• Feature

    Building a Better Referral-Management Process

    Here's how a hospital's physical therapy department designed an efficient, patient-centric system for managing referrals.

    Feature - Referral Management 01

    Physical therapy departments in acute care hospitals are under growing pressure to align their practices with hospital initiatives designed to decrease length of stay, discharge patients in a timely manner, and reduce readmissions. At Cedars-Sinai Medical Center (CSMC) in Los Angeles, it seemed that we had many more patients to see, and cases to manage, than could be handled within our desired timeframe.

    CSMC is a large urban academic and research hospital that features a level-1 trauma center. In the Acute Physical Therapy Department, we receive an average of 1,350 referrals per month but have a staff of just 44 individuals—23 full-time staff, 6 part time, and 15 per diem. At first glance, the solution is simply to hire more staff. From a business perspective, however, this would require justifying the need for more staff via productivity standards and other financial metrics—a potentially complex and time-consuming process. And hiring staff might not be the best solution, anyway. We decided to tackle the situation by first looking internally.

    Reflecting on our own processes, we began by asking some key questions:

    • Why do we have so many patients to evaluate and treat?
    • What constitutes an "appropriate" referral?
    • Are inappropriate referrals consuming time we could be spending with patients who would benefit from physical therapist intervention?
    • Are patients ready to receive skilled physical therapist intervention?
    • What is the role of physical therapy in the acute care setting?
    • Are we providing the right care, at the right time, at the right frequency, for the right duration?

    These questions propelled our department on a journey that primarily involved 3 key members of our team—the acute therapy services manager and 2 senior physical therapists (PTs). The team conducted literature reviews, researched regulatory agency guidelines, collected and analyzed department data, and collaborated with other departments to develop and implement specific operational strategies to address patient referral volume, appropriateness of referrals, and guidelines for caseload management.

    Overview of What We Did

    First, we explored the reasons physicians refer their patients to acute care physical therapy. This led to the addition of a field for "Physician Referral Reasons" in the patient's electronic medical record (EMR).

    Second, we developed a screening algorithm to help define and address the appropriateness of referrals.

    Third, we designed a clinical reasoning guideline to direct how caseloads for acute physical therapist service would be managed.

    Our guiding resources were the CSMC mission statement, the definitions of physical therapy by APTA and the Physical Therapy Board of California, a review of how the acute care PTs in our department were currently practicing, and a literature search of peer-reviewed documents.

    Reasons for Physician Referral

    We asked ourselves: Could we have an effect on patient referral volume, and on the appropriateness of incoming referrals?

    Feature - Referral Management Figure 1

    To answer those questions, we analyzed 2 weeks of cases from medical units that refer patients to acute care physical therapy. Chart reviews showed that the majority of physician referrals were for PTs to assist with (1) mobilization, (2) the discharge process, and (3) falls risk assessment.

    We presented these findings to the medical director for his edification and buy-in. We also wanted to gauge the receptiveness of physicians to making a minor changes in their workflow. The medical director supported collaboration to improve triaging and better ensure timely referrals.

    We collaborated, as well, with those in the medical center whose role is to work with departments to translate their clinical needs into business and technological requirements to improve clinical efficiency and outcomes. This partnership resulted in the medical center's Information Technology Department establishing a prompt in the EMR of "Physician Referral Reasons" for physical therapy. The prompt offered the 3 primary referral reasons and "Other" (see Figure 1).

    Implementation occurred in 2 phases. For the first 2 months, "Physician Referral Reasons" appeared on the screen as an option but not a requirement. Once the physicians became familiar with the field, selecting at least 1 reason under "Physician Referral Reasons" became required before the referral could be processed.

    Feature - Referral Management Figure 2

    Forced to select a referral option, physician participation was uniform. Implementation was seamless. There were no protests or adverse events—no feedback that physicians had felt insufficiently informed, and no delays in processing referrals.

    Developing the Screening Algorithm

    We next asked, "Upon receiving a referral, how might we further screen to ensure its appropriateness? Also, what criteria will help us best determine if this is the right time during the hospital stay, and the right level of care at which the patient should be evaluated by a PT?"

