• Feature

    Innovative Models of Care Delivery

    Creating a model to more effectively treat post-acute care patients who have had hip or knee surgery.

    Feature Innovative

    Preventing childhood obesity.

    Reducing older adults' need for surgery.

    Literally paying for quality care of patients with low back pain.

    If those sound like innovative approaches to improving health care, they should. Each arose from Innovation 2.0, an APTA initiative aimed at bolstering the impact of physical therapy within emerging models of health care such as accountable care organizations, bundled payment, direct access, patient-centered medical homes, prevention and health promotion, and value-based purchasing.

    Innovation 2.0—so named because it's an extension of APTA's Innovation Summit 2013: Collaborative Care Models—began as a dialogue among PTs and other health care players to discuss the current and future role of physical therapy in integrated models of care, explains Roshunda Drummond-Dye, APTA's director of regulatory affairs.

    The plan was for APTA to aid selected models by providing financial support, as well as advice about health care issues, health care policy, evidence-based practice, and data management.

    "We issued a request for proposals," Drummond-Dye recounts. APTA received 68 proposals, which were narrowed down to 21. Dianne Jewell, PT, DPT, PhD, CCS, chaired a selection committee of 9 PTs that included clinicians, researchers, administrators, and educators. The group of 21 were put through a "Shark Tank"-like process that resulted in 4 proposals being selected. Each "insert[s] PTs into nontraditional roles to improve health care for targeted populations," Drummond-Dye says. "Each applicant selected presented a budget designed to leverage APTA's resources to make the project happen."

    Since last September, APTA has been providing funding, following up on the work of the project teams, and has been receiving quarterly reports on the projects' progress.

    "Some projects are further along than others," Drummond-Dye notes, "but the exciting part is we already have seen some good fruits. These projects are leveraging relationships with payers and other health care providers, who are starting to take notice of the work and the quality-measurement data that is being gathered."

    The projects are funded for 12 months. Upon completion, APTA will publicize their outcomes in various ways (for instance, a session at NEXT 2015 in June examined outcomes to date), publish step-by-step templates for replication by other PTs, and otherwise lend continuing support to these fledgling efforts.

    Two other projects received honorable mentions and APTA funding. Here's a look at all of the funded projects and findings to date.

    Transitioning to Postacute Care

    Robin Marcus, PT, PhD, OCS, chief wellness officer of University of Utah Health Care (UUHC), serves as project lead for "Adding Value to Post-Acute Care Settings Through Evidence-Based Physical Therapy Services." Its purpose is to improve communication between skilled nursing facilities and UUHC after hip and knee surgery and to create a new model of postacute care for this vulnerable patient population.

    "I was looking for a way for PTs to solve a problem within the health care system, and 1 of the big problems is patient transition from acute care to the postacute care setting," Marcus says. "As PTs, we end up seeing most of the patients who go to postacute care while they are in the acute care setting, and no one was capitalizing on that connection."

    For the project, faculty, students, and community PTs interact through clinical improvement meetings, dashboards, and other feedback mechanisms, and by using personal-engagement metrics in performance evaluations. The goal is to rein in costs and provide better quality in postacute care settings.

    As of mid-June, the project had collected approximately 8,000 data points on its patients.

    "It's part of our medical record and standard of care here," she says. "It provides a mobility measure of where patients are when they enter our hospital and when they leave."

    The hospital also is in the process of implementing a gait-speed test to all patients who are ambulatory. "So, we'll have a therapist-reported measure and an actual performance measure related to mobility when outpatients leave the hospital," Marcus says. "We have 4 skilled nursing facilities in our local area that are following patients who go from our hospital to their facilities and are collecting that same information."

    UUHC is a regional hospital and the number of patients who go to those 4 facilities is not huge. But the hope is to follow and collect data from 100 patients.

    "The most important finding is that our data are reflective of other data—particularly that of the Cleveland Clinic—because they are collecting the same outcome measure on the most patients," Marcus says. "A second finding is the mobility measure seems to predict where people go at discharge in some cases, but not in other cases. Our job now is to try to figure out why. If mobility is important in predicting outcomes, then it should predict it in all patients. But it doesn't."

