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  • Summary of Board of Directors Meeting Posted at Moving Forward Blog

    If you missed the association's recent Board of Directors meeting, APTA President Scott Ward, PT, PhD, provides a recap on the Moving Forward blog. Ward's summary includes information about the governance review, a report presented to the Board on models of service delivery, APTA's research pipeline, and APTA's proposed alternative payment system.  

    Weight of the Nation Conference to Preview Documentary on Obesity

    The Centers for Disease Control and Prevention's (CDC) Weight of the Nation conference, to be held May 7-9 in Washington, DC, will emphasize how communities; educators; health care providers; workplaces; and states, territories, and tribes can be game changers by improving healthy eating and increasing active living for all Americans.

    The conference also will provide a "sneak peek" of 4 HBO documentaries that examine pressing issues of obesity as they relate to children, communities, policies, and systemic challenges. The 4-part documentary series—Consequences, Choices, Children in Crisis, and Challenges—will air May 14-15.

    DVD kits are available for organizations to host screenings of the films in their communities. The kits include the video series and discussion guides in English and Spanish that can be used to delve deeper into the concepts presented and spur individual and community action.

    The Weight of the Nation is a presentation of HBO and the Institutes of Medicine, in association with CDC and the National Institutes of Health, and in partnership with the Michael & Susan Dell Foundation and Kaiser Permanente.

    Summary on Proposed Rule for Acute, Long-term Care Hospitals Posted

    APTA's summary of Medicare's proposed rule for general acute care hospitals and long-term care hospitals, which includes quality measures for readmissions relating to hip and knee replacement procedures, now is available on the Medicare Payment and Policies for Hospital Settings webpage. (See related article posted April 26)

    Final Rule Provides States Flexibility to Offer Home and Community-based Services

    Yesterday, the Centers for Medicare and Medicaid Services (CMS) released the final rule on the Medicaid program’s Community First Choice (CFC) option as mandated under the Affordable Care Act (ACA) establishing a new option for states to provide home and community-based attendant services and supports for beneficiaries.

    With the additional flexibility to finance home and community-based services and support, the provision is expected to increase state and local accessibility to services that augment the quality of life for beneficiaries through a person-centered plan of service and various quality assurances—at a potentially lower per capita cost relative to institutional care settings.

    According to the rule, states that elect this option must make available home and community-based attendant services and supports to assist in accomplishing activities of daily living, instrumental activities of daily living, and health-related tasks through hands-on assistance, supervision, and/or cueing. Additionally, the following services may be provided at the state’s discretion—transition costs, such as rent and utility deposits; first month's rent and utilities; purchasing bedding, basic kitchen supplies, and other necessities required for transition from an institutional setting; and the provision of services that increase independence or substitute for human assistance to the extent that expenditures would have been made for the human assistance, such as nonmedical transportation services or purchasing a microwave.

    The final rule sets forth the requirements for CFC, however, requirements pertaining to "setting," under §441.530, will be addressed in future rulemaking.

    APTA Meets With Members of Congress From All 50 States

    More than 250 physical therapists, physical therapist assistants, and students who participated in this year's Federal Advocacy Forum, held April 22-24 in Washington, DC, met with members of Congress from all 50 states to discuss the repeal of the therapy cap, the physical therapist's role in managing patients with traumatic brain injury, and student loan repayment. 

    On Monday, an interactive town hall session that  featured APTA health quality and financing staff informed attendees  about regulatory hot topics such as therapy cap implementation, payment, quality, and accountable care organizations. Forum participants also attended a session on direct access and received updates on APTA's legislative and regulatory activities.

    APTA presented Sen Susan Collins (R-ME) with this year’s Public Service Award for her work on therapy cap repeal and access to physical therapy for military members and veterans. APTA member Eva Norman, PT, DPT, was awarded the 2012 Federal Government Affairs Leadership Award for her continued leadership and dedication to APTA's federal legislative issues. 

    This year's Federal Advocacy Forum was held in conjunction with APTA's Leadership Forum, which included APTA's Board of Directors meeting and Leadership Symposium.

    Kaiser Health Highlights Excessive Copays for Physical Therapist Services

    An April 22 article by Kaiser Heath News highlights the growing number of insurers and employers who classify physical therapy visits as specialty care, resulting in higher copayments for patients that often are equal to a specialist visit. The article quotes Matthew Hyland, PT, PhD, MPA, CSCS, president of the New York Chapter, and Justin Elliott, APTA director of state government affairs.  

    APTA's Fair Physical Therapy Copays webpage offers a variety of legislative resources, such as APTA model legislation and a sample letter to legislators, to help chapters in their fight against excessive copays. Examples of state strategies used by the Kentucky, Missouri, New Jersey, and New York chapters also are available.         

    Proposed Rule Includes Quality Measures for Hip, Knee Replacement Readmissions

    A proposed rule that would update Medicare payment policies and rates for inpatient stays in  general acute care hospitals and long-term care hospitals (LTCH) aims to strengthen the inpatient quality reporting program by including measures for readmissions relating to hip and knee replacement procedures. 

    The proposal, issued Tuesday by the Centers for Medicare and Medicaid Services (CMS), would strengthen the Hospital Value-Based Purchasing Program (VBP Program) to further Medicare’s transformation to a system that rewards efficient, high-quality care. This program, which was required by the Affordable Care Act, will adjust hospital payments beginning in Fiscal Year (FY) 2013 and annually thereafter based on how well they perform or improve their performance on a set of quality measures.

    Specifically, CMS proposes to:

    • Add the Medicare spending per beneficiary measure to the Hospital VBP Program, which would affect payments beginning in FY 2015. 
    • Reduce payments beginning in FY 2013 (for discharges on or after October 1, 2012) to certain hospitals that have excessive readmissions for 3 selected conditions—heart attack, heart failure, and pneumonia. 
    • Build on quality reporting initiatives by recommending measures that will be used for LTCHs for FY 2015 and FY 2016 payment determinations. 

    In the proposal, CMS projects that payment rates to general acute care hospitals will increase by 2.3% in FY 2013. The agency projects that total Medicare spending on inpatient hospital services will increase by about $175 million in FY 2013.

    For LTCHs, CMS proposes a 2.1% update to payment rates and projects that LTCHs payments will increase by approximately $100 million in FY 2013.  

