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  • PT Locum Tenens, Rehab Research Among Victories in New Health Care Legislation

    The 21st Century Cures Act—sweeping health care legislation touches on everything from mental health coverage to the regulatory approval process for new drugs—also contains some good news specifically for physical therapists (PTs) and supporters of rehabilitation research.

    The bill, passed by both the US House of Representatives and the Senate, contains 2 provisions that have been high on APTA's advocacy list: the inclusion of PTs among the health professionals permitted to enter into locum tenens arrangements, and language that will increase that stature of—and funding for—rehabilitation research at the National Institutes of Health (NIH). President Barack Obama is expected to sign the legislation into law before leaving office.

    The locum tenens portion of the legislation would allow a PT to bring in another licensed physical therapist to treat Medicare patients and bill Medicare through the practice provider number during temporary absences for illness, pregnancy, vacation, or continuing medical education. Only PTs in non-Metropolitan Statistical Areas, Medically Underserved Areas, and Health Professions Shortage Areas as defined by the US Department of Health and Human Services would qualify for the program.

    The Cures Act also includes legislation that will improve coordination of rehabilitation research throughout NIH, and require the development of a comprehensive rehabilitation research plan, updated every 5 years. The first version of that 5-year plan was unveiled in September, with APTA Chief Executive officer Justin Moore, PT, DPT, calling the roadmap "a long awaited and significant step forward" for research efforts.

    "The inclusion of PTs in locum tenens arrangements and the recognition of the importance of rehabilitation research are big wins for the physical therapy profession but, more important, for patients," said Justin Elliott, APTA vice president of governmental affairs. "APTA and other stakeholders worked hard to make the case for both of these issues, and we're pleased to see that legislators are showing increased understanding of the important role physical therapy and PTs can play in the future of health care."

    Other provisions in the act that could also affect PTs: a requirement that the Centers for Medicare and Medicaid Services (CMS) take a closer look at expanding the range of telehealth services under Medicare (including an expansion of originating sites of these services), and a delay in the implementation of Medicare fee schedule adjustments for wheelchair accessories and seating systems when used with complex rehabilitation technology wheelchairs. Under the Cures Act, the adjustments would begin in July 1, 2017, instead of January 1 of 2017.

    The more wide-ranging provisions of the legislation also include $1 billion in state grants to help fund efforts to battle the opioid epidemic.

    Researchers Find 'Unsettling' Uptick in Stroke Rates in Adults Under 55

    A recent study of stroke rates has found that while rates have declined in patients older than age 55, there has been an uptick among younger populations—and the potential underlying factors are “unsettling.”

    Authors of the study, published in theJournal of the American Heart Association, write that over the past 20 years, the incidence of stroke has decreased in many countries, but that trend may now be reversing itself. Researchers applied an “age-period-cohort” analysis to data from the Myocardial Infarction Data Acquisition System in New Jersey in an attempt to “unravel the separate effects due to aging, secular changes, and life course experience” on incidence of ischemic stroke and ST-elevated myocardial infarction (STEMI). The time periods considered were 1995-1999 (period 1), 2000-2004 (period 2), 2005-2009 (period 3), and 2010-2014 (period 4).

    Researchers found that overall, the stroke rate for individuals aged 35 to 84 decreased from 314.1 strokes per 100,000 “person-years” (PY) in period 1 to 271 in period 4. The overall rate for STEMI decreased by 60% in the same time period.

    However, the stroke rate among patients 35-39 more than doubled over that same 20-year period, from 9.5 to 23.6 per 100,000 PY. The rate also doubled for those in the age 40-44 cohort, from 22.9 to 46.0 strokes per 100,000 PY between periods 1 and 4. There also were smaller yet still significant increases for individuals aged 45-49 and 50-54. For groups older than 55, rates declined.

    These findings echo results of similar studies in the United States, as well as Taiwan, France, and Denmark, authors noted, writing that, in their study, “the downward trend in the oldest age groups, the flattening trend in the middle age groups, and the upward trend in the youngest groups suggest a birth cohort effect.” Authors suspect that higher prevalence of obesity and diabetes among younger cohorts, in addition to lack of treatment for high blood pressure and lower likelihood of having health insurance, may be contributing to this disturbing trend in the US. The rise in obesity among younger populations has also led to an increase in atrial fibrillation, a risk factor for stroke.

