Feature A Deepening Footprint Across the country, PTs are stepping into primary care roles. The journey to wider integration is under way, but obstacles remain. By Eric Ries | December 2018 Tony Bare, PT, DPT, ATC, describes Bare Physical Therapy, his cash-pay private practice in Laramie, Wyoming, as "totally a primary care environment." (In 1994, the National Academies of Sciences, Engineering, and Medicine's Health and Medicine Division, then known as the Institute of Medicine, defined primary care as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing within the context of family and community."1) Bare practices across the gamut of physical therapy—pediatrics to geriatrics, orthopedics to neurology. He fashions orthotics in his garage. He performs cranial therapy in a side gig as part of the concussion protocol team for the University of Wyoming's football team. He also volunteers twice a month at Laramie's Downtown Clinic, which offers comprehensive primary health care to low-income, uninsured residents. There, Bare works as part of a collective unit with physicians, pharmacists, nurses, social workers, and other providers. That last role reminds the retired US Army colonel of his experience in the military—in which physical therapists (PTs) are empowered to work at their full level of training and licensure, share responsibilities with other health care providers in an environment of respectful collaboration, and help get each patient to the right provider without delay. "It's a different mindset," Bare says. "No one is 'turfy' about any individual patient." Business at Bare Physical Therapy is thriving, based primarily on word-of-mouth testimonials, its owner says. That's not likely to happen in a thriving college town that offers a variety of provider options "unless you're doing something right," he says. "When you expand your physical therapy toolbox and treat patients effectively and efficiently, the PT naturally is going to become that individual's go-to provider," he asserts. Similar to Bare, Rebecca Byerley, PT, DPT, could describe from experience a compelling primary care model for physical therapist practice long before she opened her own private clinic—Elite Rehabilitation, in Soldotna, Alaska— in 2007. For 2 years in the mid-1990s, Byerley was the sole PT working in private practice in the Middle Eastern nation of Oman. There, she practiced within a model she later would replicate on the other side of the world. "My private practice in Oman was consistent with what I'm doing now, in terms of having strong support from local physicians and medical facilities, and in terms of educating the community—I worked largely in an expat environment—about my availability. I was operating consistently in a primary care setting," she continues—"examining and treating individuals, triaging them, and recognizing when care was needed that was outside the scope of physical therapy." In Alaska, which has unrestricted direct access to physical therapist services, "people walk in my door with a variety of issues, and I may be their first point of contact with the health care system," Byerley notes. "So, I have to be able to recognize when something that's presented as a musculoskeletal issue might, in fact, have another cause. I would describe a physical therapist in primary care as having a broad set of skills—clinical, professional, and administrative—and using those skills to evaluate and identify patient and client needs across a spectrum of presentations, while at the same time understanding and cultivating collaborative relationships with other medical entities," she says. Byerley is well-known in rural Soldotna, the town of fewer than 4,000 people where she's lived for 22 years. Outside her practice, she volunteers at a variety of sports events. She scores diving competitions and provides swimmers with injury-prevention and triage services. In keeping with the National Academies' definition of primary care, Byerley very much operates "within the context of family and community." Ivan Matsui, PT, brings a different perspective to PTs practicing in primary care environments. He's the assistant chief of rehabilitation services at Kaiser Permanente Northern California and is on the faculty of both fellowship and residency programs at Northern California Kaiser Graduate Education. He's also a fellow of the American Academy of Orthopaedic Manual Physical Therapists. PTs have been practicing in primary care at Kaiser Permanente Northern California since the mid-1990s. As of this summer, the health care consortium encompassed nearly 4.3 million members, 21 hospitals, and 242 medical offices and other outpatient facilities. For many years PTs were embedded in family medicine departments, with their own dedicated treatment rooms. Patients were seen upon referral as well as without a prior visit with a physician. Because of growing membership and resulting space demands, Kaiser Permanente moved in 2016 to a "roving PT" model in which PTs no longer are embedded, but they field physicians' calls by telephone while the patient still is in the examination room. The process is described in "A Perspective: Exploring the Roles of Physical Therapists on Primary Care