    CMS will accept comments on the proposed rule until June 25 and will respond to all comments in a final rule to be issued by August 1. APTA will submit comments on behalf of its membership.

    A detailed summary of the proposed rule is available on APTA's Medicare Payment and Policies for Hospital Settings webpage.

    New in the Literature: Manual Therapy for Low Back Pain (Man Ther. 2012 March 21. [Epub ahead of print])

    According to the authors of an article published online in Manual Therapy, their study is the first to show an association of within/between-session changes with disability scores at discharge in patients who were treated with manual therapy for low back pain, and the first to define the extent of change necessary for prognosis of an outcome. A within/between-session change should be considered as a complimentary artifact along with other examination findings during clinical decision making, they add.  

    This randomized controlled trial involved 100 participants who demonstrated a positive response to manual therapy during an initial assessment. Within- and between-session findings (within/between session) were defined as a change in pain report from baseline to after the second physical therapy visit. Within/between-session changes were analyzed for associations between pain change scores at discharge, rate of recovery, and a 50% reduction of the Oswestry disability index (ODI) by discharge. The results suggest there is a significant association between a within/between-session change after the second physical therapy visit and discharge outcomes for pain and ODI in this sample of patients who received a manual therapy intervention. A 2-point change or greater on an 11-point scale is associated with functional recovery at discharge and accurately described the outcome in 67% of the cases, say the authors.

    APTA member Chad E. Cook, PT, PhD, MBA, FAAOMPT, is lead author of the article. APTA members Christopher Showalter, PT, OCS, FAAOMPT, Vincent Kabbaz, PT, and Bryan O'Halloran, PT, OCS, SCS, are coauthors. 

    Fewer Workers Offered, Accept Employer-based Coverage

    Since 2002 the percentage of workers with health care coverage has been declining, mostly because fewer workers have access to coverage, says a new issue brief by the Employee Benefit Research Institute.

    Both the offer rate (the percentage of workers offered health benefits) and the coverage rate for employment-based health benefits declined between 1997 and 2010. Between 1997 and 2010, the percentage of workers offered health benefits from their employers decreased from 70.1% to 67.5%, and the percentage of workers covered by those plans decreased from 60.3% to 56.5%.

    In addition, the percentage of workers taking coverage when offered by their employers (take-up rate) declined from 86% in 1997 to 83.6% in 2010. Among the reasons given by respondents who chose not to participate in their employer’s health plan, 67.9% stated that they were covered by other health insurance in 2010, 29.1% reported that their employer’s plan was too costly, and another 2.2% reported either that they did not need insurance or that they did not want insurance.

    According to the brief, offer rates increase with firm size. In 2010, 39.4% of workers in firms with fewer than 25 employees were offered health benefits, compared with 76.5% in firms with 100 or more employees. Take-up rates, while they vary with firm size, do so much less than offer rates. In 2010, 77.8% of workers in firms with fewer than 25 employees took coverage when it was offered, compared with 84.9% of workers in firms with 100 or more employees. Both offer and take-up rates are higher for full-time employees.

    As for demographics, men, non-Hispanic workers, and workers with college degrees are more likely to be offered health care benefits.

    Lessons Learned: Implementing PQRS Into Practice

    An engaging Q&A podcast on incorporating the physician quality reporting system (PQRS) in physical therapy practices addresses the barriers that clinical staff face in learning PQRS, concerns with documentation, and PQRS implementation strategies that include administrative staff.

    This podcast is the fourth in a series on PQRS and features Kevin Svoboda, PT, clinical growth and development director at Rehab Management Solutions, Jodi Woodward, director of medical billing at Rehab Management Solutions, and Connie Ziccarelli, principal and chief operations officer of Rehab Management Solutions. The guest speakers also discuss how they intend to use the PQRS interim report that will be provided this summer for the first quarter of 2012 to modify their program accordingly for the remainder of the year and begin 2013 in compliance with PQRS requirements.    

    More Research Needed in Management of Noncyclic Chronic Pelvic Pain

    Nonhormonal and nonpharmacologic management of noncyclic chronic pelvic pain (CPP) remains understudied, say authors of a systematic review that also found little evidence to demonstrate the effectiveness of surgical approaches for this "commonly occurring and poorly understood condition."

    Researchers from Vanderbilt Evidence-based Practice Center systematically reviewed evidence on therapies for women aged 18 and older with CPP, focusing on the prevalence of conditions thought to occur commonly with CPP—change in pain, functional status, quality of life, and patient satisfaction resulting from surgical and nonsurgical treatment approaches; harms of nonsurgical approaches; evidence for differences in surgical outcomes if an etiology for CPP is identified postsurgery; and evidence for selecting 1 intervention over another after an approach fails.

    Of 36 included studies, 18 were randomized controlled trials, most of which were of poor quality; 15 were cross-sectional studies addressing the prevalence of comorbidities in which quality varied by comorbidity. Nine studies of nonsurgical approaches assessed hormonal therapies for endometriosis-associated CPP and reported similar effectiveness among active agents. One exception was an RCT comparing raloxifene with placebo, which reported more rapid return of pain in the raloxifene group. Few studies assessed nonhormonal medical or nonpharmacologic management; benefits were reported in single studies of a pelvic physical therapy approach, botulinum toxin, pelvic ultrasonography, and an integrated management approach.

    "Improved characterization of the targeted condition, intervention, and population in CPP research is necessary to inform treatment choices for this commonly reported entity," the authors conclude, noting the lack of a uniform definition of CPP and standardized evaluation of participants in the literature.

    New Diabetes Guidelines Focus on Individualized Approach, Physical Activity Education

    "Interventions designed to impact an individual's physical activity levels and food intake are critical parts of type 2 diabetes management," say new guidelines that call for a more patient-centered approach to managing type 2 diabetes. Such an approach, according to the guidelines, allows for individual patient needs, preferences, and tolerances, and takes into account differences in age and disease progression.

    The guidelines, which are less prescriptive than the previous ones, recommend providing all patients with diabetes education—in an individual or group setting—focusing on dietary intervention and the importance of increased physical activity, in addition to weight management, when appropriate. They encourage developing individualized treatment plans built around a patient's specific symptoms, comorbidities, age, weight, racial/ethnic/gender differences, and lifestyles.