    Interestingly, the STEMI rate decreased for all groups. Authors suggest this could be due to the fact that STEMI is more closely associated with lipid levels than with high blood pressure, and “the increasing prevalence of atrial fibrillation in the young would have a greater impact on rates of stroke than those of STEMI.”

    Taken together, researchers assert, “these trends may have significant implications for health outcomes and the overall healthcare burden in the future.”

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    From PT in Motion Magazine: Removing Roadblocks to Adherence

    Many physical therapists (PTs) know the pattern all too well: a patient makes significant improvement over an episode of care, only to lose ground when the PT's recommendations for posttreatment care aren't followed. So what can be done to increase adherence and stop "the revolving door" of physical therapy?

    This month in PT in Motion magazine: an exploration of what PTs can do to extend adherence after the conclusion of care. Associate Editor Eric Ries reports on several PTs who share different ways to recognize and remove the roadblocks that can get in the way of patients doing what needs to be done to stay healthy.

    While the PTs interviewed acknowledge that there is no single surefire way to guarantee adherence, they do describe some techniques that can at least help the PT get a better handle on the factors and attitudes that can be barriers. Some of the techniques, such as motivational interviewing and reflective listening, are comprehensive approaches to treatment; others, such as helping patients to understand and describe home exercise instructions in their own terms, are simple tweaks.

    The article also includes sidebars featuring the connection between adherence and technology, as well as a list of additional resources on increasing adherence.

    "Extending Adherence" is featured in the December-January issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them one of the benefits of belonging to APTA. Printed editions of the magazine are mailed to all members who have not opted out; digital versions are available online to members.

    CoHSTAR Research Center Accepting Postdoctoral and Faculty Fellowship Applications

    Physical therapists (PTs) who are interested in playing a transformative role in physical therapy health services research now have a big chance to do just that.

    The Center on Health Services Training and Research (CoHSTAR) is seeking candidates for fellowships at either a full-time postdoctoral level or a part-time faculty level. Fellowships are available at the 3 institutions participating in CoHSTAR: Brown University, Boston University, and the University of Pittsburgh.

    For the full-time fellowships, applications are being sought from PTs with a PhD, ScD, or DrPH, or from PTs with a DPT and research training, experience, and publication history. Part-time faculty fellow applicants must be licensed PTs and full-time faculty members with a doctoral degree or equivalent research experience. Faculty fellows must devote the bulk of their time to research activities, and be able to participate in CoHSTAR activities and regularly visit the CoHSTAR site.

    Application instructions are available at the CoHSTAR webpage.

    CoHSTAR was created through a $2.5 million grant awarded by the Foundation for Physical Therapy through its "Center of Excellence" initiative. In addition to the fellowships, CoHSTAR sponsors visiting scientists and provides special summer training sessions. The center also funds several pilot studies each year from investigators inside and outside the program.

    For more information about the CoHSTAR fellowships, email Audrey Kidd.

    2017 Slate of Candidates Posted

    The 2017 Slate of Candidates for APTA national office is now posted on the APTA website. The candidate webpage, including candidate pictures, statements, and biographical information, will be posted on March 13, 2017.

    Elections for national office will be held at the 2017 House of Delegates on June 19, 2017. Please contact Cheryl Robinson in APTA’s Governance and Leadership Department for additional information.

    Free Learning Lab on Partnering With ACOs Recorded and Ready

    Are you in a private practice or rehab agency trying to figure out how to partner with physicians or hospitals in an accountable care organization (ACO)? Or a hospital working on innovative approaches to improved patient access within your facility? Do you want to hear from your colleagues about their work in ACOs and learn from their experiences?

    APTA’s series of Learning Labs now offers the third of 4 opportunities for you to hear firsthand from the physical therapist innovators who were selected to pursue new, creative models of care through APTA's Innovation 2.0 program. This third online lab, recorded in November, is now available in the APTA Learning Center and focuses on how physical therapists can facilitate access and provide value as integral participants in ACOs. This free webinar includes the recorded session, with the presenters’ slide deck and a downloadable guide to replicating the program in other facilities.

