• News New Blog Banner

  • News From NEXT: McMillan Lecturer Outlines Keys to Excellence in the Physical Therapy Profession

    Tom McPoil, PT, PhD, FAPTA, said he intentionally structured the title of the 50th McMillan Lecture—"Is Excellence in the Cards?" as a question "to raise an element of doubt or uncertainty in our quest to achieve excellence." After all, he said during his delivery of the lecture on June 13 as part of the APTA NEXT Conference and Exposition in Chicago, he has several concerns regarding the profession's ability to achieve excellence.

    Before describing the reasons for his uncertainty, McPoil did recognize some of the profession's remarkable accomplishments since he began his career in 1973. "We no longer serve as a subservient technician in the health care system, our students now obtain an exceptional education and are granted a doctoral degree, we can practice in a variety of specialty areas in multiple practice environments, and we have achieved the ability to practice autonomously with patients having direct access to our services," he noted.

    But he said there still is room for improvement from both clinical and academic perspectives, and the remainder of his lecture outlined those perspectives. From the clinical standpoint, he described 3 areas.

    First, McPoil questioned continued acceptance of examination and management methods that may have been proven to have no evidence to support their use. As an example, he identified what is known as the podiatric model, which classifies foot types based on the concept of subtalar joint neutral position. McPoil said that subsequent studies—including those he and colleagues conducted—showed that "subtalar joint neutral position had no relevance to the typical pattern of rearfoot motion. In short, our results challenged the validity of the podiatric model." Yet, he continued, many physical therapist education programs and postprofessional continuing education courses still teach the model. McPoil expressed his hope that the profession will continue to stress the importance of using methods that have been validated with basic science and clinical evidence, especially at entry-level and in education programs, "as it is our new doctor of physical therapy graduates who must serve as our profession's change agents."

    Second, McPoil expressed concern over a lack of acknowledgment of historical research studies that provide evidence for a practice's continue use. He quoted a 2009 article by Mary Halefi ("Forget This Article: On Scholarly Oblivion, Institutional Amnesia, and Erasure of Research History," Studies in Art Education) that "recurring themes, issues, and concerns are part of any field" and failing to cite them along with more contemporary studies risks the loss of past scholarly endeavors upon which current research may be based. "Hopefully," McPoil said, "our professional journals will always perform their due diligence" to retain the contributions of past scholars and researchers in the profession.

    Inconsistence in the level of care was McPoil's third area of needed improvement. He noted some probable causes for inadequate care, such as limited patient time resulting from low payment rates, some highly specialized areas of practice that not all PTs are familiar with, and lack of clinical practice guidelines (CPGs) that address needed services. As for specialized areas of practice, he said that physical therapist-to-physical therapist referral was "rare," and the need for intraprofessional referral needs more emphasis during entry-level education. Concerning CPGs, McPoil argued that while important, they cannot always guide the clinician to an appropriate decision and "cannot replace the need for clinical reasoning and practice knowledge." He continued that such knowledge "can be achieved only through residency or fellowship training."

    To that end, McPoil said that it may no longer be feasible to train a generalist at the entry-level, and the profession must consider allowing specialization to begin before graduation. He identified challenges to developing residency and fellowship programs, such as student loan debt, salaries not commensurate with advanced clinical specialization, and a lack of federally funded support. He expressed his hope that the profession will prioritize development of these programs, as needed funding for them won't occur until they are the expected route following professional graduation. "Our pathway to excellence demands no less!" he said.

    McPoil followed up with his thoughts on achieving academic excellence, specifically the need for every faculty member to have "a personal agenda for scholarship that includes publication."

     

     

    News From NEXT: Building Wellness Programs in the Least Likely Places

    Sometimes, basic assumptions beg to be questioned. Just ask physical therapists (PTs) in the oncology rehabilitation department of Froedtert Hospital and Medical College of Wisconsin, who wondered why prevention and wellness couldn't be a part of the patient experience from the moment they entered the facility's doors.

    That questioning led to the development of an innovative group exercise program for patients checked in to the hospital for chemotherapy and other treatments primarily related to blood cancers—and so far, the program seems to be allowing many patients to leave as mobile, if not more so, than when they arrived. On June 13, the PTs shared their story of how they established and grew the program, known as the "Strength in Numbers" exercise class, as part of APTA's NEXT Conference and Exhibition in Chicago.

    The idea behind the program was based on a reality check of the typical path of an oncology patient visiting the hospital for treatment, explained Kelly Colgrove, PT. Unlike patients who arrive with other conditions such as congestive heart failure, "our patients walk in strong and independently." During the course of treatment, however, they often experience decreased muscle strength, challenging PTs to play catch-up before the patient is discharged.

    The Froedert PTs wanted to "Strength in Numbers" change that. As it now operates, the program—known as "SIN" to the amusement of patients—offers a 1-hour group circuit training class 2 times a week. Colgrove describe SIN as "a fun environment based on camaraderie and music, but all within the acute care setting."