Teams," a 2017 APTA document (see "APTA Resources" on page 30) that was sought by the APTA House of Delegates to investigate and identify the roles of PTs on primary care teams, the services of PTs that may qualify as primary care components, and current and future opportunities for PTs to integrate those roles into practice, education, and research: The physician presents the case to the roving PT over the phone and, among other things, articulates the problem, question, or other circumstance that warrants a request for a PT's 10-15- minute consult during the same office visit with the physician in the exam room. The PT helps the physician answer many different questions during these visits. The physician may call and request the consult to find out whether a presenting arm issue is arising from a shoulder impingement or a cervical radiculopathy—or on occasion, to specifically add to the physician's decision-making with regard to further workup for cardiac, neoplastic, or other non-musculoskeletal disease. More common questions are whether or not imaging, physical therapy, or other specialty referral is indicated. The results of such collaboration can be powerful, the APTA document continues: Often these clinical questions are explored and answered in the presence of both the physician and the patient. This is uncommon in most outpatient settings, and, inevitably, learning in these teams takes place by both clinicians. Immediately and over time the understanding of each other's recommendations and practice are more clear and efficient. Besides the improved quality of care for the patient, collaboration between the physician and the PT has been cited as critical in program implementation. Matsui, who helped write the APTA paper, attests to all that. "As a result of our history, physician teams at Kaiser Permanente Northern California are knowledgeable about what PTs bring to the table and are comfortable not only with sending us patients to treat, but also with asking us questions such as whether the patient has a back problem or a hip problem, or a shoulder impingement or a cervical radiculopathy," Matsui notes. "Or, the physician might ask the PT whether the patient should take time off work, have X-rays, or be sent to physical therapy specialty care," he adds. "We can come over to that exam room and provide tier 1 treatment or share our input, as the situation demands." Under the Kaiser Permanente Northern California model, "patients see PTs more quickly, which reduces the number of follow-up visits and closes care episodes faster—with positive implications for the patients themselves and for health care costs," Matsui says. "Our insights also help physicians make fully informed decisions on matters that benefit from our expertise." The US Department of Veterans Affairs (VA), meanwhile, began a pilot in October 2017 that is embedding PTs in primary care teams at 7 medical centers and an outpatient clinic administered by the VA Midwest Health Care Network 23, which covers Minnesota, North and South Dakota, Iowa, and Nebraska. "This initiative is extremely important," says Mark Havran, PT, DPT, service chief of extended care and rehabilitation at VA Central Iowa Health Care System. "It mimics what the Department of Defense has long done at military treatment facilities. The goals are the same as in the military model—to improve timeliness to care and to reduce downstream costs." The results, says Havran—who is president of APTA's Federal Physical Therapy Section—thus far are encouraging. "We're seeing improvements in functional outcomes as reported by patients, reduced waiting time for physical therapy, less utilization of imaging, and fewer consults to specialty care." That bodes well for potential future expansion of the pilot to all 170 VA medical centers, Havran says. He hopes such expansion might, in turn, further nudge other health care systems to follow Kaiser Permanente of Northern California's lead and better integrate PTs into primary care provision. Such prospects energize Bill Boissonnault, PT, DPT, DHSc, FAPTA, executive vice president of professional affairs at APTA. As part of the VA pilot, he traveled to Minnesota in July to teach a course to an audience of PTs, physicians, physician assistants, nurses, and administrators on the PT's role in triaging of patients. "What the VA is doing is very exciting." he says. "Besides the benefits to the health care system, the potential for this program to become a nationwide model has huge implications for the profession of physical therapy. It could have a domino effect in the public sector." Boissonnault, who has written a textbook on PTs in primary care,2 is encouraged by the profession's trajectory over the past several years, while mindful of the challenges that lie ahead in deepening physical therapy's footprint. "More and more PTs are working in primary care settings," he says, "which benefits not only patients, but also the health care system in terms of appropriate utilization of resources and decreased health care costs. We are experts when it comes to treating people's musculoskeletal issues—back pain, neck pain, knee pain—and we're well trained to triage patients with nonneuromusculoskeletal