    This project was conducted with private physical therapy practices in Northern Colorado participating in the Medicare Shared Savings Program through the Mountain and Plains Division of Central US Accountable Care Organizations and led by Tim Flynn, PT, PhD. It evaluates the role of early access to physical therapist services for patients with musculoskeletal complaints, specifically lower back pain. In this model, physical therapists are working collaboratively with ACO primary care physicians to optimize management of low back pain in the outpatient setting.

    The Innovation 2.0 series is designed to promote the participation of physical therapy in innovative models of care delivery by replicating successful models throughout the country. Free access to the course and materials is available through the APTA Learning Center.

    Other Innovation 2.0 Learning Labs topics include pay for performance in treating patients with low back pain (available now), adding value to a postacute care setting (available now), and a patient-centered medical home model that addresses childhood obesity (later this year).

    For details on all of the projects selected for development, as well as projects that received honorable recognition, go to Innovation 2.0 Background. Profiles of each project also were featured in a September 2015 article in PT in Motion magazine.

    Study: Research Indicates PT-Delivered CB Interventions Work for LBP – But Can They be Translated to Practice?

    Researchers from England are confident that when physical therapists (PTs) add cognitive behavioral (CB) interventions to their treatment of patients with back pain, outcomes improve—especially for individuals with long-term disability. But when it comes to what, exactly, those CB interventions should be, how they can be replicated in practice, and how PTs can acquire adequate training on them … things start to get a little less certain.

    In a systematic review published in Disability and Rehabilitation(abstract only available for free), researchers analyzed data from 5 randomized controlled trials involving 1,390 participants with nonspecific low back pain (LBP). Each study compared an "active treatment" including education and "standard physiotherapy interventions" (as recommended in the European Guidelines for LBP) with PT-delivered CB interventions used as a primary treatment component. Studies that used passive, pharmacological, or invasive interventions such as surgery were excluded.

    Researchers looked at data from patient-reported questionnaires and found high-quality evidence that the use of CB interventions was effective in reducing disability, though the impact on quality of life was found to be statistically insignificant. The most powerful effects were recorded in participants with long-term disability and long-term pain; individuals with short-term pain and disability reported smaller effects when CB interventions were used.

    According to the study's authors, all PT-led CB interventions were aimed at "increasing physical activity and coping skills, [and] modifying unhelpful beliefs associated with pain such as thoughts that their pain will never get better or it is indicative of a more serious spinal condition." The duration and session schedules were roughly similar—6 to 8 sessions over a 4 to 6 weeks, with session duration ranging from 30 minutes to 2 hours. Two studies used a 1-on-1 approach; 3 used groups (group size varied from 4 to 10).

    Researchers were satisfied that the PT-led CB interventions were effective but noted that the studies they reviewed begged a few big questions: namely, what, exactly did these PTs do during their interventions, how did they learn how to do it, and what's the likelihood that these interventions could be replicated in a clinical setting?

    While authors were able to identify common CB techniques used by all the studies—CB-related education, cognitive restructuring, activity pacing, and relaxation techniques—they noted that specific methods varied. To cloud matters even further, they write, "we found no information on how to replicate the procedural content of these interventions in practice. Without this information, successful translation of evidence-based CB interventions in physiotherapy practice is more difficult."

    "Importantly, our results support the conclusion that, with some additional training, physiotherapists can deliver CB interventions to treat patients with LBP and achieve sustained reductions in pain and disability over the long-term," authors write. However, they include a caveat: "For this approach to be translated into practice, access to additional training (as was provided in the included studies) is necessary for physiotherapists who work in clinical practice. It is likely that without training and access to the requisite manuals and materials in a manner that is affordable and accessible on a large scale, these interventions would not be successfully replicated into practice."

    And that's where researchers come in, according to the review's authors.

    "There is inadequate information in the studies on how to implement the evidence-based CB interventions in clinical practice," they write. "We recommend firstly that researchers improve the level of reporting on intervention procedures and secondly that appropriate training should be accessible to build training in CB interventions."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

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    Researchers: A City's 'Stress Level' Could Affect Local Hospital Ratings

    Could it be that when it comes to the Centers for Medicare and Medicaid's (CMS) star rating system, no hospital is an island? Some researchers are wondering just that, after finding a high correlation between a city's level of "stress" among residents and lower overall ratings for local hospitals.

