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  • From PTJ: Are Pain Measures Asking the Right Questions?

    In terms of measuring how a patient is impacted by chronic pain, there is a gap between what commonly used questionnaires ask and what patients care about most, say authors of a study in the July issue of PTJ(Physical Therapy). It's time, they write, to "embed patients' values and preferences" into the instruments providers use to evaluate the effects of chronic pain.

    In the first phase of an effort to develop a "patient-driven" instrument, researchers in the Netherlands conducted focus groups and developed an online survey to identify the attributes of pain that have the most impact on participants' daily lives. Survey respondents were asked to provide information about their diagnosis and level of pain, complete the Pain Disability Index, and select the 8 (from a total of 84) most important attributes of pain.

    Authors say that while many instruments measure areas such as pain sensation, psychological impact, functional disability, related symptoms, activities of daily living, social functioning, coping strategies, environmental factors, and financial burden, those aren't necessarily the factors that are most important to patients. In the end, the 8 most frequently chosen attributes of pain identified by the 949 survey respondents were fatigue, social life, cramped muscles, sleeping, housekeeping, concentration/focus, feelings of not being understood, and control over pain.

    Authors also broke down the results by gender, age group, diagnosis, and pain intensity. The only significant difference between men and women was the rating for "housekeeping" – ranked at 5 for women and 29 for men. Individuals with back pain rated "concentration" and "not being understood" much lower than did other diagnostic groups.

    Comparing the results against attributes measured in several widely used instruments and item banks, there was some overlap; however, many standard test items were not deemed important by survey respondents. Similarly, some items rated important to patients are absent from these instruments—for example, researchers note that fatigue was consistently identified as an important attribute in their survey, but it is not included in many instruments used for patients with chronic pain.

    Authors say that the results of the study are being used to develop a prototype pain survey, based on the 8 areas identified through the survey and focus groups, that will measure the impact of chronic pain on health-related quality of life (HRQoL). "A preference-based measuring method allows attributes to be weighted so that HRQoL can be calculated," they write, adding that "a substantial amount of information can be ascertained from these 8 attributes."

    "These attributes in [themselves] are not in fact new, but discovering which attributes are most important to people with chronic pain leads to new insights, which should be used to guide further development of a truly patient-centered, preference-based instrument," authors write.

    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.

    The Good Stuff: Members and the Profession in the Media, July 2018

    "The Good Stuff" is an occasional series that highlights recent media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    A Good Stuff update: Back in 2016, Good Stuff shared the story of Leigh Anne Anger, PTA, who was fighting back after a triathalon bicycling accident that left her with multiple skull fractures, a broken clavicle, a fractured jaw, and detached ligaments in her shoulder. The road to recovery looked long and hard.

    Guess what? She's back.

    Leigh Anne's husband, Jay, tells PT in Motion News that not only is Leigh Anne competing again, but she just earned the top podium spot for her age group in the Rufus Racking Summer Roundup Triathalon. Congratulations, Leigh Anne!

    Turning over a new leaf at the Forest Service: Jess Kehoe, PT, DPT, and Leah Versteegen, PT, are helping members of the US Forest Service avoid injury and move more efficiently thanks to their experience working with tactical athletes from other professions. (Missoula, MT, Missoulan)

    Exercise? Just do it: Ryan Woods, PT, DPT, explains why any amount of exercise is better than none at all. (Picayune, MS, Item)

    Planting the seeds of prevention: Greg Bachman, PT, points out why it's important for gardeners to stay flexible year-round to avoid gardening-related injury. (Emporia, KS, Gazette)

    The realities of seeing a PT first: Mark Donald Bishop, PT, PhD, FAPTA, makes the case for physical therapy for pain management—and identifies obstacles in the health care system that make it hard for patients to connect with PTs. (theconversation.com)

    Weakness cometh before a fall: Strengthening exercises can help people who are older guard against falls, says Greg Hartley, PT, DPT. (AARP online)

    Concussion is a player in baseball, too: Jessica Schwartz, PT, DPT, says more awareness of concussion is needed in baseball and many other supposed "noncontact" sports. (New York Times)

    Oh, baby! Ronit Sukenick, PT, emphasizes the importance of rehabilitation for new mothers during the fourth trimester. (New York Times)

    No slouch when it comes to good advice: Eric Robertson, PT, DPT, provides insight on taking a realistic approach to improving posture. (Popular Science)

    Diving into falls: Sylvie de Rham Tortorelli, PT, answers questions about falls and falls prevention. (Bellingham, WA, Herald)

    Mighty Miss Maya: Anna Semelbauer, PT, DPT, has been helping 4-year-old Maya Tisdale achieve her dream of walking unassisted. (Traverse City, MI, 9&10 News)

    Making the PT vs personal trainer choice: Ann Wendel, PT, ATC, discusses the factors that should guide a person considering working with a personal trainer or a PT. (refinery29.com)

    Women and text-neck: Szu-Ping Lee. PT, PhD, and fellow authors of a study have found that text-neck pain disproportionately affects women. (ScienceDaily.com)

    Stretching for a long stretch of road: David Reavy, PT, MBA, provides tips on the best stretches for road trips. (Men's Journal)

    Taking a stand for healthy work environments: Rebecca Sanders Fung PT, DPT, and Eric Lederhaus, PT, discuss the importance of office environments that help employees avoid long periods of sitting. (Employee Benefit News)

    Quotable: "Physical therapists are on the front lines: they're really good at being able to say, 'You're normal for feeling this way, it's totally reasonable that you're crying.'" – Clinical psychologist Deborah Roche, PhD, on the emotional demands of recovering from injury. (refinery29.com)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    What's the Best Post-TKA Intervention in the Acute Care Setting? There's No Easy Answer, Say Researchers

    For patients who undergo total knee arthroplasty (TKA), this much is known: physical therapy in the acute care setting is a key component in successful rehabilitation. What's not so easy to pinpoint are the individual interventions associated with the best outcomes, according to authors of a new systematic review. Their investigation into 20 years' worth of clinical trials and other studies revealed no clear standout interventions but did find "very low" evidence for the use of cryotherapy, accelerated rehabilitation, and neurostimulation within the first 7 postoperative days (PODs).