    Developed jointly by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), the guidelines are being published concurrently in Diabetes Care and EASD's journal Diabetologia. The need for a joint task force to review and revise the guidelines was driven by the "increasingly complex and to some extent controversial" nature of glycemic management for type 2 diabetes, the "widening array of pharmacological agents now available, mounting concerns about their potential adverse effects, and new uncertainties regarding the benefits of intensive glycemic control on macrovascular complications," says the ADA.

    New Joint Commission Resource: Health Care-associated Infections Portal

    The Joint Commission's recently launched Health Care-associated Infections (HAI) Portal allows users to search by topic, such as surgical site infections and ventilator-associated pneumonia, or by health care setting. The portal also provides information on infection control and prevention, including hand hygiene and education materials that can promote conversations with patients about what they can do to prevent infections.  

    APTA Launches Online Communication Survey

    With the rise of social media and smartphones, opportunities for communication and collaboration are always just a few (thumb) clicks away. But while most people have some kind of social media account, how those platforms are used varies significantly from person to person.

    In an effort to understand how members communicate and stay informed in a rapidly changing online social/information landscape, APTA has launched an online communication survey.

    The survey, which takes 5-8 minutes to complete, is open to APTA members, and 1 lucky respondent will be rewarded with an iPad.

    Respondents also have the opportunity to express interest in participating in a related focus group at PT 2012.

    Surveys are due May 4.

    Background Papers and House Handbook Posted

    Background papers and the House Handbook have been posted to the House of Delegates Community's Packet I and House Handbook section and may be found as compiled PDF documents. Packet I also is posted in the House Community to help you prepare for the 2012 House of Delegates. Contact Cheryl Robinson or Peyton Zeek with any questions.

    New APTA Resource Helps Practice Owners and Managers in Collection Efforts

    Recent increases in copays and deductibles have made collection at time of service critical for the financial health of physical therapy practices. To help members in this administrative function, APTA has launched a new resource titled Collection of Copays, Deductibles, and Other Patient Fees: Best Practices for Physical Therapists. Two new podcast recordings and transcripts complement this resource. Collecting Patient Fees: An Overview reviews compliance issues related to copay collection and describes the relevant resources available for members on this topic. The second podcast, Collecting Patient Fees: One Practice's Success Story, is an interview with a director of operations at a physical therapy private practice who describes a fresh approach for successful collection of patient fees.

    Orthopaedic Section Publishes Low Back Pain Guidelines

    New evidence-based clinical practice guidelines are available to help physical therapists manage patients with low back pain. Developed by the Orthopaedic Section, the guidelines describe the peer-reviewed literature and make recommendations related to (1) treatment matched to low back pain subgroup responder categories; (2) treatments that have evidence to prevent recurrence of low back pain; and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability. 

    The Orthopaedic Section has an ongoing effort to create evidence-based practice guidelines for orthopedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health.

    The low back pain guidelines will be considered for review in 2017, or sooner if new evidence becomes available. Any updates to the guidelines in the interim period will be posted on www.orthopt.org.

    New in the Literature: Upper Limb Training in Children With CP (Dev Med Child Neurol. [Epub 2012 March 17.])

    Intensive goal-directed upper limb training programs using either constraint-induced movement therapy (CIMT) or bimanual training (BIM) achieved domain-specific changes in quality of life relating to feelings about functioning and participation and physical health in children with unilateral cerebral palsy (CP), say authors of an article published online in Developmental Medicine and Child Neurology. A condition-specific quality of life measure compared with a generic measure may be better able to detect changes in quality of life in children with unilateral CP, they add. 

    Researchers randomly assigned 63 children (mean age 10 years 2 months [SD 2 years 6 months]; 33 boys, 30 girls) with CP of the spastic motor type (n=59) or with spasticity and dystonia (n=4) to 2 groups. The children were assessed as Manual Ability Classification System level I (n=16), II (n=46), or III (n=1). Each group received 6 hours of daily intervention (either CIMT or BIM) for 10 days over a 2-week period (total intervention time 60 hours). Children aged 9 years and older completed the Cerebral Palsy Quality of Life Questionnaire for Children (CPQOL-Child), and those aged 8 years and older completed the KIDSCREEN-52. All parents completed proxy versions of each measure. Assessments were made at baseline and at 3, 26, and 52 weeks after the end of the intervention.

    Thirty-five children completed the CPQOL-Child and 41 completed the KIDSCREEN-52. No changes in social or emotional well-being were reported by children in either group. Children and parents from both groups reported a significant improvement in their or their child's feelings about functioning as well as participation and physical health on the CPQOL-Child. The parents of children receiving CIMT reported positive and sustained changes in their child's social well-being (CPQOL-Child). The CIMT group showed significant improvements in physical well-being, psychological well-being, and moods and emotions (KIDSCREEN-52) at 3 weeks post intervention, which were maintained over the study period.

    Demonstrating High-value Care a Priority in New Payment Models

    Preventing unwarranted variation in practice, analyzing claim data, and demonstrating high-value care are a few of the topics covered in 2 new videos and handouts aimed at helping APTA members prepare for changes in the health care environment. The videos, featuring Tony Delitto, PT, PhD, FAPTA, are part of a series that illustrates various nontraditional, creative practice models developed by APTA members. The handouts and videos can help physical therapists gain insight and inspiration as they look for ways to become involved in new models of care delivery.

    APTA Responds to Chiropractic Segment on Dr Oz Show

    APTA cites the results of its recent low back pain survey in a letter to the producer of "The Dr Oz Show," which recently featured a segment on chiropractic intervention for back pain. The letter also offers the producer  information about APTA's new webpage on low back pain that features the e-book Low Back Pain: Management and Prevention to help consumers understand the causes of low back pain and provide strategies to help prevent and manage the condition. Additionally, APTA encourages viewers to join the BlogTalkRadio show scheduled for April 23. (See related article titled "BlogTalkRadio Guests to Discuss Low Back Pain" posted April 19.) 

    HPSO Report Details Risk Exposures for PTs and PTAs

    A new report has been released by Healthcare Providers Service Organizations (HPSO), in collaboration with CNA, on professional liability risk exposures. The report focuses on the risks faced by physical therapists (PTs) who are insured either as individuals or as employees of physical therapy practices. In addition, the report addresses the specific professional liability risk exposures for physical therapist assistants (PTAs) insured by HPSO/CNA and other health care professionals providing services on behalf of a HPSO/CNA-insured physical therapy practice.   