issues. That's what I see growing in the future." He acknowledges, though, that "the challenge, at times, is getting our foot in the door. Having a seat at the table when primary care clinics and models are being developed. Ensuring that other providers know that patients can see us without a referral. Making certain that providers and the public are aware of PTs' depth of training and breadth of knowledge. Some of these things we have direct control over. For others," he notes, "it's going to take some time and work." Hurdles and Hope The APTA perspective paper on PTs in primary care—compiled by a work group of association members that included Matsui and APTA staff that included Boissonnault—states that "PTs are well-positioned to provide a larger portion of ongoing primary care services, versus solely episodic care or entry-point encounter." Among the existing programs the document highlights to illustrate that point are the military and Kaiser Permanente Northern California models, as well as international models in Canada, the United Kingdom (UK), Ireland, New Zealand, and Sweden. Physiotherapists in the UK, for example, "have the jurisdictional scope of practice to make medicine recommendations, prescribe medications with a physician's counter- signature, and perform injection therapy," the paper notes. But the APTA document concedes challenges to the advancement of PTs in primary care in the United States. They include: Terminology. Outside of the National Academies definition, primary care- related terminology is inconsistent from state to state. Education. Formal entry-level or postprofessional educational opportunities specific to practice in primary care don't currently exist, and there's no dedicated curricula on it in doctor of physical therapy programs. Regulation. To date, the document notes, no state practice act designates or lists PTs as primary care providers. Furthermore, "direct access" typically comes with strings attached—"not only coordination with other patient providers, but oversight by a primary care physician or nurse practitioner following the initial evaluation or 30 days of treatment. Work in this area," the perspective paper states, "needs to include adding regulatory language about the physical therapist's ability to order and interpret specific imaging and lab tests, and to prescribe medications. If we are going to adopt the military system or that of another country," the authors observe, "we have a lot of work to do in this arena." Payment. Medicare does not name PTs among practitioners who can be referred to as primary care providers. In hospital settings in the US health care system, physical therapy is billed as part of a group of services, as opposed to as an independent provider consultation. In outpatient settings, it is deemed a specialty that requires a patient copay. Many insurance companies won't pay for physical therapy beyond the initial evaluation or beyond 30 days of treatment without a referral from a physician or other primary care provider. Public perception and population health. Few members of the public view PTs as their primary care provider. To that end, APTA encourages annual visits to a PT for a checkup3 and offers resources, but the service isn't much provided. Also, while the association supports PTs' roles in health and wellness (see "Primary Care and APTA" on page 27), that area still is evolving in terms of expanding beyond individual health to community or population health. (Many PTs are active in community health, however, as highlighted earlier this year in PT in Motion.4) Professional expectations. APTA, the perspective document notes, "has not taken a stance or clearly defined the roles of physical therapists in primary care, the services they would provide, or a discrete plan to advance the profession under the primary care umbrella." To get a better handle on that last area, the association this fall surveyed association members who practice in primary care environments. The goals (survey results were pending at this writing) were to determine the key competencies of primary care delivery by PTs and the qualities that board certification as a clinical specialist might require (should such a designation be pursued). More than 8,000 individuals were asked questions related to knowledge areas, professional roles and responsibilities, and practice expectations in patient and client management. The survey described prospective candidates as follows: "This specialist has advanced expertise to practice across the lifespan to both evaluate and treat clients across a wide spectrum of health conditions. This specialist may be working in a variety of settings, including a rural setting in which patient choices for health care services are limited, acute/urgent care, hospital-based outpatient, or private practice." One thing Boissonnault wants to make clear is that regardless of whether a new specialist certification in primary care is developed, "PTs won't stop practicing in these settings." To the contrary, he says, "I see more and more PTs becoming involved in primary care." While all of the challenges cited in the perspective paper are real, "those obstacles have been there for a long