    The study, published in the Journal of Acute Care Physical Therapy, involved extensive reviews of research published between 1996 and 2016 on various physical therapy-related interventions used in the acute care setting post-TKA. Authors were on the lookout for evidence of effectiveness of a particular approach, because, they write, "despite seemingly routine use of physical therapy and its potential importance in reducing complications after [total joint replacement] in the acute hospital setting, no approach to rehabilitation in this setting appears to be standard."

    In the end, through a review process that pared down a list of 686 research titles to 40 studies that met inclusion criteria, authors were able to come up with a definitive conclusion, albeit not the most rewarding one for those looking for guidance: existing evidence isn't strong enough to support any clear winners when it comes to post-TKA physical therapist interventions in the acute care setting.

    The studies that yielded no or weak evidence looked at approaches including additional sessions of rehabilitation, compression and manual lymph drainage, knee range-of-motion (ROM), continuous passive motion, knee ROM manual passive exercise, knee ROM-active assistive exercise, biofeedback, and acupressure, acupuncture, and traditional Chinese medicine. According to authors, evidence either was insufficient or included a significant risk of bias, or both.

    Three other interventions fared somewhat better than the rest, although none were supported by strong evidence. They were:

    Cryotherapy. Reviewers identified 2 systematic reviews supporting the use of cryotherapy to reduce early postoperative pain and improve ROM, though evidence was described as "very low" quality by authors of both reviews.

    "Early" or "enhanced" physical therapy—for example, having patients walk within hours after surgery. Authors identified "very low level" evidence supporting these approaches to improve ROM and walking ability, and to reduce length-of-stay.

    Neurostimluation. "Very low level" evidence suggested that neurostimulation may help to reduce pain—but only when electrodes were placed near the surgical site, according to authors.

    Further clouding the evidence in most (31 of the 40) studies was the fact that some form of "physical therapy" or exercise intervention was used—in both the special intervention group and the comparison group—in addition to the intervention being studied. "Possibly, the lack of evidence for the effectiveness of most of the studied interventions is due to similar management of the intervention and comparison groups, and that changes in the outcomes studied are largely affected by various forms of interventions suggested by the term 'physical therapy' or 'standard care,'" authors write. In addition, they point out, all study participants likely received medical pain management, which makes it even harder to isolate the effects of a particular intervention.

    Authors say there's a clear need for more research on interventions in the acute setting, but acknowledge that such research may be challenging "because of the difficulty controlling for all the variables that may influence outcomes that affect function."

    For now, authors say, don't count on any clear recommendations on the single best intervention to use for patients post-TKA in the acute care setting.

    "Given the state of the evidence, physical therapists will need to rely on empirical evidence and physiologically plausible rationales for selecting type, intensity, frequency, and duration of interventions," authors write. "In addition, given the likely symbiotic relationship between pain management and physical therapy interventions, peri- and postoperative medical management may have important effects on the immediate gains in patients' function after TKA that cannot be separated from the effects of interventions provided by physical therapists."

    APTA members Alisa Curry, PT, DPT; Meri Goehring, PT, PhD; and Diane Jette, PT, DSc, FAPTA, were among the coauthors of the study.

    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.

    Proposed 2019 Fee Schedule: Goodbye Functional Limitation Reporting, Hello MIPS?

    It's official: the US Centers for Medicare and Medicaid Services (CMS) is proposing that physical therapist (PTs) join the list of providers who must participate in the CMS Quality Payment Program (QPP), which would mean that beginning in 2019 PTs providing services under Medicare Part B must participate in either the Merit-based Incentive Payment Program (MIPS) or an Advance Alternative Payment Model (APM).

    But that's not the only significant change proposed by CMS. In a win for APTA and its members, the proposed rule would also eliminate functional limitation reporting (FLR), a requirement consistently opposed by the association.

    APTA regulatory affairs staff are reviewing the proposed rule and will provide more detail in the coming weeks. Here are the major takeaways so far:

    MIPS-eligible clinicians would include PTs
    PTs, occupational therapists, clinical social workers, and clinical psychologists who furnish services under Medicare Part B would be added to the list of providers required to participate in the MIPS program or, alternatively, an approved APM as part of the QPP. Currently, PTs may voluntarily participate in the QPP; if the proposed rule is adopted, the program would begin for PTs in 2019.

    MIPS requires reporting in 4 performance categories—quality, promoting interoperability, clinical improvement activities, and cost. Providers earn points in each category, producing a total annual MIPS score, which in turn determines whether the providers earn a payment incentive, remain neutral in payment, or be subject to a penalty. Several of the data points must be reported electronically through certified EHR vendors or registries such as APTA’s Physical Therapy Outcomes Registry. The inclusion of PTs comes as MIPS enters its third year of the program.

    (Editor's note: check out this article from PT in Motion magazine to get the basics on MIPS)

    Goodbye FLR?
    The FLR requirement, long-characterized by APTA as an unnecessary burden on PTs and other providers, would be eliminated under the proposed rule. Change or elimination of the FLR requirement was an ongoing target for the association, which provided data to CMS showing that the requirement didn't accomplish the value-based care goals that CMS envisioned.

    Physical therapist assistant (PTA) differential officially established
    Under the proposed rule, CMS would establish 2 new therapy modifiers to identify the services furnished in whole or in part by PTAs or occupational therapy assistants (OTAs) beginning. January 1, 2020. The change, mandated by the Bipartisan Budget Act of 2018, establishes modifiers to be used whenever a PTA or OTA furnishes all or part of any covered outpatient therapy service, and would set the stage for a planned payment differential that would reimburse services provided by PTAs and OTAs at 85% of the fee schedule beginning in 2022. CMS anticipates the creation of a voluntary reporting system for the new modifiers beginning in 2019.

    Payment would get a slight increase
    After applying adjustment factors mandated by the Bipartisan Budget Act of 2018, the proposed fee schedule conversion factor would be increased slightly, from $35.99 to $36.05.