    For those who find it more convenient to listen to the information in the report than read it, APTA is offering a 1-hour audio conference about the liability risks in the report and strategies to reduce risk. The audio learning opportunity has a .2 CEU value. 

    The risk management information presented in the report is based upon an analysis of 552 closed professional liability claims that resulted in sizable settlements or adverse judgments. Following the analysis, HPSO offers risk control recommendations and a self-assessment checklist to help individual therapists and practices enhance safety while minimizing risks.

    APTA's risk management webpage provides additional resources to help members manage professional and personal risks 

    BlogTalkRadio Guests to Discuss Low Back Pain

    APTA will host its first BlogTalkRadio show, a live, online radio broadcast, on April 23 at 7 pm ET. You can listen live online here or dial 646/564-9841 to listen by phone. APTA spokesperson Mary Ann Wilmarth, PT, DPT, OCS, MTC, will frame the issue of low back pain, discuss some of the key findings of APTA's Low Back Pain Survey, and explain how to prevent and manage the condition with the help of a physical therapist. She will be joined by 2 guests—APTA member Mike Ryan, PT, ATC, athletic trainer for the Jacksonville Jaguars, and AARP Georgia volunteer Colette Morgan, MD, with Emory University. They will discuss low back pain as it relates to pro and non-pro athletes and the aging population, respectively. Listeners will have the option of calling into the show to ask questions of the guests or submitting questions to Move Forward's Facebook or Twitter pages in advance or during the show. Listeners also will be encouraged to visit www.moveforwardpt.com for more information and to find a physical therapist in their area. (See related article titled "APTA Responds to Chiropractic Segment on Dr Oz Show" posted April 19.)

    National Minority Health Month Focuses on Unity in Community

    April is National Minority Health Month. This year's theme, "Health Equity Can’t Wait. Act Now in Your CommUNITY," is a call to action and unity for state and local offices of minority health, health departments, and all organizations and partners involved and invested in reducing health disparities. To support community efforts in the goal of ending health disparities and promoting health equity, the Office of Minority Health offers a National Partnership for Action to End Health Disparities Toolkit for Community Action. The toolkit provides community members with the information and resources they need to help engage fellow citizens and local media as they spread the word about health disparities and educate others about the impact disparities have in the lives of individuals and the greater effect on society.

    Pittsburgh-Marquette Challenge Deadline Is Tomorrow

    So far this year, more than 40 schools have pledged to participate and raise funds for physical therapy research.    

    The deadline to submit all donations with completed donation forms is April 20, 5 pm ET. The total raised and prize winners will be announced during the Foundation's Gala at PT 2012.

    All participating schools receive national recognition. Awards to the top fundraising schools include complimentary APTA Annual Conference registration, Foundation gala tickets, and much more.

    Patients' Expectations of Activity Following Knee Replacement Not Realized

    Following knee replacement surgery, patients' physical activity levels are significantly lower than what they expected they would be, says a Reuters Health article based on study in The Journal of Arthroplasty.

    Researchers surveyed 83 patients with arthritis who were about to have a knee replaced, then questioned them again 1 year after the procedure. At the time of surgery, study participants reported that they were active about 2 hours a week, "mostly doing moderate-intensity activities such as yard work, strength training, and walking."

    The patients expected to spend about 23 hours per week exercising 1 year after their surgery, the article says. According to the second survey, people were more active postsurgery but not to the degree that they had anticipated, averaging 11 hours a week of activity.   

    Lead author and APTA member Dina Jones, PT, PhD, said the reason people's expectations don't match reality is likely because those expectations are rarely brought up in presurgery conversations, which usually focus on the knee's function immediately after the operation.

    Even if surgeons don't always discuss long-term exercise goals with patients, "from the data we've collected I don't see anything that says physicians are telling people they'll have more function than they used to," Jones told Reuters Health.

    Jones and her colleagues are working on developing educational pamphlets and presentations that would help people manage their exercise-related expectations for after knee replacement.

    APTA member James J. Irrgang, PT, PhD, ATC, coauthored the study. 

    APTA Has Strong Presence at Safe Patient Handling Conference

    APTA members were prominent once again at the annual Safe Patient Handling and Movement Conference, held March 18-22, in Orlando, Florida. APTA member Kenneth Harwood, PT, PhD, CIE, welcomed the nearly 700 participants on behalf of APTA. A highlight of the conference was an awards presentation in which association member Marc Campo, PT, PhD, and research partner Amy Darragh, PhD, OTR, received the Bernice Owens Award for Research in Safe Patient Handling. In their presentation, Campo and Darragh reported that "… therapists are getting injured at work … and these injuries affect their productivity and quality of life. In addition, safe patient handling strategies were found to prevent injuries and may actually help patients." In addition to Harwood's presentation, other presentations were provided by APTA members Margaret Arnold, PT, CEES, Drew Bossen, PT, MBA, Judith Burnfield, PT, PhD, Patti Mechan, PT, MPH, CCS, Stephanie Radawiec, PT, DPT, MHS, Alexandra Rella, PT,DPT, and Kathleen Rockefeller, PT, ScD, MPH, MS.

    APTA cosponsored the conference, which has been held for 12 years, with the American Nurses Association, the Veterans Health Administration, and the National Institute of Occupational Safety and Health.  

    Pelvic Floor Exercises Effective for Stress, Urgency Incontinence

    Pelvic floor muscle training is effective for treating adult women with urinary incontinence (UI) without risk of side effects, according to a new report from the Agency for Healthcare Research and Quality (AHRQ). The report also found that drug-based treatments can be effective, but the degree of benefit is low and side effects are common.

    In response to a request from the public, AHRQ funded a systematic review of the clinical research to determine what is known about the comparative effectiveness, benefits, and adverse effects of UI interventions for women and the utility of methods for diagnosis and treatment evaluation. The systematic review included 905 publications presenting the results of clinical studies published from January 1990 through December 2011.

    Researchers concentrated on 2 types of incontinence—stress incontinence and urgency incontinence. Exercises to strengthen the pelvic floor muscles were found to be effective in increasing women's ability to hold their urine. Pelvic floor muscle training combined with bladder training improved mixed (stress and urgency) incontinence, the report found. Estrogen treatment was found to be effective in treating stress incontinence, but with some side effects. Another drug treatment, the antidepressant duloxetine, was not found to be effective, while carrying high risk of side effects.