    For example, the hospital's total joint arthroplasty patients have the same mobility score at discharge, but some of those patients go home with home care, while other go home without it. Marcus hopes the model will determine why that occurs.

    "Obviously, it could be that mobility is not the only predictor of whether you need home care," she says. "We are trying to figure out if some patients really need home care while others do not, or whether this just is a variability in standard of care that we need to look at." Marcus reports that the project also is examining whether mobility at discharge predicts readmissions.

    Helping Prevent Childhood Obesity

    Brian Wrotniak, PT, PhD—a professor in the department of physical therapy at D'Youville College in Buffalo, NY, and a clinical researcher scientist at that city's Women and Children's Hospital—leads the Innovation 2.0 project "Patient-Centered Medical Home: An Innovative Model for Childhood Obesity Prevention with the Physical Therapist as a Key Player to Improve Quality of Care and Reduce Costs."

    "After I finished my physical therapy training, I had a growing interest in offering community health programs for families," Wrotniak says. "Noticing that movement dysfunctions seemed more common among my patients who were heavy, I felt there was a need for community family-based programs designed to improve weight through physical activity and healthy nutrition. As my interest in childhood obesity and community health grew, I completed a PhD degree in epidemiology, then a postdoc in pediatric epidemiology at The Children's Hospital of Buffalo. Through these experiences," he says, "I worked with leaders in the field of childhood obesity and behavioral medicine."

    The Innovation 2.0 project focuses on obesity prevention rather than treatment because preventing obesity, Wrotniak notes, will have the greatest impact on reversing the epidemic and mitigating its health and economic costs. Children classified as overweight (between the 85th and 95th percentiles of BMI, or body mass index) are included in the study so that Wrotniak and his team can assess how well the patient-centered medical home (PCMH) model prevents progression of overweight to obesity. Children weighing in at as low as the 75th BMI percentile similarly are included to assess prevention of overweight.

    "The goal of this project is to study cost-effectiveness and quality of care when PTs are integrated into the PCMH model for obesity prevention in a low-income population," Wrotniak says. "Physical therapists typically are not included in the PCMH team, and are at risk of being excluded from this emerging health care model. Yet PTs, as experts in optimizing movement to improve the human experience, are well equipped to address chronic health conditions such as obesity that are brought on, in part, by adverse lifestyle behaviors."

    "The main aim is to examine a PCMH for pediatric obesity prevention with the PT as a primary team member and co-project leader," Wrotniak says. "Children at risk for obesity will be identified by primary care providers and a review of patient registries. "Children will be seen for initial assessments and 8 follow-up visits by the entire health care team—comprised of a PT, physician, nutritionist, nurse, and patient care coordinator. Each child/family will be assigned a health coach for the duration of the project to support lifestyle behavior-change strategies."

    Physical therapy outcomes to be assessed for each cohort at baseline, 3, and 6 months include BMI z-score (standard deviation), pediatric obesity syndrome, and weight-specific health-related quality of life. There will be a particular focus on assessing the feasibility and acceptability of the PCMH based on child and family satisfaction surveys and focus groups.

    Cost-effectiveness will be assessed by monitoring incidence of obesity (crossing the 95th BMI percentile), physical therapy referrals for human movement disorders, asthma exacerbations, endocrine referrals, orthopedic problems, emergency department visits, hospital admissions, hospital length of stay, and overall patient medical expenditures and reimbursement.

    "The results of this project will be used to help inform the development of a multisite study to more precisely assess cost-effectiveness and quality of care of a physical therapist co-led PCMH for pediatric obesity prevention, using a 12-month controlled trial study design with group randomization at the practice level," Wrotniak says.

    "We expect the study will be completed by the end of 2016," Wrotniak continues. "We predict that the PT co-led PCMH will be feasible, acceptable, and cost-effective. If this hypothesis proves correct, our results will provide support for including PTs in the PCMH for childhood obesity prevention. This could serve, in turn, as a model for managing other chronic health conditions that affect human movement."