    KX modifier requirements remain
    The permanent fix to the Medicare therapy cap enacted in 2018 included requirements to continue using the KX modifiers for claims that exceeded a threshold, which in 2018, is $2,010 for PT and speech-language pathology (SLP) services combined. CMS also references the targeted medical review process, noting the threshold amount of $3,000. That system would continue, but the proposed rule emphasizes that not all claims exceeding the threshold would be subject to review.

    More alternatives to MIPS
    Providers who elect to participate in the QPP through APMs would be allowed a bit more leeway in the new rule. For example, providers participating in the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration project would avoid MIPS reporting and payment adjustments if they participate in Medicare Advantage arrangements that are "substantially similar" to APMs.

    "The proposed rule contains provisions that, while not unexpected, have some far-reaching implications for physical therapists," said Kara Gainer, APTA director of regulatory affairs. "APTA will be analyzing the proposed rule in more detail and providing more information as it becomes available."

    The association will also be providing comments on the proposed rule by the September 10 deadline.

    APTA Helps Create New Grant Opportunities for PTs

    A new "mini grant" project aimed supporting implementation of a self-directed and group intervention program for adults living with arthritis is now accepting applications. The grants of at least $2,000 each are available to individual physical therapists (PTs) as well as APTA state chapters. APTA is a cosponsor of the program.

    The grants will be awarded to successful applicants who propose ways to implement the "Walk With Ease" (WWE) program either directly or in partnership with an external agency. Developed by the Arthritis Foundation, WWE is a community-based walking program based on group walking sessions and pre-walk discussions held multiple times per week. The initiative is a US Centers of Disease Control and Prevention (CDC)-recommended physical activity program.

    Grantees are expected to recruit at least 200 participants and work to ensure all participants complete 100% of the intervention by September 29, 2018, the end of the 3-month project period. Selected applicants can anticipate an average award of $2,000, although the number of awards is contingent on the availability of federal funds.

    Applications will be accepted and considered for funding on a rolling basis. Final applications must be received by Friday, July 27, 2018 at 11:59 pm ET and can be downloaded from the grant announcement webpage. Interested applicants must email the completed application to nmccoy@chronicdisease.org.

    APTA collaborated with the National Association of Chronic Disease Directors and the CDC's Division of Population Health Arthritis Program in the creation of the grants program.

    OB-GYN Group Embraces 'Fourth Trimester' Concept, Acknowledges Role of Physical Therapy in Postpartum Care

    A task force for the American College of Obstetricians and Gynecologists (ACOG) says it's time to frame postpartum care as an "ongoing process" requiring a personalized, cross-disciplinary approach—including the use of physical therapy when appropriate. APTA and its Section on Women's Health have registered strong support of the recommendations.

    In a committee opinion issued in May, ACOG's Presidential Task Force on Redefining the Postpartum Visit embraced the concept of the "fourth trimester," the idea that mother and child need ongoing care through at least the first 12 weeks after delivery. According to the task force, the fourth-trimester concept stands in contrast to the practice of an "arbitrary" single encounter with a primary care provider, often at 6 weeks after giving birth.

    Instead, the task force recommends contact with a maternal care provider within the first 3 weeks postpartum, during which the provider and patient would discuss a wide range of postpartum issues—from feelings of depression to the need for physical therapy to address incontinence and resumption of physical activity. Later, but within 12 weeks postpartum, a "comprehensive postpartum visit" should take place, according to the recommendations. That visit would also serve as a transition into ongoing well-woman care.

    The formal acknowledgement of physical therapy's role in postpartum care represents a significant conceptual shift, according to Carrie Pagliano, PT, DPT, president of the APTA Section on Women's Health.

    "Physical therapy has played a role in the postpartum health of women for many years; however, patient access to care was often limited to mothers who have a referring provider having prior experience with physical therapy, or it was simply left to the patient to find her own answers for her postpartum issues," Pagliano said. "Formal recognition of physical therapy in the fourth trimester not only recognizes our expertise in this area of care but provides a clearly stated standard of care for physicians providing postpartum care options for their patients."

    In a joint letter to ACOG on behalf the section and APTA, Pagliano and APTA President Sharon Dunn, PT, PhD, applauded the inclusion of physical therapists as a part of the health team envisioned in the recommendations.

    "Physical therapists' knowledge base and expertise related to the assessment and treatment of urinary and fecal incontinence, and for perinatal musculoskeletal issues including sexual dysfunction, pelvic girdle, and low back pain, as well as diastasis recti and painful scar tissue, will complement the contributions of other health care providers working in this important area of practice," the letter states. "Including physical therapy as a standard of postpartum care will increase the resources available for women to return to or improve their quality of life."

    For its part, the task force hopes the recommendations will influence payment and other policies around postpartum care, and will help to underscore the importance of fourth-trimester care among new mothers, among whom an estimated 40% never attend a single postpartum visit

    "The recognition of the fourth trimester is extremely important," Pagliano said. "Historically, women have talked about postpartum issues among themselves but may have been told 'that's just what happens when you have a baby.' These recommendations move the conversation into the light, providing a clear pathway, opening opportunities to discuss prevention, education, and treatment options for mothers following birth."

    Innovative Collaborative Effort Between APTA, United Healthcare, and OptumLabs Could Introduce Important Changes to Pain Management Policies

    What would happen if payers encouraged patients with low back pain (LBP) to explore low-risk treatments such as physical therapy by waiving copays for initial sessions? Thanks to a collaboration between APTA and the nation’s largest private health insurer, we may find out.

    Through its work with APTA, United Healthcare is identifying 10 markets for a pilot program that would employ a variety of policy changes to its pain management program, including the elimination of cost-sharing for an initial physical therapist (PT) visit, easier appointment scheduling for patients, and stepped-up public and physician education efforts emphasizing the benefits of early referral to a PT for pain. If successful, the pilot could help to transform the payment landscape in ways recommended in a recent APTA white paper on addressing the opioid epidemic through better pain management policies.

    The pilot accelerates the practical application of findings from a joint study by APTA, United Healthcare, and OptumLabs on the potential impact of early physical therapy and other nonopioid strategies to address LBP. That study paid particular attention to cost and downstream utilization associated with early physical therapy for LBP.

