musculoskeletal concerns
 4% of patients from PCMH clinics unhappy with wait
times for initial consult with embedded PT
 26% of patients surveyed referred from PCM to main PT
clinic unhappy with access to care wait times


Score of “3” or less
Up to 28 days for initial PT appointment
HEDIS Low Back Pain Imaging Metric
MEDCOM vs. FBCH
HEDIS Metric: Family Med vs. Internal Med
HEDIS Low Back Pain Imaging Metric:
Analysis by Clinic Type
Embedded PT
Intervention: Coding Go-By
 Clinically, providers understand the metric and are




making sound clinical decisions for imaging
Confusion over coding flags many providers as
“inappropriate” for imaging
The ED works on a “paper” record, and coders choose the
ICD-9 code based on provider’s description
No formal education on the metric or coding – lack of
clear direction
Black Belt Team developed Coding Go-By


Team Leads conducted education to all providers, including ED
Clinics initiated weekly coding reviews/checks
Coding Go-By Provider Handout
NO
Considering Imaging
for Low Back Pain?
YES
DO NOT order
imaging for Low
Back Pain within
28 days of Dx
May code
“Lumbago” or
“Lower Back Pain”
724.2
NO
Imaging Medically
Justified?
YES
SYMPTOMS LASTING
LONGER THAN 28
DAYS OR HX OF
“CHRONIC” PAIN
SELECT A CODE:
338.29 – Chronic Pain
905.7 – Late effects of
injuries/strain
musculoskeletal
RECENT TRAUMA
OR INJURY
SELECT A CODE:
959.9 – Blunt Injury
959.19 – Lower Back Injury
800-839: Dislocation of Joint
850-854: Intracranial injury
860-869: Internal injury of chest,
abdomen & pelvis
905-909: Late effects of injury
952: Spinal cord injury
958: Early complications of
trauma
NEUROLOGIC
FINDINGS
SELECT A CODE:
729.2 – Radiculitis,
Neuralgia, Neuritis
334.6 – Cauda Equina
HISTORY OF OR
DRUG USE
HISTORY OF CANCER
SELECT A CODE:
304.0 – Opioid dependence
304.2 – Cocaine dependence
304.4 – Amphetemine
dependence
305.4 – sedative abuse
140-209 or 230-239
Neoplasms
DO NOT ADD A “LUMBAGO” OR “LOWER BACK PAIN EQUIVALENT” CODE TO YOUR ENCOUNTER IF
ORDERING AN IMAGE USING THE ABOVE CODES
IF A PREVIOUS DX WITHIN 28 DAYS USES “LUMBAGO” CODE, THIS WILL BE THE FLAGGING INITIAL
EVENT, EVEN IF APPROPRIATE CODE IS USED ON SUBSEQUENT VISIT INSIDE 28-DAY WINDOW
Importance of Early Access
X-Ray: 155 MRI: 28 CT: 2
Over 3 times more likely to receive an MRI for back
pain if seen out of network when compared to MRI
numbers from our facility
Change 2: Move to Direct Access
 Initial process cumbersome and not patient-
centric



PCM visit required for PT referral
May take multiple visits for PCM to refer to PT
Complicated and time-consuming process to make PT
appointment
 Direct Access has been within the scope of
practice of military PTs since the 1970s (James, 1975)
Evidence-Based Care:
PT Skilled for Direct Intervention
PTs ideally suited and trained to
treat musculoskeletal conditions
Passing score = 73%
Doctor of Physical Therapy
degree with advanced training in
differential diagnosis, appropriate
imaging, and pharmacology

 PTs in military settings are
credentialed to order imaging,
refer to specialty clinics, provide
profile/quarters, prescribe limited
medications
 Diagnostic accuracy of PTs
similar to orthopedic surgeons,
better than non-orthopedic
providers
Childs JD, Whitman JM, Sizer P, Pugia ML, Flynn TW, Delitto A: A
description of physical therapists’ knowledge in managing musculoskeletal
conditions. BMC Musculoskeletal Disorders 2005; 6: 32.
Evidence-Based Care: Direct PT Intervention
 Evidence for Direct Access to PT
A Systematic Review: Direct Access vs. Physician
Referred PT (Ojha, 2014)
 8 articles, level 3-4 evidence (Grade B-C)
 Statistically significant, clinically meaningful across
studies






Superior satisfaction and outcomes
Lower costs
Fewer visits
Less imaging and medication
Fewer additional non-PT appointments
No evidence of harm
Steps Taken To Receive Physical Therapy Care
50 year old with
back pain
He is scheduled
in a routine
appointment
within 7 days
with his PCM
Direct Access PT
PT decides next
level of care
needed
Orthopedic Consultation
Sports Medicine Consultation
Advanced Imaging
PCM Consultation
Change 2: Process for Direct Access for PTs
PCMH Integrated Physical Therapy Clinic Booking Procedures
When a Patient (15-65 years old) has ONLY a musculoskeletal complaint offer an appointment with a Doctor
of Physical Therapy by saying the following:
“At Fort Belvoir we have Doctors of Physical Therapy who are experts in musculoskeletal
care. Do you want to see a Physical Therapist instead of a Primary Care Provider?”
If yes: Connect to PCMH Integrated PT Clinic at (571) 231-0271
If no: Book in accordance with PCMH guidelines
Musculoskeletal complaints include:
Neck pain, back pain, shoulder pain, elbow pain, hip pain, knee pain, foot/ankle pain
A Physical Therapist can:
Request appropriate imaging studies (i.e. X-rays, MRIs, CT, EMG, etc)
Assign patients to quarters for up to 72 hours
Refer patients to specialty clinics
Write temporary limited duty profiles
Write prescriptions for selected medications to treat musculoskeletal
conditions (to include but not limited to Acetaminophen, NSAIDs,
Muscle relaxers)
Patients with ONLY a musculoskeletal
complaint who ask to see both a PT
and their PCM read:
“If for any reason, you feel that you
require an evaluation by your Primary
Care provider we can coordinate this
after your physical therapy
appointment.”
PT in PCMH Results Overview
Quality
Cost
Access
Direct Access PT Pilot MAY 2015
Improved access to PT: 7-10 days
Improved patient satisfaction
Added 2nd PT to Internal Medicine – JUN 2014
Combined improved HEDIS measure: 75th percentile
Internal Medicine only HEDIS measure: 90th percentile
Embedded PT Pilot SEPT 2013
Savings of $1M network cost FY13-FY14
35% reduction in network deferrals
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