    Using Physical Therapy, Not Surgery, to Reduce Low Back Pain

    Timothy Flynn, PT, PhD, owner of Colorado Physical Therapy Specialists, leads the project "Facilitating Access, Improving Care: Physical Therapists as Integral ACO Members." It will assess the integration of PTs as essential members of an accountable care organization (ACO) collaborating in the Medicare Shared Savings Program.

    The project has 2 goals: (1) to evaluate the role of early access to physical therapy for patients within the ACO who report musculoskeletal issues—specifically low back pain, and (2) to determine if early and/or direct access to physical therapy for Medicare beneficiaries with low back disorders will result in decreased spine surgeries, less MRI utilization, and decreased overall costs of care.

    "My research and passion has been in back pain, and more specifically, the overutilization of invasive and harmful procedures to mitigate it," Flynn says. "It's known that if you get physical therapy early you're less likely to go the invasive route. What isn't clear, however, is how we can best nudge people to make the right decisions. It's very difficult to change provider behavior. Data alone does not change behavior. You have to find other ways to encourage and guide practitioners and patients to make better decisions."

    Flynn is teaming with Jan Gillespie-Wagner, MD, executive director and medical director of the Northern Colorado Individual Practice Association Inc and executive director of Mountain and Plains ACO LLC. The project's study population includes Medicare beneficiaries enrolled in Mountain and Plains ACO.

    Variables for determining the project's success, Flynn says, include the number of lumbar MRIs administered to the study population, the number of lumbar surgeries performed, the total ACO costs for lumbar diagnosis, and the total ACO costs of care. These variables are being compared by quarter and annually, matching the education and care pathway period with the benchmarking period.

    Individual and group provider-training sessions on current best practice have been implemented. The program includes referral to physical therapy in the first 2 weeks after the patient's initial visit to his or her primary care provider (with the report of low back pain that is limiting daily activities, or referral to physical therapy, as the first point of contact). Primary care providers are being educated on the process, and various physician-reminder systems are being designed.

    One of the challenges of trying to coordinate care across multiple independent practices is tracking referrals. "We are working on implementing coordination software used by a number of ACOs," Flynn says. "Ideally that will trigger a referral to a PT that can be tracked. We trying to get the system consistent across all practices to make sure referrals are happening."

    "The project's goal is to see if we can improve referral patterns for PTs in older adults with low back pain," Flynn says. "Part 1 is to improve and increase referrals to physical therapy on a timely basis. If we do that, do we decrease surgical, imaging, and injection rates in that patient population, thus decreasing costs?"

    A focus group will continue to develop, modify, and monitor compliance with the low back pain protocol that will be implemented for ACO patients. The focus group will help identify and resolve barriers to implementation of best-practice low back pain management and serve as strategic champions on its management within the ACO. The group also will enlist key stakeholders within the primary care physician and specialty care community.

    Results will be published after a 12-month data-collection period.

    Paying For Quality

    Gerard Brennan, PT, PhD, director for clinical quality and outcomes research for Intermountain Healthcare, leads the project "Pay for Quality Program to Improve Value-Based Care for Patients with Low Back Pain." It is a "pay for quality" program that provides financial incentives to PTs to improve care and achieve better outcomes in patients with low back pain. Another goal is to achieve a statistically significant and meaningful reduction in the "failure to progress" rate of patients with low back pain.

    The program involves approximately 57 PTs across 21 outpatient physical therapy clinics.

    Prior to the program, 42%-43% of patients were failing to improve following physical therapy. "When 40% are failing to improve, that is 'quality waste,'" Brennan says. The program set a benchmark of 38.4% failing to improve, with a goal of 34.7%. He concedes, "It's been very hard to move that needle…Our hunch is that there is a cohort of patients failing because we don't know their risk at the outset and we are not effectively engaging them," Brennan says. "We've tried to create tools to assess risk, and a process to spur improved decision-making and idea-sharing by PTs."

    Honorable Mentions

    One of Innovation 2.0's honorable mention projects is "A New Model of Care in Workers Compensation: Direct Access to Physical Therapist Services by Workers with Low Back Pain." It is led by Craig Johnson, PT, MBA, president of the Minnesota Physical Therapy Society.