    The study was one of the topics covered during the 2018 Rothstein Roundtable at the APTA NEXT Conference and Exposition (see video dispatch below). During the Rothstein discussion, David Elton, senior vice president of clinical programs for OptumHealth, characterized the study's findings as ones that "confirm what we've seen"—that "good things happen" when physical therapy is used early in an episode of LBP.

    While not yet finalized for publication—something that could happen as early as fall of this year—the study's results were convincing enough to cause the insurer to move quickly toward the creation of the pilot program.

    "The collaborative work between APTA, United Healthcare, and Optum is an innovative approach that brings providers and payers together to work on truly transforming the health care system in ways that make a difference to patients," said Carmen Elliott, MS, APTA vice president of payment and practice management. "We are excited about the publication of the joint study and pleased for the opportunity to make real-world changes to improve patient access."

    According to United Healthcare, APTA chapter leadership in the 10 markets under consideration will be contacted to schedule webinars that provide an overview of the pilot.

    OptumLabs and OptumHealth are businesses of Optum. Optum and UnitedHealthCare are benefits and services companies of UnitedHealth Group.

     

     

    From the 2018 APTA House of Delegates: Rimmer, Corcos, Polvinale, Receive Honorary APTA Membership

    Two researchers and a longtime APTA staff member were formally recognized as honorary members of APTA by the 2018 House of Delegates for contributions that have allowed physical therapists (PTs) and physical therapist assistants (PTAs) to better serve patients and clients.

    James H. Rimmer, PhD, has conducted research that is widely known for its emphasis on health promotion and wellness for people with disability, particularly as it relates to physical therapy. This, in turn, has fostered development of models for the integration of health promotion into PT practice. He is also the creator of large-scale centers that promote health and wellness, and currently directs 2 federally funded centers: the National Center on Health, Physical Activity, and Disability; and the Rehabilitation Engineering Research Center on Interactive Exercise Technologies and Exercise Physiology for People with Disabilities.

    Daniel M. Corcos, PhD, a scientist whose research focuses on the neural basis of motor control, has a 30-year history of collaborating with PTs in a variety of ways, from serving as a doctoral chair to coauthoring peer-reviewed publications. In addition, Corcos played critical roles in developing grants that have supported the work of PTs and has been the recipient of grants that have included PTs as principal or co-principal investigators.

    With more than 38 years as an APTA employee, Bonnie Polvinale, former APTA chief operations officer (now retired), is the longest-serving staff member in the association's history. During her tenure with APTA, Polvinale helped to refine or re-envision some of the association's most popular offerings including the NEXT Conference and Exposition, the APTA Learning Center, and the Combined Sections Meeting. APTA President Sharon Dunn, PT, PhD, described Polvinale as a "truly outstanding" individual "committed to helping others" whatever the need. "Bonnie Polvinale possess the same compassion and caring for the individual that called us all to our profession in the first place," Dunn said.

    Final language for these recognitions and all actions taken by the House will be available by September after the minutes have been approved.

    APTA Input Included in Health Care Exec Group's Roadmap for Addressing Opioid Crisis

    In recommendations that at times echo those in a recently published APTA white paper, a new "roadmap" for addressing the opioid crisis adds to the voices calling for increased patient access to nonpharmacological and multidisciplinary approaches to pain management. APTA was among the organizations that helped guide development of the report.

    "A Roadmap for Action" is based on a summit sponsored by the Healthcare Leadership Council (HLC), a coalition of chief executives from hospitals, pharmaceutical companies, health insurers and other organizations. Summit participants, which included APTA, developed what HLC describes as "a concrete set of recommendations that identify best practices, prioritize solutions, and identify policy reforms necessary to collaboratively address the opioid crisis." APTA members may find the roadmap useful in advocacy and consumer education efforts.

    The roadmap focuses on 5 broad "priority areas" that require a range of actions at the legislative, regulatory, and industry level "to remove barriers to improved care, essential flow and use of data, and the development of therapeutic tools," according to the report. They are:

    • Improved system approaches to pain management
    • Improved system approaches to prevent opioid misuse
    • Expanded access to evidence-based substance-use disorder treatment and behavioral health services
    • Improved care coordination through data access and analytics
    • Development of sustainable payment systems that support coordination and quality care

    The list is followed by separate recommendations for "health care leaders," lawmakers, and regulators that are largely consistent with those developed by APTA in its white paper "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health Care." Both the HLC and APTA resources call for increased public and provider awareness of nonpharmacological options for pain management, increased payer support for nonopioid approaches, and wider use of multidisciplinary teams. The HLC roadmap includes physical therapists as providers whose expertise should be put to use "through recognition and payment of services, as well as integration into care teams and opioid stewardship models."

    "This document is a call to action, not only for lawmakers and regulators, but also for all sectors of American healthcare," the HLC report states. "While public policy has a vital role to play in removing barriers to advancements in care and empowering accelerated therapeutic innovation, private sector leadership is critical on every aspect of this issue, from improvements in pain management to data-driven proactive interventions to strengthened opioid stewardship."

    From PT in Motion Magazine: Pedaling Past Injury

    According to an industry survey, more than 100 million Americans ride a bike each year. Some ride recreationally or for exercise, some bike to work or school, and others race competitively. No matter the kind of riding they do, all riders face some of the same challenges, such as risk for falling, overuse injuries, and improper alignment due to a poor bike fit. That's where physical therapists (PTs) and physical therapist assistants (PTAs) come in.

    A feature in this month’s PT in Motion magazine explores the PT's role in helping cyclists avoid injury, not just recover from it. Author Keith Loria interviewed several competitive cyclists, as well as PTs who have helped cyclists of all types.

    Alex Fraser-Maraun, an emerging elite Canadian road cyclist, said it was after he saw a PT that he learned his injuries “all stemmed from poor training and recovery practices, and from poor bike fits." Fraser-Maraun credits his therapist, Erik Moen, PT, with helping him return to racing. Moen notes, "Physical therapy can help bicyclists achieve their goals by identifying musculoskeletal limiters in their ability to pedal well and maintain positions consistent with bicycling."