time," Boissonnault observes. "We've already overcome a lot as a profession in just the past few decades. There's now some form of direct access to the services of physical therapists in all 50 states, the District of Columbia, and the US Virgin Islands, and unrestricted direct access in 18 of them." Also encouraging, Boissonnault says, is that "more and more PTs are assuming administrative leadership positions in their workplaces—which is a really good thing, because it helps educate the decision-makers about the important roles PTs are playing and can play in primary care." He adds, however, that the profession "must do a better job in terms of outreach. We need to communicate more, and more effectively, with physicians, nurses, pharmacists, and other members of primary care teams. And we need to push more strongly for interprofessional education," Boissonnault says. "Students and faculty from different health disciplines working together is a powerful way to raise awareness and understanding of PTs' knowledge, level of training, and expertise—and of the difference they can make as their role in primary care expands." That's one reason he's so enthusias- tic about the VA's fledgling primary care model. "So many PT students have clinical experiences within the VA system," Boissonnault notes. "It's important that PT students get exposed to innovative care models in which physical therapists can work at the top of their license. The more exposure students get to those types of opportunities, the better." Boissonnault encourages PTs to seek out interdisciplinary activities in their communities—such as the clinic at which Tony Bare provides services to low-income residents. "Typically, multiple disciplines are present in those settings," he notes—"physicians, med students, pharmacists, nurses, occupational therapists. Physical therapists are working side-by-side with those providers to help people in the most efficient and effective way possible." Bare describes one such interaction at the Downtown Clinic. "I said to the physician, 'I have a patient with cervical radiculopathy. What do you think about giving him Prednisone?' She responded, 'That sounds good. What dose?' We have those kinds of conversations, in real time." Boissonnault urges PTs employed by health care systems that have a primary care model to lobby for inclusion of PTs on interdisciplinary teams if such inclusion doesn't already exist. "There are models out there that PTs can use as templates to present their case," he advises—citing the military and Kaiser models and the success of private practitioners such as Bare and Rebecca Byerley. Data is another key to a wider role for PTs in primary care, Boissonnault says. "The promise presented by the Physical Therapy Outcomes Registry is enormous," he says. "That data is going to show the effectiveness of PTs who are providing this type of care—which in turn will fuel programmatic development." Patient Stories PTs practicing in primary care modes can offer countless examples of its efficacy for patients. Byerley cites the case of a young adult who self-referred with lightheadedness and prolonged numbness in his arms and legs, but whose symptoms "didn't add up." He didn't have nausea and hadn't sustained an injury. The neurologic and physical tests she performed yielded "unremarkable" results. Byerley then elicited that her patient, an oil field laborer, had been cleaning equipment without wearing his protective body suit and face mask. She sent him back to his physician, who diagnosed chemical exposure for which the young man was successfully treated. Expertise in differential diagnosis—determining a condition's likely root cause by analyzing and synthesizing reported symptoms, medical history, and test results—is central to the skill set of PTs in primary care. Byerley also recalls the case of a patient in her 50s with thoracic pain who ended up being diagnosed with pancreatic cancer after Byerley sent her back to her family physician for additional medical review. Another patient came to Byerley for a "frozen shoulder"—pain and stiffness in her shoulder joint—but the underlying cause was determined to be breast cancer. "Strong critical thinking skills are key," Byerley says. "Is what the patient is reporting consistent with your clinical findings? If not, what might really be going on?" Ivan Matsui recalls a recent Kaiser patient in her 80s whose pain and movement issues, a "roving" PT determined, stemmed from 5-day-old hip bursitis rather than the aftereffects of total hip replacement 2 years before. As a result, possible follow-up steps such as X-rays and additional referrals were avoided. Rather, the patient's issues were resolved within 2 weeks through exercise and education. Not only that, the woman didn't have to cancel a long-planned trip. "She'll be a happy camper when she goes to Lake Tahoe," Matsui comments. To instill patient confidence and thrive as a primary care provider in private practice, it's imperative, Bare says, that PTs employ "all the tools in their toolbox" to fully explore the array of health issues that individual might be experiencing. "Almost no musculoskeletal presentation is a simple 1-joint or 1-segment pathology," he