    Overall, the report found that the drugs reviewed showed similar effectiveness. However, with some drugs, more women discontinued treatment due to bothersome side effects.

    The full report is available from AHRQ. A summary is provided to clinicians to inform discussions of options with patients and to assist in decision making along with consideration of a patient's values and preferences.

    Call for Posters: Active Aging

    Physical therapists are invited to share programs, best practices, or research study through poster presentations at the International Council on Active Aging Conference, November 29-December 1, in New Orleans.

    The International Council on Active Aging (ICAA) is seeking 3 categories of posters:

    • Research—this category is aimed at applied and translational research, although basic and clinical research also is considered. Research studies must be completed, with final results relevant to work with older adults.
    • Programs—this category includes evidence-based, evidence-informed, and proven programs that have a structure and defined goals. This category is open to programs that are not based on a research study but do meet a need of older adults and have demonstrated outcomes.
    • Promising and best practices—this category is for a proven approach that has worked successfully in meeting a need of older adults. The practices can be adopted by other organizations seeking positive results. Given the range of responsibilities of ICAA delegates, a promising/best practice could be, for example, an organizational structure, age-friendly design, or a method to disseminate a program.

    Peer reviewers will evaluate proposals based on adherence to the criteria listed in the Call for Poster Presentations. The deadline for poster applications is May 4.

    Self-referral Study Finds Higher Costs, No Improvement in Cancer Detection

    A new study that links urologists' self-referral to increased use of tests to detect prostate cancer without better outcomes is being hailed by the Alliance for Integrity in Medicare (AIM) because it provides independent, peer-reviewed evidence that self-referral is a serious problem that drives up costs with no benefit to patients. AIM is a broad coalition that includes APTA and other medical specialty, laboratory, radiation oncology, and medical imaging groups.

    The study, published this month in Health Affairs, found that urologists involved in self-referral arrangements bill Medicare for 72% more specimen evaluations for patients with suspected prostate cancer than urologists who send specimens to independent providers of pathology services. Despite the increased billing, the study found that self-referring urologists usually detect cancer at a much lower rate than do urologists who do not self-refer. The per-patient cancer detection rate for self-referring urologists in 2007, according to the study, was 12 percentage points lower than that for non-self-referring urologists.

    AIM is urging Congress to revise the physician self-referral law's in-office ancillary services exception that allows urologists to self-refer patients to pathology labs they own directly or in which they have an ownership interest. "Other medical services, including advanced diagnostic imaging, physical therapy, and radiation oncology, are also prone to significant abuse through this exception," says AIM.

    AIM's press release has been featured in The Wall St Journal and Politico.

    Model for Breast Cancer Rehabilitation Featured in American Cancer Society Journal

    The Prospective Surveillance Model, an innovative new model of breast cancer rehabilitation, is featured in a special supplement to the American Cancer Society's journal Cancer, released April 6. APTA members Nicole L. Stout, PT, MPT, CLT-LANA, and Jill Binkley, PT, MClSc, CLT, were among a panel of internationally known experts who developed the model over the past year.

    The goal of the Prospective Surveillance Model for cancer rehabilitation is to identify impairment at the earliest onset, to alleviate impairment, or prevent it from progressing. Soon after diagnosis, a physical therapist will perform a preoperative examination to establish a baseline level of function. Follow-up examinations are then conducted postoperatively at 1 month and then 3-month intervals, for up to 1 year.

    The panel of experts and national organizations involved in developing the model will continue to raise awareness about the model, with the goal of increasing the number of women who receive rehabilitation and exercise in order to maximize quality of life for the 1 in 8 women who will be diagnosed with breast cancer in their lifetime.

    Read more about the model in APTA's press release or view the supplement online. The study, Breast Cancer-related Lymphedema: Comparing Direct Costs of a Prospective Surveillance Model and a Traditional Model of Care, led by Stout, was published in the January issue of PTJ. Hear Stout describe the model in this APTA video.

    Aetna Clarifies MPPR Methodology

    With numerous multiple procedural payment reduction (MPPR) policies in effect, it is important for physical therapists to understand the methodology each payer uses in determining payment. Aetna's methodology for the application of its MPPR policy varies slightly from the policy adopted by the Centers for Medicare and Medicaid Services (CMS). CMS has only 1 payment rate and payment structure in a given geographic area, while Aetna may have several different types of payment structures in the same area. Therefore, Aetna is unable to efficiently apply the exact CMS calculations to arrive at a final payment amount.

    Aetna bases its reduction for the second and subsequent therapy services on the contribution of the practice expense relative value unit (RVU) to the total RVUs for a given procedure. Aetna, unlike CMS, does not use geographic practice cost indexes (GPCIs) in calculating its reduction. An example of Aetna's methodology can be found here.

    Heard on the Hill Special Edition: Legal Issue Pending in the US Supreme Court

    A special edition in the Heard on the Hill podcast series provides an overview of the pending legal issues before the Supreme Court on the Affordable Care Act. Learn about the anti-injunction act and how it could cause the court to dismiss the case for the time being, the 3 constitutional provisions that the plaintiffs used in their argument against the constitutionality of the individual mandate, and how the concept of "severability" will come into play if the individual mandate is ruled unconstitutional. The podcast also covers the less known provision of the health care law related to Medicaid expansion. 

    A transcript accompanies the prerecorded podcast

    Terry Bradshaw to Deliver Keynote Address at PT 2012

    Hall of Fame quarterback and NFL analyst for FOX Terry Bradshaw will deliver the Keynote Address to thousands of physical therapy professionals who will gather for PT 2012, APTA's Annual Conference & Exposition in Tampa, Florida, on Wednesday, June 6.

    In his dual roles as cohost and analyst on Fox NFL Sunday, Bradshaw has been a primary force in making the 4-time Emmy Award-winning show America's most-watched NFL pregame program.

    The first pick in the 1970 NFL draft out of Louisiana Tech, Bradshaw was the Pittsburgh Steelers' dominating quarterback from 1970-1983, leading the team to 4 Super Bowl titles and 8 AFC Central championships. He was a  2-time Super Bowl MVP and 3-time Pro Bowl selection, and was inducted into the Pro Football Hall of Fame in 1989, his first eligible year.

    Bradshaw also hosts "Today in America with Terry Bradshaw," an educational TV show that profiles organizations making a difference in how people live, play, and work. He has recently dedicated his time and efforts to shedding light on the subtle and chronic long-term problems associated with concussions.