    Clinicians also share advice for recreational riders, who often experience overuse injuries, or back, neck, or knee pain. Robert Wellmon, PT, DPT, PhD, who also is a competitive cyclist, told PT in Motion, "One of the best ways to avoid these problems is having a bike that fits well: the seat is the right height and width, and aligned properly."

    Pedaling Past Injury" is featured in the July 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.

    Working with patients who are cyclists? Have them check out MoveForwarPT.com's "Tips for Health Cycling" page.

    Proposed CMS Home Health Rule Includes Major Change to Payment System

    The US Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule for home health payment that resurrects elements of last year's proposal for an entirely new payment methodology by, among other changes, shifting care from 60-day to 30-day episodes and removing therapy service-use thresholds from case-mix parameters. And while the new proposal doesn't mimic last year's proposal in terms of across-the-board cuts, the practicalities of the payment system could have an impact on providers.

    On July 2, CMS unveiled the Patient Driven Groupings Model (PDGM) as part of its proposed 2019 home health prospective payment system (HH PP). If adopted, it would represent 1 of the most significant changes to home health payment in decades by moving to 30-day episodes of care and structuring payment around some 216 case-mix groups that don't include therapy visits as a factor. In a fact sheet on the proposal, CMS asserts that the new system, mandated by the Bipartisan Budget Act of 2018, would "move Medicare toward a more value-based payment system that puts the unique care needs of the patient first while also reducing the administrative burden associated with the HH PP." If adopted as proposed, the PDGM would take effect in 2020.

    APTA regulatory affairs staff will analyze the proposal in-depth over the coming weeks, but initial readings seem to indicate that much of the PDGM is a rehash of the Home Health Groupings Model (HHGM) that CMS proposed last year. That proposal met with stiff resistance from many patient and provider organizations including APTA and the association's Home Health Section, with APTA describing the HHGM as a system with "significant flaws" that "will have a harsh and dramatic effect on patient care."

    Ultimately, CMS backed off from adopting the system in 2017, promising a retooled proposal in 2018. In the intervening months, the agency convened a technical expert panel to review the issue. That panel included APTA member Bud Langham, PT, MBA, with APTA Director of Regulatory Affairs Kara Gainer attending as an observer.

    The proposed PDGM has at least 1 significant change from the HHGM: because it's designed to be implemented in a budget-neutral way, it doesn't include the same $950 million in cuts associated with the 2017 proposal.

    But that doesn't mean providers are out of the woods, according to Gainer.

    “While the budget neutrality will prevent massive across-the-board cuts, CMS notes that the impact on payments as a result of the proposed PDGM will vary by specific types of providers and location," Gainer said. "Some individual home health agencies may experience different impacts on payments due to a variety of factors, most notably the ratio of overall visits that were provided as therapy versus skilled nursing.”

    Essentially, the PDGM classifies 30-day episodes according to a combination of factors related to 5 major buckets. They are:

    Timing—"early" vs "late." Only the first 30-day episode would qualify as "early"—all other episodes would be considered "late."

    Admission source—"community" vs "institutional." A 30-day period would be classified as "institutional" if the patient had an acute or postacute facility stay within 14 days of the start of the episode—if not, the admission source would be labeled "community."

    Clinical group. Based on principal diagnoses, patients would be assigned to 1 of 6 clinical groups: musculoskeletal rehabilitation; neuro/stroke rehabilitation; wounds (both surgical and nonsurgical); behavioral health care (including substance use disorder); complex nursing; and medication management, teaching, and assessment.

    Function level—"low impairment," "medium impairment," or "high impairment." CMS would rely on Outcome and Assessment Information Sets (OASIS) codes to designate a patient's level of function.

    Comorbidity adjustments—"no adjustment," "low," or "high." A single secondary diagnosis that falls within a list of 11 comorbidity subgroups could qualify the patient for a low-comorbidity adjustment; 2 or more that results in comorbidity subgroups interacting could result in an adjustment for high comorbidity.

    The combination of categories are what comprises the 216 PDGM payment groupings. Those groupings would define payment for the 30-day episode and could in turn receive further adjustments if fewer than 2 to 6 visits are furnished during the 30-day episode, depending on the PDGM group.

    The proposed rule also includes changes to certifying and recertifying patient eligibility for continued home health care; an allowance for home health agencies to report the cost of remote patient monitoring; and a transition toward payment for home infusion therapy. The changes proposed by CMS would result in an estimated 2.1% increase in payments in 2019, or about $400 million.

    APTA staff will continue to review the proposal and develop a fact sheet in the coming weeks. The association will prepare comments on the proposal for submission before the August 31 deadline. APTA also will create a template letter that members can use to provide their own comments to CMS.

    NEXT 2018: Rothstein Roundtable Takes on Reasons Payers Are Slow to Make Changes That Support Physical Therapy

    David Elton, senior vice president of clinical programs for Optum Health, describes the opioid epidemic as a lit match—the crisis that sparked payers to sit up and take notice of physical therapy's ability to not only reduce later opioid use, but to lower downstream health care costs for a variety of conditions. It didn't take long for the 2018 Rothstein Roundtable to reflect that same heat, as a discussion initially focused on increasing the use in physical therapy as an alternative to opioids spread to an exchange on both the promise of physical therapy to become more broadly supported by private payers, and the factors that could get in the way.

    The roundtable, a regular part of APTA's 2018 NEXT Conference and Exposition, held true to its reputation for facing hot topics in the profession head-on. This year, the title of the discussion was "Physical therapy decreases opioid use: what will it take to change policy?"

    The answer, more-or-less agreed upon by Elton and his fellow panelists: policy is already changing, but not as quickly—or as broadly—as some in the physical therapy profession might prefer.

    Moderator Anthony Delitto, PT, PhD, FAPTA, launched the discussion by asking, “What’s taking so long?” for payers to act on the evidence that shows physical therapy's efficacy in treating chronic pain, as many payers impose restrictions, high copays, and other barriers that make it hard for patients to get nondrug care.