observes. "So, when a patient comes in to see me with shoulder pain, it might be mostly shoulder-related, or it might be mostly cervical spine, or it might be mostly gallbladder. But let's say that based on the patient history and physical exam, I determine that the shoulder is the biggest pain contributor. So, I treat that. "The next visit," he continues, the patient doesn't need the same shoulder treatment, so I treat the cervical spine—the next-biggest pain contributor. I continue in that manner through a few more visits, and the patient feels better on multiple levels. Now, chances are, I've got a patient for the long haul—someone who trusts me to help resolve whatever issue he or she is experiencing." Bare says he has tapped his knowledge of lower extremity biomechanics to resolve the heel pain of a patient who'd been misdiagnosed and ineffectively treated by various providers for 18 years. He's resolved abdominal pain and constipation following hysterectomy by using manual and myofascial therapy for patients' surgical scars and manual visceral therapy to address colon-related issues. Bare says he got another patient off medication for acid reflux that the man had been taking for more than a decade—even though, he notes, that condition had nothing to do with reason the patient had come to see him in the first place. "No one's ever going to get referred to a physical therapist because he or she has heartburn," Bare observes. "But that doesn't mean that a PT can't—by asking the right questions, calling on his or her clinical tools, and taking appropriate action—address and successfully treat that condition." Hence, he says, the word-of-mouth success of Bare Physical Therapy. "My patients refer me to their friends and family because they see me as a problem-solver. Some individuals come from Denver to see me in Laramie. That's a 4- or 5-hour drive," Bare observes. Building a Culture In a blog post5 that appeared on APTA's website in September, career Army officer Jason Silvernail, PT, DPT, DSc, noted that a critical shortage of physicians in the US military during the wind-down of the Vietnam War gave rise to a "capabilities" care model that affords PTs primary care advantages over their civilian counterparts. The model, as Silvernail described it, "determines what functions, or capabilities, need to be present for success, then identifies the resources to provide those functions." In other words, PTs either see patients directly and pass them along to other team members as appropriate, or are in position to quickly treat individuals who are sent their way by another care provider. Silvernail acknowledged barriers to widespread translation of the military model to civilian health care, citing "high copays and Medicare not recognizing PTs as primary care practitioners." He noted, however, that those barriers are "based on health policy, not medical necessity or appropriateness." He closed his post by urging his peers and the profession as a whole to "be willing to confront the policy obstacles that stand between Americans and the quality care delivered by doctors of physical therapy as part of primary health care teams." That's the long game. In the meantime, there are 2 key messages from the military model that Brian Young, PT, DSc, believes need trumpeting in the civilian world: PTs in primary care roles pose no added risk to patient safety, and there is value in "cultivating a culture of PTs being frontlines providers." "A takeaway from the musculoskeletal realm in the military is that having PTs in primary care is safe—that's been published in a large study,"6 Young tells PT in Motion. He's the director of curriculum for the DPT program at Baylor University, having retired last year after more than 21 years in clinical, educational, and leadership positions in the US Air Force. In the military, Young notes, "PTs are out there on the front lines in places like Iraq and Afghanistan, keeping soldiers healthy and able to continue their mission. We're comfortable and confident in that role. It's part of our culture in the military, and it's important that civilian PTs adopt that mindset, recognizing what they can bring to primary care." Boissonnault agrees, noting that today's new graduates already are getting a good introduction. "That 'primary care culture' starts in DPT programs, where students are being trained to provide that necessary broad level of service," he says. "Students get academic grounding in differential diagnosis and medical screening necessary for patient triaging responsibilities." Boissonnault adds, however, that "the more exposure students can get to primary care models during their clinical rotations—as in the VA model—the better, so they can see this type of care delivery in action and be fully appreciative of the possibilities and opportunities that exist for PTs in primary care." The bottom line, Boissonnault says, is that primary care presents "a huge opportunity for physical therapists, the profession, and the health system in terms of producing better care outcomes, ensuring optimal utilization of resources, and decreasing costs. There's a gap in the provision of primary care that PTs are the best-trained providers to fill." Johanna