    LOI Deadline for Physical Therapy Referral Investigation Extended

    Investigators have until April 20 to submit a Letter of Intent (LOI) for the Foundation's special issue Request for Applications titled The Influence of Physical Therapy Referral Characteristics and Practices on Quality, Cost Effectiveness, and Utilization Patterns.

    Potential applicants should visit the Foundation's website to view guidelines and instructions and apply for this opportunity. E-mail Scientific Program Administrator Karen Chesbrough for more information.

    Investigators with extensive experience and publication in health services research are invited to apply for this opportunity.

    Oklahoma Adds Wellness Services to Physical Therapy Practice Act

    Patients and consumers in Oklahoma have expanded options in fitness and wellness services, thanks to a new law that adds these services to the state's physical therapy practice act. Signed by Gov Mary Fallin on Monday, SB 1592 was sponsored by Sen Clark Jolley and Rep Gary Banz. Rep Sean Roberts, PT, MPT, was instrumental in the bill's success, which also was supported by the Patients First Coalition, a group of representatives from the 2 physician associations in the state.

    Call for Submissions: Competency-based Learning and Assessment Resources

    The Association of American Medical Colleges (AAMC), as a partner in the Interprofessional Education Collaborative (IPEC), is seeking submissions for competency-based learning and assessment resources in support of IPEC's Core Competencies for Interprofessional Collaborative Practice report. Physical therapists involved in interprofessional education and practice are encouraged to submit a resource development award application.

    Funded in part by the Josiah Macy Jr Foundation, this initiative is designed to create a national clearinghouse of competency-linked learning resources for interprofessional education and models of team-based or collaborative care.

    AAMC, with guidance from the IPEC-MedEdPORTAL Advisory Committee, will select up to 15 applicants for resource development awards of $2,000 to accelerate content refinement in preparation for formal submission and peer-review to MedEdPORTAL. Award application deadline is May 25, 5:00 pm ET, with applicants notified of funding decisions by June 18.

    To review the full call for submission proposals and apply online, visit the MedEdPORTAL website.

    CMS Selects First 27 ACOs

    The Centers for Medicare and Medicaid Services (CMS) recently selected the first 27 accountable care organizations (ACOs) to participate in the Medicare Shared Saving Program (Shared Savings Program). The selected organizations have agreed to be responsible for improving care for nearly 375,000 beneficiaries in 18 states through better coordination among providers. All ACOs that succeed in providing high-quality care—per their performance on 33 quality measures while reducing the costs of care—may share in the savings to Medicare. 

    Two of the ACOs will participate in a version of the program that allows them to earn a higher share of any savings, in return for which they have agreed to be held accountable for a share of any losses if the costs of care for the beneficiaries assigned to them increase.

    Five of the 27 ACOs that are starting this month will participate in the advance payment ACO model established by the Center for Medicare and Medicaid Innovation to encourage rural and physician-based ACOs to participate in the Shared Savings Program. Under this model, each participating ACO will receive advance payments to help cover the costs of establishing the infrastructure needed to coordinate care for the beneficiaries they serve. 

    CMS currently is reviewing more than 150 applications from ACOs that are seeking to participate in the Shared Savings Program beginning July 1, of which more than 50 are applying for the advance payment ACO model.

    APTA's ACO webpage offers a variety of resources to help members determine if participation in this new model of care is a viable option for them. Resources include videos and podcasts, assessment tools, and links to summaries of ACO regulations. 

    New in the Literature: Preoperative Home-based Physical Therapy (Arch Phys Med Rehabil. 2012 Feb 23. [Epub ahead of print])

    Intensive preoperative training at home is feasible for frail older people waiting for total hip arthroplasty (THA) and produces relevant changes in functional health, say authors of an article in Archives of Physical Medicine and Rehabilitation.  

    This single-blind pilot randomized controlled trial was conducted in patients' homes and a general hospital in The Netherlands. Participants were 30 frail people aged 65 and older. Intervention was a preoperative, home-based program supervised by an experienced physical therapist to train functional activities and walking capacity. The control group received usual care consisting of 1 session of instructions.

    Feasibility was determined on the basis of adherence to treatment, patient satisfaction, adverse events, walking distance (measured with a pedometer), and intensity of exercise (evaluated with the Borg scale). Preliminary preoperative and postoperative effectiveness was determined by the Timed Up & Go (TUG) test, 6-minute walk test (6MWT), Chair Rise Time, and self-reported measures of functions, activities, and participation.

    Patient satisfaction and adherence to the training were good (median=5 on a 5-point Likert scale) and no serious adverse events occurred. The Borg score during training was 14 (range 13-16). Preoperative clinical relevant differences on the TUG test (2.9s) and significant differences on the 6MWT (41m) were found between groups.

    According to the authors, a larger multicenter randomized controlled trial is in progress to investigate the cost effectiveness of preoperative training. 

    CMS Issues Proposed Rule to Delay ICD-10 Implementation

    Yesterday, the Department of Health and Human Services proposed a 1-year delay-from October 1, 2013, to October 1, 2014, to comply with the transition to the International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).

    The ICD-10 compliance date change is part of a proposed rule that would adopt a standard for a unique health plan identifier (HPID), adopt a data element that would serve as an "other entity" identifier (OEID), and add a National Provider Identifier (NPI) requirement. The proposed rule was developed by the Office of E-Health Standards and Services, within the Centers for Medicare and Medicaid Services (CMS), as part of its ongoing role to establish adopt standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

    Deadline Approaches for Applications for MoveForwardPT.com Editorial Board

    APTA members who wish to participate in the development of physical therapy-specific content for APTA's consumer website have until April 20 to apply for the new MoveForwardPT.com editorial board.

    Members of the MoveForwardPT.com editorial board will help write, edit, and review content, such as the detailed symptoms and conditions guides, according to their area of expertise, and/or will help to facilitate content development and review with other physical therapist experts in the field.

    APTA is seeking applications for initial 2-year terms. Applicants must be APTA members with a PhD, DPT, or equivalent, a strong clinical background, proven writing skills, and a keen interest in developing evidence-based, consumer-friendly content.

    If interested in this volunteer opportunity, review the full position descriptions for editorial board members and/or the editorial board chair (position also available), and send a curriculum vitae, letter of intent, and appropriate writing samples to Katie Kissal, consumer portal specialist.