    It's not simply a matter of payers being unaware of physical therapy's effectiveness, explained panelist Kenneth Schaecher, MD, associate chief medical officer for the University of Utah Health Plans—it's also that most clinicians don't think of physical therapy as an option for their patients. "And even if they do,” he said, “they're not aware of the evidence."

    Stephen Hunter, PT, PhD, physical therapy administrator at Intermountain Health Care, said that financial implications play a role, too. Often, he explained, physical therapy presents a disincentive for patients: multiple visits, with multiple copays—providing, of course, that the patient has made it past her or his high deductible in the first place. "Due to the historical approach to physical therapy … payers have created the circumstances that have pushed people away from physical therapy," Hunter said.

    Elton largely agreed with Schaecher and Hunter, but was more hopeful about the future. The evidence, he said, can no longer be ignored, particularly when an estimated 50% of all health insurance claims are related to back pain, and 75% are related to musculoskeletal conditions—the exact areas in which physical therapy has been demonstrated to be most effective. But, as panelists pointed out, change can't really start happening until payers and the profession itself do a better job of making the case for physical therapy to the public.

    Hunter explained that at Intermountain, it was commonly assumed that the reason patients weren't seeing physical therapists (PTs) is that physicians weren't referring them. That does happen sometimes, he explained, but when they looked closer they found the real problem was with the patients themselves.

    "Patients were referred to PTs but would never show up," Hunter said. "They don't see the value."

    Charles Thigpen, PT, PhD, clinical research scientist for ATI Physical Therapy and director of observational clinical research with the Center for Effectiveness Research in Orthopaedics at the University of South Carolina, agreed, saying that the issue is about "getting in front of the patient."

    "A lot of patients don't understand why they're coming to therapy," Thigpen said. "We have a messaging issue."

    Schaecher thinks it's not simply about better marketing to consumers—those within the physical therapy profession need to rein in unwarranted variation in practice and truly commit to value-based care.

    From a payer perspective, Schaecher said, the practice of physical therapy can seem broad and inconsistent, which can lead to a perception that PTs "are not engaged in a value-based approach to care—they're engaged in making money."

    "You need to start seeing therapists that are looking at their services as a value and not a revenue generator," Schaecher added.

    Elton only partially agreed. The variability issue is present in physical therapy, he countered, but is not nearly as bad as it is in some of the medical specialties.

    Thigpen added that the variability issue in physical therapy may have to do with issues other than revenue generation, such as payer variation and patient market factors that can add to variability in treatment.

    Thigpen said he also worries that for some PTs, their commitment to their profession and a belief in the good it can do can morph into a maybe-unconscious willingness to please the patient at all costs. "You feel obligated to give the patient what the patient wants," he said. "In that way, we sometimes don't do a great job in shared decision-making," he said, which leads to unwarranted variation in practice.

    Delitto acknowledged that the current payer landscape for physical therapy was created at least in part in reaction to what he described as the "free-for-all" days of the 1980s and 1990s, when payers were much less restrictive. Returning to a place where physical therapy receives the level of support warranted through evidence will require PTs to better track and report outcomes, but that begs other questions: will the administrative burden be too heavy? Are there simpler approaches to supplying the needed data?

    Elton pointed out that APTA is already attempting to respond to these questions by way of the Physical Therapy Outcomes Registry. According to Elton, profession-driven data collection efforts could make a key difference.

    But, he added, turning the corner toward value-based care that will open payment doors will also require collaborative efforts between payers, PTs, and other professions. "What we need to be asking is, how do payers and groups like APTA come together to get a total view of this?" he said. APTA and Optum are currently pursuing a joint initiative that will be announced in the coming months, he added.

    It could be possible that payers just don't care about data, Delitto said.

    Oh, but they do, countered Schaecher, because data show where the money's going, and payers care very much about that.

    Elton agreed, but framed the issue differently.

    "Cost is really a proxy for clinical outcomes," he said. The problem is that data are often limited to what happens during and at the end of treatment, with no tracking of what happens over time—if, for instance, the physical therapy patient eventually winds up getting other treatments, undergoing surgery, or pursuing imaging at some point down the road. That's what's known as "the tail" of a particular provider's treatment. The lack of sufficient data on physical therapy's tail is the "Achilles' heel" of the profession, Elton said.

    Still, with all the internal and external challenges in place, Elton believes that for physical therapy, the bottom line is the bottom line.

    "The fact is, there's a 10-to-1 [return on investment] with physical therapy," Elton said. "More physical therapy equals less cost."

     

     

    Study: Ignoring Inappropriate Patient Sexual Behavior Doesn’t Work, but Other Strategies Might

    Inappropriate patient sexual behavior (IPSB) is a problem in health care, but researchers have pinpointed some concrete strategies for responding to these incidents, according to a study in PTJ e-published ahead of print. While several of these strategies can be used by the clinician during treatment, authors say less-than-stellar incident reporting outcomes and lack of administrative support “demonstrate a clear opportunity for the profession to improve.”

    The release of this study happens to coincide with action last week by APTA’s House of Delegates to strengthen the association’s position on sexual harassment in all forms, including encouraging incidents of harassment to be reported, with permission of the affected individual, to ensure that others are not similarly harmed.

    Funded by the APTA Section on Women’s Health, the study follows up a 2017 survey of PTs, PTAs, and students that found 84% experienced IPSB—47% in the previous year. In the prior study, authors defined IPSB as a range of behaviors, "from leering and sexual remarks to deliberate touch, indecent exposure, and sexual assault." Physical therapy clinicians were more likely to experience IPSB if they were female, treating mostly male patients, or newer to the profession.

    Researchers surveyed 1,027 members of APTA specialty sections and students in PT and PTA education programs to learn how individuals who experienced IPSB responded to it, and if those responses were effective at mitigating the problem.

    Similar to the previous survey, 38% had experienced IPSB. The participants described a variety of responses, from simply ignoring the patient’s behavior to documenting and reporting it to management. Respondents who are younger (under age 40) and less experienced (students or clinicians with less than 10 years of experience) were more likely to ignore IPSB. The less experienced group also were more likely to respond by joking with patients. Respondents younger than 40 were more likely to ignore IPBS, while students and newer Not surprisingly, ignoring inappropriate sexual behavior—a strategy used by more than 70% of respondents—was not found to be a successful response.