    Patients are selected for the voluntary program based on their health at the time of check-in, Colgrove explained. Those whose condition is more fragile receive more typical 1-on-1 physical therapy. But the patients who qualify for SIN are assessed, given goals, and scheduled to participate in the group. Once the SIN group, patients still can choose to return to the more traditional therapy program.

    Besides the direct physical benefits to patients, the SIN program has helped to reinforce what the presenters call a "culture of mobility" at the hospital.

    The presenters led attendees through their process of developing and maintaining the program, encouraging audience members to think about similar possibilities in their own practice settings. They explained the importance of a solid basis in research, careful consideration of stakeholder concerns, evaluation of current and needed resources, and program metrics to evaluate outcomes, among other areas.

    Through their recaps, the presenters demonstrated how flexibility and creativity are key elements in all areas of development, implementation, and evaluation. "Being able to adapt and evolve is going to be key," explained Alyssa Kelsey, PT, DPT. For the SIN program, that means seeking ongoing input from patients and staff, as well as monthly check-in meetings to monitor operations and identify future goals.

    That flexibility should also include the capacity to question your own assumptions and evaluative measures, explained Colgrove. "Sometimes, the questions you think you want to answer at the beginning of the program may not be the questions you want to answer after a year," she said.

    One question has been consistent throughout the SIN program: Does it work? So far, the answer seems to be yes. Outcome measures for patients with a length of stay longer than 20 days and more than 50% participation in SIN found that 72% maintained or improved their 5-time sit-to-stand scores, 64% maintained or improved on Functional Gait Assessment, and 53% maintained or bettered their scores related to self-perceived deficits at discharge.

    And if patient enthusiasm for the program is any measure, the SIN program also seems to be doing well: according to the presenters, patients frequently have the same criticism of the offering—that the classes only occur 2 days a week.

    News From NEXT: How One Hospital Implemented Direct Access

    A panel of PTs from the Hospital for Special Surgery (HSS) in New York explained how that institution implemented direct access (DA) to physical therapist services during a June 13 session at APTA's 2019 NEXT Conference and Exposition. They then advised attendees how to operationalize DA at their own institutions.

    Presenters from HSS were Carol Page, PT, DPT; Mary Murray-Weir, PT, MBA; Robert Turner, PT, DPT; and Jaime Edelstein, PT, DScPT. Also presenting was Aaron Keil, PT, DPT, from the University of Illinois at Chicago.

    Keil noted that DA was achieved in all 50 states and the District of Columbia in 2015, but only 18 states have unrestricted access. The others include limiting or restrictive provisions, meaning there still are barriers to DA.

    He cited a 2015 APTA survey for which nearly 65% of respondents said the major administrative barrier to DA implementation was "My supervisor/facility requires all patients to have a referral." Keil noted that this is especially true in hospital-based inpatient and outpatient facilities, as hospitals tend to be more risk averse and "may be more restrictive than state law."

    Page said that an essential first step to achieving DA was getting buy-in. One key group was physicians—particularly surgeons—who were concerned that their patient levels would drop. Page explained, "We showed that direct access would 'widen the funnel' and actually provide them more patients," while at the same time screening to avoid sending inappropriate patients to the surgeons.

    Administrative staff was taught how to screen patients and schedule them with appropriate PTs. They also were made responsible for tracking timing and number of permissible visits for adherence to state provisions, building on an HSS foundation of training and competency programs it conducts for all staff.

    The hospital established criteria for DA PTs that were more stringent than required by the state. For example, while New York requires 3 years of clinical experience, HSS required that experience to be at outpatient facilities. It also required CEUs in certain areas, such as spine, manual therapy, and differential diagnosis.

    Turner described the development of a written exam for aspiring DA PTs. Questions were developed following the same item-writing guidelines used by the American Board of Physical Therapy Specialties. A score of 80% is required to pass the test.

    HSS also developed a practical examination involving an actual patient. The primary question to be answered is: "Can you take this patient and treat him or her? Or do you refer to a physician?"

    The program was made voluntary for PTs since some didn't initially feel comfortable with it. "Not everyone fits the mold," Turner said.

    Page addressed operationalizing DA, which she divided into 4 categories. The first was resources. She said, "APTA has amazing resources." She advised those in the audience to search APTA's website for "direct access" and browse the resources. The second category is billing, which she made clear "is different in a hospital setting" from a private practice and requires a hospital-wide effort. The team leading the DA program at HSS made a conscious decision not to contact insurance companies in advance and announce their intentions. "We did a soft launch with a small number of patients. We let them know that their interventions might or might not be covered," Page said, but he found that most insurers did cover the services, and HSS now contacts insurers in advance.

    The other elements of operationalizing DA were documentation and marketing. These included developing specific policies and procedures, providing notice of advice for patients, identifying common ICD-10 codes, and developing tip sheets for patients and physicians.

    The panel listed a series of lessons learned—things to do and things not to do. For example, don't:

    • Assume people understand what DA is.
    • Give up.
    • Be mean, defense, argumentative, or otherwise difficult to deal with.

    On the other hand, do:

    • Assume some people will think DA is illegal and/or unsafe.
    • Highlight improved patient access and patient care.

    Ask "How can we?" rather than "Can we?"