    Effects of EHRs Differ Between Provider Populations

    Physicians order fewer lab tests when they have access to a patient's electronic health records (EHR), but the efficiency may be confined to state-of-the-art records exchanges for now, says a Reuters Health  article based on a study published March 26 in Archives of Internal Medicine.

    The study is on the experience of 2 hospitals-Brigham and Women's and Massachusetts General-that form Partners HealthCare, a nonprofit health care system in Boston. In the year 2000, the 2 hospitals established a health information exchange to access each others' EHRs.

    The researchers examined EHRs of 117,606 people who were outpatients at 1 of the hospitals between January 1, 1999, and December 31, 2004. Of those, 346 had recent tests done at the other hospital-44 patients had them done before the information exchange was rolled out. As for those who did not have recent test results available, 21,968 were at 1 of the hospitals before the exchange.

    Study author Alexander Turchin, MD, MS, told Reuters Health that the number of lab tests ordered for each patient before the exchange in 1999 was about 7. That number fell to about 4 in 2004. For patients without prior tests, the amount slightly increased to roughly 6 tests per patient from about 5.

    Compared to the slight increase for patients without tests, the number of tests ordered for those with previous results decreased 49% after the exchange was established. After adjusting for age, sex, the year, and number of the tests, the number of tests ordered decreased about 53%.

    The findings, however, contradict those of an article published last month in Health Affairs that suggest that office-based physicians with electronic access to imaging and lab results order more tests.

    "We studied a different population," said Danny McCormick, the author of the Health Affairs study. The question is the same, the population is very different."

    McCormick said that the Partners HealthCare study is "consistent with other past research and looks at the Partners' exchange system-which he called cutting-edge-whereas his study looked at what is currently happening in physicians' offices across the US."

    Although physical therapists (PTs) are not yet required or incentivized to adopt EHR systems for such initiatives as Medicare's Meaningful Use Program, physicians and facilities that are included in the program will expect PTs with whom they share patients to use compatible EHR systems. As such, APTA has developed a number of resources for members to assist in assessing and implementing electronic health records.

    Packet I Posted

    In preparation for the 2012 House of Delegates, materials for Packet I will be posted to the House of Delegates Community later today, April 6. The House Handbook and Background Papers will be posted April 20. In addition, 2 discussion boards will be threaded on the House of Delegates Community for use by delegations: Packet I discussion board will be for conceptual discussion surrounding this year’s motions and a Motion Cosponsors discussion board for delegations to pledge cosponsorship for a motion. Contact Cheryl Robinson or Peyton Zeek with any questions.


    APTA Launches Low Back Pain Campaign

    This week, APTA launched a public awareness campaign to educate consumers about how to prevent and treat low back pain with the help of a physical therapist. The goal of the campaign is to drive people to www.moveforwardpt.com to learn more about low back pain, the ways in which a physical therapist can help, and to find a PT. The initial phase of the campaign will target top-tier national print, broadcast and online media.

    The effort is supported by the results of APTA's “Move Forward” Low Back Pain Survey of more than 2,600 people aged 18 and older who disclosed their experiences and habits regarding low back pain. View APTA's press release for some of the key findings. Working with member volunteers, APTA also developed Low Back Pain: Prevention and Management, an e-book that broadly examines the types, causes, and symptoms of low back pain and when to seek medical advice.

    Social media also will play a large role throughout the promotion of the campaign. An infographic titled Low Back Pain by the Numbers, which graphically illustrates the results of the survey, is being shared across Move Forward's Twitter and Facebook pages, in addition to Move Forward's new Pinterest page. APTA will encourage fans, followers, and friends to "Pin-Away Low Back Pain," for a chance to win prizes.

    Move Forward will host its first BlogTalkRadio show on April 23, 7 pm ET, to discuss the results of the survey. Guests will include APTA spokesperson Mary Ann Wilmarth, PT, DPT, who will discuss strategies for relieving low back pain. Mike Ryan, PT, ATC, PES, athletic trainer for the Jacksonville Jaguars, and CoLette Morgan, MD, with Emory University and AARP's Georgia chapter, will join the show to discuss back pain as it relates to athletes and aging, respectively. The show will also cover prevention strategies and proper techniques for everyday activities.

    Letters of Intent for Foundation Study Due April 6

    Tomorrow is the deadline to submit a Letter of Intent for the Foundation for Physical Therapy's investigative research study on the influence of physical therapy referral characteristics and practices on quality, cost effectiveness, and utilization patterns. The Foundation has received $350,000 in combined funding from multiple sources to be used for this investigation.

    Investigators with extensive experience and a strong publication record in health services research are invited to apply for this opportunity by noon April 6, ET. Interested parties should visit the Foundation's website for RFA specifications, eligibility criteria, and application requirements.

    Evidence Supports Using More Chest Compressions for Nonshockable Cardiac Arrest

    People who have a cardiac arrest that can't be helped by a defibrillator shock are more likely to survive if given cardiopulmonary resuscitation (CPR) based on updated guidelines that emphasize chest compressions, according to the American Heart Association (AHA).

    AHA changed its CPR guidelines in 2005 to recommend more chest compressions with fewer interruptions. The emphasis on chest compressions continued in the 2010 guidelines update.

    After the 2005 guidelines, several studies showed improved survival from shockable cardiac arrest.

    However, new evidence shows that most cardiac arrests—nearly 75%— are due to conditions that don't respond to shocks. Researchers identified 3,960 patients in King County, Washington, who had a type of cardiac arrest that doesn't respond to shock from a defibrillator, or nonshockable cardiac arrest.

    They compared survival rates among patients who had nonshockable cardiac arrests from 2000-2004—before the 2005 guidelines changes—to those who had nonshockable arrests from 2005-2010 and found:

    • The likelihood of survival to discharge from the hospital improved from 4.6% before to 6.8% after the new guideline changes.
    • The proportion of patients who survived with good brain function increased from 3.4% to 5.1% between study periods.
    • One-year survival almost doubled from 2.7% to 4.9%.

    Free full text of the study is available online in Circulation.  

    CMS Tools for Practitioners

    Search the Centers for Medicare and Medicaid Services' (CMS) acronym finder and glossary for acronyms and terms that are commonly used by CMS and the health care industry. Browse the agency's Frequently Asked Questions for information on billing, coding, fraud and abuse, enrollment and certification, Medicare demonstrations and reports, and more.