    Respondents also identified strategies that, according to them, significantly improved the situation more than half the time. They include:

    • Distraction
    • Choosing a more public place for treatment or a different treatment method
    • Direct confrontation
    • Establishing a behavioral contract with the patient
    • Transferring care to a different clinician
    • Using a chaperone

    Authors suggest that clinicians be educated on “assertive communication and redirection strategies” but add that the changes shouldn't stop there.

    There is a “need for clear workplace policies coupled with training for managers and supervisors to support clinicians in resolving IPSB,” authors write. They encourage practices to establish policies on using behavioral contracts and warning letters, chaperones, and transfer of care in response to IPSB.

    (Editor's Note: Articles e-published ahead of print are not the final version. The final version of this article will be published in the September issue of PTJ.)

    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.

    NEXT 2018: Maley Lecture: Health Care Must Adopt a Biopsychosocial Model

    The health care system needs to evolve from a medical to a biopsychosocial model, asserted Robert Palisano, PT, ScD, FAPTA, in the 23rd Maley Lecture, delivered during NEXT 2018. "Healthy living is a societal and systems issue. The focus of the traditional medical model of health care is on the individual and acute conditions." The title of his lecture was "Lifecourse Health Development of Individuals With Chronic Health Conditions: Visualizing a Preferred Future."

    Palisano is associate dean for research at the College of Nursing & Health Professions at Drexel University.

    Lifecourse health development, a biopsychosocial model, previously had been applied to children and youth with cerebral palsy. Palisano extended the concept of lifecourse health development to adults with acquired chronic conditions such as spinal cord injury, traumatic brain injury, stroke, multiple sclerosis, Parkinson disease, and arthritis.

    He noted that APTA's Vision Statement for the Physical Therapy Profession—transforming society by optimizing movement to improve the human experience—served as the springboard for his presentation. Palisano defined "lifecourse" as a progression of socially defined events and roles in which a person engages. Health development, he said, occurs through person-to-environment and environment-to-person transactions that change over time. His preferred future, Palisano said, will be characterized by a person's physical, mental, and emotional well-being; participation in desired social roles throughout life; and achievement of personal goals.

    Using 2 case studies—a boy born with cerebral palsy and a woman who contracted polio at 16 months old—Palisano traced their successful transition from childhood to adulthood and identified experiences that contributed to their lifecourse.

    He said that the transition to adulthood for youth with disabilities has been described as "falling off a cliff" due to lack of preparation, limited support, lack of skills needed for adult roles, and disjointed adult services. He noted that a successful transition requires that timing "real-life" experiences and interventions coincide with the person's environment and readiness for change. "Unfortunately, implementation of comprehensive and coordinated health transition services and supports has not been widely achieved, and finding adult health care providers is often difficult," Palisano said.

    He noted that some laws, such as the Americans with Disabilities Act (ADA), can be of assistance. For example, the ADA defines "disabled but able to work" as an individual with a physical or mental impairment who is able to perform essential functions of a job with or without reasonable accommodations. Employers have a legal obligation to make reasonable worksite and workplace accommodations that are not an undue hardship. However, Palisano cited research that, during the hiring process, employers often have little guidance and are unaware of or do not comply with accommodations required by ADA and other laws.

    Further, he said, "Person-workplace transactions often are not timed or adapted to build capacity." Although assistive technologies "offer promise for improving work participation," access to appropriate assistive technologies and qualified providers and teams are "frequently limited."

    Addressing community living, Palisano said that key considerations are availability, accessibility, adaptability, and affordability. "Research indicates that young adults in supported living experience more variety in community activities and do preferred activities more frequently than do young adults living in group homes."

    Palisano summarized his theme: "The value proposition of lifecourse health development is healthy living. Healthy living involves managing, adjusting, and adapting to changes in health capacities and environments."

    To achieve the vision of a preferred future, Palisano said, "A system similar to the pediatric health system is recommended, whereby the health of adults with chronic conditions would be monitored by interprofessional teams, and a care coordinator would be available to coordinate services."

    He also called for physical therapy to occur in real life settings, also referred to as "natural environments. Research suggests that rehabilitation services in clinical settings do not optimize participation outcomes….Generalization of learning requires practice in different contexts, including open environments that are not predictable."

    Palisano concluded, "A preferred future that embodies lifecourse health development is ambitious, but not beyond the reach of a profession whose vision is to transform society and improve the human experience."

     

     

    2018 NEXT: Physical Therapy Can Play a Part in Addiction Treatment

    The power of physical therapy to help prevent people from starting opioid use has been well-documented, but work now being done by physical therapists (PTs) and physical therapist assistants (PTAs) is showing that the profession also has an important role to play in the lives of those recovering from addiction. And that role has everything to do with applying the knowledge and skills PTs and PTAs already possess.

    In their session "Beyond #ChoosePT: Physical Therapy and the Opioid Crisis," delivered at APTA's 2018 NEXT Conference and Exposition, presenters Mark Bishop, PT, PhD;Eric Chaconas, PT, PhD; and Ahmed Rashwan, PT, DPT, made an engaging, sometimes moving, case for why physical therapy shouldn't be thought of simply as a path for avoiding opioid addiction, but as an approach that can also help addicts achieve and maintain sobriety.

    Chaconas, an associate professor at the University of St Augustine, led the discussion framing addiction as a "cunning, baffling, powerful" disease that doesn't discriminate and should not be associated with a certain class of individuals. The addict's world is, in a way, frighteningly similar to the world of the non-addicted, he said, insofar as the addict is driven to act by cravings that are beyond her or his control. "It's no different from the craving you and I have to drink when we're thirsty or eat when we're hungry."

    Efforts, such as APTA's #ChoosePT opioid awareness campaign, are crucial in helping to stop opioid dependence before it begins, Chaconas said, but there's much more work to be done for the millions whose lives have already been devastated by addiction. Once good place for PTs and PTAs to start: by working with addiction treatment programs.