    The report, published as a research letter in the November 28 edition of JAMA Internal Medicine (abstract only available for free), compares CMS hospital ratings with the results of a recent study that compiled demographic, health, and financial data on residents of 150 cities across the US. The CMS star system, posted at its Hospital Compare website, bases its ratings on factors such as readmission rates, surgical mortality, and hospital-acquired infection. The stress study, sponsored by WalletHub, looked at 5 categories of stress: work, money, family, health/safety, and coping mechanisms. Using data that touched on a range of issues including, among others, poverty levels, divorce rates, suicide rates, average hours of sleep per night, binge drinking, and number of psychologists per capita, WalletHub researchers assigned an overall "stress level" score to each city.

    Authors of the JAMA letter compared the star ratings of 657 hospitals with the stress ratings of the 150 cities in which they were located. They found that the less stressed a city is, the more likely it would be to contain hospitals with higher overall star ratings. For example, 2 of the most highly stressed cities in the US—Detroit, Michigan, and Newark, New Jersey—also contained hospitals with relatively lower star ratings. The same was true at the other end of the spectrum: low-stress cities such as Madison, Wisconsin, and Sioux Falls, South Dakota, tended to have hospitals with higher star ratings.

    Researchers for the JAMA article estimate that "around 20% of the variance in the star ratings can be explained by community characteristics such as poverty or unemployment rate."

    The correlation may cast the CMS rating system in a somewhat different light, say researchers—one that isn't entirely related to factors within the hospital's control.

    "On one hand, hospitals in stressed cities might provide care of lower quality on average, perhaps because of inability to invest in needed clinical or technological infrastructure or staff shortage," authors write. "On the other hand, the star rating component measures may be affected by community factors such as poor public transportation or limited social support services through causal pathways other than hospital quality."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Trump Taps Price for HHS, Verma for CMS

    President-elect Donald Trump has announced his hoped-for changes to leadership of the US Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS), with Georgia Rep Tom Price (R-6th) to be nominated for HHS secretary, and Seema Verma, CEO of the Strategic Health Policy Solutions (SVC) consulting group, tapped to serve as CMS director.

    Price joined Congress in 2004, where he now serves as chairman of the House Budget Committee, and is a member of the Health Subcommittee of the House Ways and Means Committee. Trained as an orthopedic surgeon, Price worked in private practice for nearly 20 years.

    In her work with SVC, Verma is credited with an instrumental role in crafting Healthy Indiana 2.0, Indiana's Medicaid program introduced by Gov Mike Pence, now the vice president-elect.

    “No matter what health care changes are ahead, APTA’s goals remain unchanged. APTA will continue to advocate for policies that benefit the health of all Americans by removing barriers to physical therapist treatment," said APTA President Sharon L. Dunn, PT, PhD. "And we will continue to be guided by our vision of transforming society by optimizing movement to improve the human experience.”

    Price's and Verma's nominations need to be confirmed by the Senate.

    Outpatient Payment, Home Health Fact Sheets Now Available From APTA

    Now available to APTA members: context and details to help you understand final 2017 rules from the Centers for Medicare and Medicaid Services (CMS) on the home health (HH PPS) and outpatient (OPPS) prospective payment systems.

    The final OPPS rule, which grabbed headlines earlier this year for its elimination of pain management questions from patient satisfaction surveys, also includes payment increases and changes to the ways hospital-owned off-campus outpatient departments are paid. The APTA fact sheet covers these provisions, as well as comprehensive ambulatory payment classifications, and CMS’ plans for future quality reporting. To access the fact sheet, visit the APTA Medicare Payment and Policies for Hospital Settings webpage. Scroll to the "Outpatient Care" area and look under the "APTA Fact Sheets and Summaries" header.

    The 2017 HH PPS rule continues planned cuts next year, and includes changes to the home health quality reporting program and the way payments are made for negative pressure wound therapy, among other topics. The APTA fact sheet can be accessed on the association's Medicare Payment and Policies for Home Health webpage, under the "APTA Fact Sheets and Summaries" header.

    APTA’s November 9 Insider Intel call-in program included an outline of HH PPS and OPPS provisions. To listen to a recording of the program, visit the Insider Intel webpage and click on the November 9 link under “Archives.” Want even more information on CMS-related changes in store for 2017? Don't miss the December 8 webinar, "Medicare Payment and Compliance: What You Need to Know for the Year Ahead." The program is available at no cost to APTA members.