    To address these questions, we established guidelines upon which to base "appropriate" referral for a physical therapist evaluation:

    • We established a timeframe to determine the patient's baseline or prior level of function. We took into account the individual's need for, and the potential benefits of, physical therapy during hospitalization (as opposed to postdischarge), and the timeframe within which deconditioning and adverse effects might occur. We accordingly defined "baseline function" as the patient's functional level 1 week before the PT addressed the referral.
    • The patient should be medically and cognitively able to tolerate, participate in, and make measurable gains with physical therapy.
    • The patient should require skilled physical therapist intervention in the acute setting that could not optimally be deferred to the next level of care or to a preventive nursing program. Also, we stipulated that functional deficits from the baseline be associated with compromised medical status, with resolution expected with current medical management.

    Next, we incorporated the 3 criteria into an algorithm. (See Figure 2.)

    Now, after we receive a referral and review the patient chart, the screening algorithm helps determine if we should proceed with a physical therapist evaluation or proceed to a physical therapy screen. A template in the EMR explains why a screen and not an evaluation was performed. Also, for productivity tracking purposes, a nonbillable charge was created for screens performed.

    Two months before department-wide implementation of the screening algorithm, data collected through chart audits revealed that, on average, 20% of physical therapy referrals on the medical units were deemed inappropriate because the patient:

    • Did not meet cognitive readiness indicators,
    • Was not sufficiently medically stable to participate in and/or tolerate skilled physical therapist intervention at the time of referral,
    • Was at his or her functional baseline and required only routine mobility with nursing, or
    • Required treatment at the next level of care.

    Staff training in the screening algorithm and EMR documentation began during 2 consecutive monthly staff meetings. In this group setting, we used various patient scenarios as training tools.

    We conducted random chart audits to identify staff members needing 1-on-1 training. Within this training, staff could ask questions, and were asked to demonstrate their competency through patient-scenario quizzes and random chart reviews.

    Two months after training and implementation, we tested the accuracy of the screening algorithm with approximately 50% of all physical therapy staff and found 100% congruence.

    One month after implementing the 2 operational strategies—the physician referral reasons and the screening algorithm—inappropriate referrals on the medical units had decreased from 20% to 6%.

    Developing the CRG

    Our third operational strategy addressed management of the cases we defined as being appropriate for evaluation and yielding demonstrated benefits from physical therapist intervention at the acute care level. To provide criteria for how physical therapist services would be determined and delivered, we developed and implemented a clinical reasoning guideline (CRG) encompassing prevention, preparation, and progressive programs (CRG; Table 1), and readiness indices (Table 2).

    The CRG helps stimulate thoughtful reasoning and determine the justification for skilled services, while being mindful of services' efficient use. It is designed to be clinically driven—based on the individual's need for and readiness to receive physical therapist services at the acute care level—rather than being determined by protocol or diagnosis. The guideline couples the first 2 operational strategies with a therapy dosage.

    The final step is for the therapist to identify which therapy dose and program is appropriate for the patient, based on satisfaction of cognition, strength, and stamina-readiness indices.

    The guideline's progression identifies:

    • Change in baseline function. The PT notes the patient's functional level 1 week before the PT addressed the referral.
    • Current performance and functional level. This information is obtained through a chart review of documentation and through direct communication with the health care team. It helps identify whether patient are:
      1. Currently medically managed and/or improving in their functional performance, allowing them to actively participate in physical therapy and make measurable gains in less than 1 week,
      2. Fluctuating in their medical and functional status and will require more than 1 week to achieve measurable functional gains through skilled physical therapist intervention, or
      3. At their functional baseline and/or stable.
    • Disposition. Will physical therapist intervention in the acute setting facilitate readiness for the next level of care? In particular, discharge disposition was identified as 1 of the primary reasons for physician referral. By following steps 1-3, as in the screen, the PT determines if the criteria have been met to evaluate or screen the patient. If those criteria have been met, the guideline's next and final step is to select a therapy program.
    • Program selection. After the PT completes the examination and selects 1 of the 3 programs and its attendant therapy dosage, the patient is assigned to:
      1. The progressive program, with 1-4 consecutive days of intervention and functional gains to be met in 1 week or less;
      2. The preparation program, with 1-4 nonconsecutive therapy days per week and more than 1 week required to meet functional goals; or
      3. The prevention program, with 0-2 days of intervention and goals to be met in 1 week or less. Goals are follow-up with and training of caregivers and/or family members before the patient is placed in CSMC's nursing program for routine mobility and preventive care.