    Minnesota's current neutral budget payment model results in isolated, narrow ("silo") cost management. The Minnesota legislature in 2013 passed legislation that included a study of the medical costs in that state's workers' compensation system. A new value-based payment model aligns incentives and stabilizes budget for the workers' compensation program and its stakeholders.

    "We want to collect data and use it in advocacy to change the system in Minnesota," Johnson says. "Payment reform of the workers' comp system is critical as employees move to high-deductible plans or health information exchanges."

    The timing of physical therapy services is a critical factor in determining cost in the workers' compensation system, Johnson says. Early or direct access to such services is safe and can mean cost savings to the system.

    "Early direct access to the services of a PT will deliver lower episode cost—medical and indemnity—per claim, decrease lost work days, and maximize return to work for injured workers with low back pain," Johnson says.

    The current clinical pathway for a patient with low back pain—an initial meeting with a physician that can involve a waiting time of up to a month—typically costs $2,100-$2,200. The new pathway, in which the patient immediately sees a physical therapist, cuts those costs to $900-$1,000.

    Key objectives of the project include reducing overall episode cost (both medical and indemnity) per claim, decreasing lost work days, demonstrating that direct access to physical therapy services is a safe delivery model, and gathering data to support future legislative changes related to the clinical pathway and payment.

    A second Innovation 2.0 honorable mention went to "Integration of Physical Therapy in 90 Day Post-Acute Episodes of Care." This project is led by Allison Orofino, PT, of the Marshall Medical Center in Cameron Park, California. Marshall is partnering with the Centers for Medicare and Medicaid Services in a pilot project for bundled payments in the 90 days following an acute care stay for pneumonia and congestive heart failure.

    What Innovation 2.0 Means for PTs and Patients

    Two sessions at NEXT 2015 this past June focused on Innovation 2.0 and included representatives from most of the projects. They talked about the challenges they've encountered as well as the opportunities they've identified and the lessons they've learned.

    "There is an inherent pitfall," Brennan noted, "in pay for performance, because PTs don't just respond to that. There has to be more—delivery of good care and doing the right thing."

    One recurrent theme was the importance of spreading the word about the benefits of physical therapy. Johnson spoke about educating other health care players. "They know they have to reduce costs," he said. "It's more challenging to argue that physical therapy is a solution. We're still thought of as just a part of the episode. We want to show that PTs should be at the front of the project."

    Others talked about the difficulty of communicating across professions. "Our challenge," Flynn said, "is communication with different provider types. [The problem is] not the PTs. It's the other participants."

    Communication barriers can be technological as well as human, Marcus noted. "We were told that there'd be no way to get 2 electronic medical record (EMR) systems to talk. So far, that's true," she conceded. "We want to track patients over the course of their stay. Our biggest barrier is getting the EMRs to talk with each other."

    Another recurring theme was the need to share outcome and cost information with stakeholders. "We need to share the data not just with the providers, but also with the patients and their families," Marcus said.

    Flynn addressed the related issue of pricing transparency, the growth of which particularly is being spurred by social media. "Word spreads. The insurance industry is in for some disruption when people realize that you can spend $80,000 for spinal fusion or $1,000 for physical therapy," he stated.

    Project leaders also talked about empowering the consumer and eliminating intermediate parties. Responding to an audience question about self-insured companies, Marcus answered, "Our university of 17,000 employees is self-insured. Our CEO is very interested in what we're doing."

    "The incentives are changing," Flynn noted. "There's a move to cut out the middle man. People don't want to go to hospitals to get our kind of care. Half of what we'll do in 5 years will be directly with businesses."

    The roadmap to get there, he advised, is "Keep the conversation going with the employers. Don't overcomplicate it. 'It's musculoskeletal pain. We can help.'"

    Keith Loria is a freelance writer.

    For More Information


    On September 24, APTA will present the first of a series of webinars on Innovation 2.0 projects and how they can help nonparticipant PTs in their practice. The first will focus on the accountable care organization (ACO) model of Timothy W. Flynn, PT, PhD.

    Future webinars will be presented in 2016.


    Innovation 2.0


    Innovation Summit


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