    New Video: Examining Frequency and Duration in Pediatric Physical Therapy

    A new addition to APTA's Innovations in Practice video series highlights how a frequency-and-duration program has changed practice for some 80 therapists in the Children's Hospital of Philadelphia rehabilitation division. The program aims to ensure that the therapists' services are being used optimally, not only in mindfulness of insurance resources that may need to be spread among different health care providers but also to give the best possible care to their young patients. The program has focused on establishing guidelines for frequency and duration of visits for different levels of intensity of services; setting realistic goals for each patient based on the guidelines; and moving each patient and his or her parents, as appropriate and with monitoring as needed, toward self-care, independent from hospital visits. Hear Kim Nixon-Cave, PT, PhD, PCS, explain how the program was created and implemented, and check out the handout that illustrates this innovative model of care.   

    New in the Literature: Walking Speed and Knee Osteoarthritis (Arthritis Care Res [Hoboken]. 2012 Mar 5. [Epub ahead of print])

    Slower walking speed may be a marker for incident knee osteoarthritis (OA), say authors of an article published online last month in Arthritis Care & Research.    

    For this study, 1,858 noninstitutionalized residents age 45 years or older who lived at least 1 year in 1 of 6 townships in Johnston County, North Carolina, completed questionnaires and clinical examinations at baseline and at follow-up testing. Walking time was assessed using a manual stopwatch in 2 trials over an 8-foot distance. Walking speed was calculated as the average of both trials. For the hip and knee, researchers examined 3 outcomes per joint site—radiographic OA (weight-bearing anteroposterior knee radiographs, supine anteroposterior pelvic radiographs of the hip), chronic joint symptom, and symptomatic OA. Covariates included age, gender, race, education, marital status, body mass index, number of prescriptions, depressive symptoms, self-rated health, number of lower-body functional limitations, smoking, physical activity, and number of self-reported, health care provider-diagnosed chronic conditions.

    Faster walking speed was consistently associated with lower incidence of radiographic (adjusted odds ratio [aOR]=0.88) and symptomatic knee OA (aOR=0.84). Slower walking speed was associated with greater incidence of these outcomes across a broad range of different clinical and radiographic OA outcomes.  

    APTA member Jama L. Purser, PT, PhD, is lead author of the study. APTA member Yvonne M. Golightly PT, PhD, is coauthor.

    APTA Summary Available for National Proposed Coverage TENS Treatment for CLBP

    APTA has posted a summary of the recent National Coverage Analysis Proposed Decision Memo from the Centers for Medicare and Medicaid Services (CMS) regarding transcutaneous electrical nerve stimulation (TENS) for chronic low back pain (CLBP). For patients meeting the specified definition of CLBP in the memo, CMS proposes coverage only when those patients are enrolled in a clinical study. The clinical study must address whether TENS provides a clinically meaningful reduction in pain, improvement in function, or reduction in other treatments or services. In addition, the study must adhere to specified standards of scientific integrity and relevance to the Medicare population.

    CMS will accept public comment on this proposed decision memo through April 12. APTA will submit comments on behalf of membership.

    The summary is available to APTA members on the Medicare Coverage Issues webpage under the "TENS" heading.

    'Outstanding Work' Represented in April PTJ

    The articles in this month's PTJ demonstrate documentation of effectiveness of current physical therapy interventions, proposed novel interventions, and the application of knowledge to different patient populations. As you listen to this month's Craikcast, keep in mind that—as  illustrated in the article by Wiles, Matricciani, Williams, and Olds—in 1945, the typical paper in PTJ  was anecdotal, authored by 1.4 US authors who worked in hospitals, and consisted of 4 pages and 4 references. In 2010, the typical paper used a cross-sectional survey or randomized controlled trial design, with 4.6 authors working in universities across the globe, and consisted of 12 pages and 49 references.

    APTA Announces 2012 Photo Contest

    APTA invites members to participate in this year's photo contest. Each photo submitted should reflect physical therapy practice, education, or research. Winning entries should:

    • Reflect the full scope of practice and depict strides in contemporary physical therapy practice, education, or research.
    • Depict models of excellence in a variety of settings.
    • Portray a diverse population of physical therapists, physical therapist assistants, patients, researchers, faculty, or students.
    • Reflect high quality in terms of aesthetics, composition, and technical standards.  

    Winners will be selected by a distinguished panel of judges. Winning entries will be displayed at association headquarters, may appear in APTA's online or print publications, and on APTA's website.

    The first-place winner will receive $500. The second and third place winners will receive $250 each. No cash prizes will be awarded for honorable mentions. Winners will be announced in a future issue of PT in Motion. Complete contest rules and additional details appear on APTA's website. The contest begins April 2 and ends July 2. Winners will be notified by December 14.

    Don't miss out on this outstanding opportunity to help identify and preserve the best in contemporary physical therapy practice, education, and research through your own creativity and initiative.  

    New Summary: Medicaid Eligibility Under ACA

    In a new online summary, APTA breaks down the final and interim final rules recently issued by the Centers for Medicare and Medicaid Services that update regulations to include the new Medicaid coverage groups created by the Affordable Care Act (ACA), simplify eligibility policy for Medicaid and the Children's Health Insurance Program, streamline the eligibility and enrollment processes, and coordinate eligibility procedures with those of the Affordable Insurance Exchanges.

    Highlights of the rules, Medicaid Program: Eligibility Changes Under the Affordable Care Act of 2010, can be found on the Summaries of Health Care Reform Rules & Regulations webpage under the heading "Additional Summaries."

    Comments on the interim final rule are due May 7. APTA will comment on these provisions as necessary.

    National Public Health Week Begins Today

    This year, with the recent release of the National Prevention Strategy, National Public Health Week (NPHW) will address the issue of prevention and wellness to ensure that all is being done to improve the nation's health. Strategies will focus on preventing chronic diseases, which cause Americans to miss 2.5 billion days of work year each year; injuries related to violence; and unintentional injuries, such as motor vehicle crashes, poisonings, and burns. 

    Uniting around this year's theme—A Healthier America Begins Today: Join the Movement—NPHW will work to encourage more Americans and their communities to take preventive measures to help improve their lives. Use NPHW's 2012 toolkit, logos, and other resources to spread the word this week about public health's critical role in making America healthier.