    The CRG serves as a scaffold for decision-making by PTs while allowing them to use their clinical reasoning and judgment to assign therapy frequency outside the guideline's recommended 1-4 days per week. All plan-of-care decisions require supporting documentation. To establish the frequency, the team conducted literature reviews and gathered input from members of the physical therapy staff and other health care team members familiar with both customary cases and ones that are more nuanced.

    Three factors helped determine that the assigned treatment frequencies should be 1-4 days per week rather than 5-7 days per week.

    First, most of the primary diagnoses on the surgical and medical units had length of stays that correlated with the national average length of stays of less than 7 days.1,2,3,4

    Second, we took into account the adverse physiological effects that 3 days of bed rest can have on patients.

    To help determine the intensity of the therapy program we established general readiness index guidelines for cognition, strength, and stamina. This helped staff determine a patient's ability to tolerate and participate in skilled intervention based on whether the patient, at the time of assessment by the PT, was progressing, fluctuating, or stable (Table 2).

    CRG Implementation and Training

    Data collected by the team showed that 24% of all evaluations were being assigned weekly treatment frequencies of 5-7 days per week. However, random chart reviews revealed that such frequency was not supported by PT documentation in the EMR. To determine how staff were establishing treatment frequencies, a questionnaire was created and administered to all full- and part-time members.

    The survey revealed that 55% of staff were establishing frequencies of 5-7 days per week based on the misconception that this was their role in the acute setting. These staff members also believed that this frequency was based on an established protocol. This was the evidence we needed to institute staff training in use of the clinical reasoning guideline and provide clarification and education on:

    • The physical therapist's role is in the acute setting,
    • The role of CSMC's established nursing program for routine mobility and preventive care, and
    • The absence of department protocols setting a fixed acute therapy frequency.

    Staff education was provided over the course of 2 months. It consisted of:

    • Training during 2 staff meetings,
    • Three post-training quizzes about protocols and the role of physical therapy in the acute care setting, and
    • Three posttraining quizzes that presented various patient scenarios to determine the participant's competency in using the clinical reasoning guideline.


    After the 2 training sessions, a second quiz found that now only 9% of treatment frequencies were based on misconceptions—a 46% improvement. This also showed, however, the need for additional education to clarify policy and the PT's role in the acute care setting. Additional education was conducted in 1-on-1 meetings. Quizzes with patient scenarios continued to gauge competency in using the guideline.

    Two quizzes were administered to the same 44 staff members. Quiz 1 was administered 1 month after training and found that 56% of staff were correctly using the guideline. Quiz 2 was administered the second month after training. It revealed that 78% of staff were correctly using the guideline. Further remediation was offered through 1-on-1 training.

    Again, baseline data revealed that 24% of all patients evaluated were being assigned treatment frequencies of 5-7 days per week. After the first month of training and implementation, the number of cases being assigned to the high-frequency group decreased from 24% to 7.7%. Data showed a further drop to 1% after 2 months and 0.7% after 6 months.

    Data collection and random chart audits also revealed that staff now were accurately using the guideline as support and assigning more cases to the preventive therapy program—with its associated low treatment frequency of 0-1 days per week, discharge from physical therapy, and hand-off to nursing for routine mobility and preventive care. Data also showed an increase in assignment to this program from 19% before implementation to 23% at 2 months and 24% at 6 months afterward.

    Finally, at 4 months posttraining and implementation we conducted random chart audits to determine applied competency. Of 80 random charts audited before implementation, 61% had been assigned a different therapy program from the auditors' selected therapy program, and not supported by documentation in the EMR. At the end of 4 months, 80 random chart audits revealed that 28% of patients were assigned to a different therapy program or to the outlier group, with supporting documentation appearing in the EMR. This continued to improve with 1-on-1 training as individual staff members' needs were identified through chart reviews. After 9 months, another 80 random charts were audited. Discrepancies had further decreased to 24%.

    While implementing the "Physician Referral Reason" field itself on the EMR went smoothly, we believe we would have needed less training after implementation if we had better prepared staff with more robust education on the front end.