Gabbard, PT, DPT, offers the last word on the subject. She recently retired after working for more than 2 decades as a clinical specialist for Kaiser Permanente in both northern and southern California. She was an eyewitness to the benefits that Kaiser's PTs afford patients as part of the primary care team. "Physical therapy to me is an art as much as it is a science," says Gabbard, who is a board-certified clinical specialist in orthopaedic physical therapy and a fellow of the American Academy of Orthopaedic Manual Physical Therapists. "The art comes in recognizing and integrating the intellectual, emotional, and physical needs of the patient, then using the best evidence and latest scientific knowledge to treat and/or triage that individual. PTs are empowering patients in primary care to achieve optimal results and to be the best they can be." Eric Ries is the associate editor of PT in Motion.Primary Care and APTAThe following are excerpts of House of Delegates and Board of Directors positions related to PTs in primary care. They appear in full in Appendix A of the document "A Perspective: Exploring the Roles of Physical Therapists on Primary Care Teams."Primary Care and the Role of the Physical Therapist (HOD P06-06-07-03) states that PTs "participate in, and make unique contributions as individuals or members of primary care teams to, the provision of primary care."Continuity of Care Record (HOD P06-08-12-10) advocates for "the inclusion of elements of physical therapist patient/client management to key groups including: organizations that are creating CCR specifications and implementation guides, and standards development organizations that are creating terminology codes to be used in the CCR."Principles and Objectives for the United States Health Care System (HOD P06-13-20-18) states that PTs "are integral to health care and health care teams, and make unique contributions that are essential for comprehensive health care, regardless of the model of health care delivery."Physical Therapists' Role in Prevention, Wellness, Fitness, and Disease Management (BOD P02-14-02-01) notes that PTs, "like most health professionals, are educated to provide services in the health services delivery environment." It adds that, "Unlike many health professionals, physical therapists are also uniquely trained to adapt health recommendations to the community environment where individuals live, work, learn, and play."Physical Therapy as a Health Profession (HOD P06-99-19-23) cites "promotion of optimal health and function" as the profession's "primary purpose," and notes that physical therapy "encompasses areas of specialized competence" to meet "existing and emerging health needs."Autonomous Physical Therapist Practice (HOD P06-06-18-12) states the PTs "have the responsibility to practice autonomously in all settings, practice environments, and employment relationships." Among the characteristics of that autonomy is "ability to refer to and collaborate with health care providers and others to enhance physical therapist patient/client management."Diagnosis by Physical Therapists (HOD P06-12-10-09) states that when the patient/client is referred with a previously established diagnosis, "the physical therapist should determine that the clinical findings are consistent with that diagnosis." It adds, "If the diagnostic process reveals findings that are outside the scope of the physical therapist's knowledge, experience, or expertise, the physical therapist should then refer the patient/client to an appropriate practitioner."Annual Visit With a Physical Therapist (HOD P05-07-19-20) recommends that "all individuals visit a physical therapist at least annually to promote optimal health, wellness, and fitness, as well as to slow the progression of impairments, functional limitations, and disabilities." "A Perspective: Exploring the Roles of Physical Therapists on Primary Care Teams"(www.apta.org/ScopeofPractice/PTRolePrimaryCare/)Background and history, description of existing primary care models, benefits to society, challenges to wide implementation, and items for further consideration. Direct Access in Practice Webpage(www.apta.org/DirectAccess/)Links to articles, videos, and a podcast covering an array of aspects—from direct access in hospital-based settings and Medicare to integrating it into clinical practice, addressing payment issues, marketing tips, supporting research, and advocacy assistance. Imaging Webpage(www.apta.org/Imaging/)Articles, videos, postprofesssional learning opportunities and more related to an important skill set for the first-contact practitioner. Physical Therapy Outcomes Registry(www.ptoutcomes.com/)Information on purpose and goals, benefits, and how to enroll. Visitors can request a free demo.PTNow(www.ptnow.org/)Clinical summaries, clinical practice guidelines, tests and measures, an article search, and morePhysical Therapy and Society Summit (PASS)(www.apta.org/PASS/)Highlights of a think-tank summit in 2009 that was convened to empower PTs to be leaders in integrating innovative technologies and practice models, and in establishing collaborative interdisciplinary partnerships that address current, evolving, and future societal health care needs.