    As a teaching hospital, we are challenged to provide new residents and fellows, new faculty, and new care team members with ongoing education about the role of physical therapy in acute care. The physician referral reasons show the value of physical therapy services for these patients. In our department, we have established orientation and training for new hires in using the tools. We continue to conduct random chart audits to ensure the tools are used accurately, and we present annual refreshers during staff meetings.

    Data collected at 9 and 12 months after implementation demonstrated that the strategies were continuing to make their mark:

    • Inappropriate referrals continued to trend downward. At 9 months, they had fallen to 4.7% on our medical units, from 20% before implementation.
    • Therapists were assigning more cases to the preventive therapy program. Patients then were being handed off to nursing for routine mobility and preventive care. Data at 12 months revealed 24% assignment to this program, versus 19% before implementation.
    • PTs were using the clinical reasoning guideline to establish the therapy dose. There was a sustained downward trend in cases being assigned to the outlier high frequency group of 5-7 days per week. At 12 months, that rate was 1.7%, compared with 24% at baseline.

    We are considering additional measures in our department to further address patient volume, caseload management, and timely care provision. These include:

    • Establishing alternative and staggered staffing schedules,
    • Fine-tuning triaging, as referrals are received and acknowledged in the EMR prior to scheduling with staff,
    • Collaborating with medical groups to educate physicians and residents about the role of physical therapy in the acute setting,
    • Collaborating with nursing and safe patient-handling team members to develop new, unit-specific early mobilization programs, and
    • Incorporating components of the clinical reasoning guideline into our computerized documentation for consistency and ease of implementation.

    These operational strategies have resulted in improved management of patient volume and identification of appropriate patients for physical therapy at CSMC. With an average of about 50% of cases on the medical and surgical units having a physical therapy referral, and with higher patient turnover due to shorter length of stays, we will continue to use the screening algorithm and the clinical reasoning guideline for caseload management and standardization of practice.

    Debra Powell, PT, DPT , and Lorraine Kimura, PT , work in the Department of Physical Medicine and Rehabilitation, Acute Therapy Services, at Cedars-Sinai Medical Center in Los Angeles.


    1. Nigam Y, Knight J, Jones A. Effects of bedrest: Musculoskeletal and immune systems and skin. Nursing Times. 2009;105(23):18-22.
    2. Calvo-Ayala E, et al. Interventions to improve the physical function of ICU survivors. <i>Chest</i>. 2003; 44(5):1469-1480.
    3. Steiner C, Andrews R, Barrett M, Weiss A. HCUP Projections: Mobility/Orthopedic Procedures 2003 to 2012. 2012. HCUP Projections Report # 2012-03. US Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports/projections/2012-03.pdf. Accessed October 6, 2015.
    4. Smorawinski J, et al. Effects of 3-day bed rest on physiological response to graded exercise in athletes and sedentary men. J Applied Physiology. 2001;91(1):249-257.
    5. American Heart Association. Sudden blood pressure drop with position change linked to higher risk of heart failure. http://newsroom.heart.org/news/sudden-blood-pressure-drop-with-230541. Accessed October 6, 2015.
    6. * Jones CD, Loehr L, et al. Sudden blood pressure drop with position change linked to higher risk of heart failure. http://newsroom.heart.org/news/sudden-blood-pressure-drop-with-2305. Accessed November 21, 2014.


    This utilization review highlights some important factors related to poor management of referral process, but seems to not acknowledge important administrative factors as well as the all important matter of quality of care. What complications happened in the lower vs higher utilization group? What about referral to PT for pain? What follow-up care differences existed for the different utilization groups, i.e. Did patients receiving less acute care services ultimately require greater sub-acute and/or long term care? Did those patients triaged to preventative nursing services experience greater numbers of complications such as falls, DVT, infection. It is important to evaluate cost of care over the entire episode rather than simply the costs incurred in acute care setting as the hospital is merely the entry point to the healthcare setting and the impact on total cost for the episode of care would be a much more telling variable regarding the impact of various case management strategies in the acute care setting.
    Posted by William Bieker on 6/18/2016 8:06:03 AM
    A very relevant and timely article for physical therapy utilization in an acute care hospital. Thank you. Demetra Ouellette, OTR/L, President Roger Williams Medical Center
    Posted by Demetra Ouellette on 2/5/2017 1:53:36 PM

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