    Bishop focused his portion of the presentation on the clinical "why" of the matter—specifically, why physical therapy is a profession uniquely suited to join the addiction treatment team. As Bishop explained, it's all about the brain and the ways in which addiction resembles many of the same brain processes as those associated with the experience of chronic pain.

    "If you're comfortable working with someone who's in chronic pain you have the skill set to work with someone struggling with addiction," Bishop said. "If you accept that chronic pain is a neurocognitive disorder, then be prepared to accept that addiction is, too."

    Bishop led the audience through a series of slides that not only explained the neural pathways taken by pain and the cravings experienced by an addict, but highlighted the ways in which dopamine response levels to drugs—which can sometimes be 500 times more powerful than the pleasure responses delivered by food or sex—can fuel addiction. The University of Florida professor also explained the chemical changes that take place when an individual experiences ongoing high stress levels, whether because of chronic pain or via the addiction cycle.

    So how is it that physical therapy can make a difference? Bishop said the PT's ability to help reduce stress and pain are key, but perhaps just as important is the PT's own belief in the power of her or his treatments, and the ability to engage in effective motivational interviewing that helps the patient develop an expectation of improvement.

    According to Bishop, studies have shown that patient faith in any treatment accounts for as much as 30% of the overall improvement experienced. In many ways, he said, the overall change patients experience "depends on what the patient thinks when they come in on day one." If the PT treating the patient with chronic pain can recognize and help to recalibrate those attitudes, improvement becomes that much more possible. "The good news is that those intervention strategies are the same for someone recovering from addiction," Bishop added.

    Rashwan was all about the "how" of the issue. As chief operations officer for Advanced Therapy and Wellness, Rashwan oversees a business that places PTs in addiction treatment centers as integral elements in the treatment process.

    Rashwan developed his business model partly after experiencing frustration with what he called the "hamster wheel" of outpatient physical therapy, and partly by accident. As he explained, one day at his clinic, he received a call from a treatment facility looking for PT services for a few of their patients. Rashwan was happy to take on the patients, but wondered how the facility had decided to call him. The facility staff explained that 2 other clinics had denied providing services after learning the patients were in active treatment for substance use disorder. That's all it took for Rashwan to begin thinking about how to make a difference.

    According to Rashwan, PTs in his company begin working with patients as soon as they've been medically stabilized and are placed in a residential or inpatient treatment setting. Treatments are designed to address any pain-related issues the patient might have, and puts a heavy emphasis on strength training. No modalities are used, and gear is limited to portable strength training equipment, foam rollers, and yoga mats. Keeping things simple and small helps the patient understand that she or he can easily continue the exercises at home, Rashwan explained.

    Rashwan echoed Bishop's emphasis on the importance of establishing a strong therapeutic alliance with each patient. Even among the most recalcitrant of patients, hearing a PT say "I want to know who you are, I want to know what makes you tick" can be a significant experience for someone whose addiction has led to estrangement from loved ones and societal rejection, Rashwan said.

    How to answer the question of whether physical therapy works in the addiction setting depends on who's asking, but the short answer in any case is "yes." Rashwan explained that as PTs and PTAs well know, physical therapy reduces pain and stress, and enhances a sense of wel-lbeing. But the program is also a win for the treatment facilities, which have decreased rates of patient actions "against medical advice" by 22%, increased length-of-stay rates by 15%, and seen improvements in relapse rates and in patient involvement in counseling sessions. And, Rashwan added, there's a business angle that shouldn't be ignored: facilities with a physical therapy program can advertise a more "holistic" approach to treatment, which can increase the patient census.

    Rashwan urged the audience to consider the power of physical therapy in addiction treatment.

    "We're helping people recover," Rashwan said. "We're working with the entire person, not just a diagnosis, and we're planting seeds in our patients. If we can save one life, we've done something important."

    2018 NEXT: PTs Offer Guidance on Developing Leadership Abilities

    A panel of 5 physical therapists (PTs) in various stages of their careers offered NEXT 2018 attendees their advice on how to become leaders and succeed professionally. The PTs were Carrie Cunningham, PT; Michael Gans, PT, DPT; Matthew DeBole, PT, DPT; Stephanie Weyrauch, PT, DPT, MSci; and Elizabeth Nixon, PT, DPT.

    Despite their varying levels of experience and their supporting anecdotes, their advice to those in attendance was similar.

    One agreed-upon observation is that leadership success is usually preceded by failures or setbacks. Cunningham, a board-certified clinical specialist in orthopaedic physical therapy who described herself as a mid-career PT, said, "Falling down is a part of life. I've learned from failures. Don't let fear stop you from the things you need to do to be a leader."

    Nixon, who graduated in 2016, admitted. "I had a lot of failures before I succeeded. For example, I interviewed at the University of North Carolina 3 times before I got in. I applied to get scholarships to attend professional meetings. But I kept losing out, so I paid to attend. I kept applying for scholarships, and I eventually got a few. If I'd given up the first time I'd gotten rejected, I wouldn't be standing here today."

    Many panelists cited positive experiences attending APTA programs, particularly as students. Matthew DeBole recalled, "I attended CSM in Chicago along with 3 other classmates. We were overwhelmed and in awe. There was a major program scheduled that everyone else went to. But I went to another session on leadership. I was super-curious and intrigued. By the time I got back home, I wanted all my classmates to attend the next meeting and even formed a Facebook group so we could attend CSM in San Diego the next year. I was motivated to run for a position on the Student Assembly Board of Directors and won. I was welcomed and helped. Others were open and very willing to help."

    Weyrauch said, "I attended NEXT in Charlotte. At a luncheon, I was seated next to some icons of the profession. And they talked to me—and all of us [with respect]."

    Many agreed on another aspect of academics: Getting the best grades isn't necessary to succeed as a PT or as a leader.

    For instance, Gans—now president of the Connecticut Chapter—admitted, "I wasn't the greatest student. My goal on graduation was to pass the Boards. Then I read Anthony DeLitto's McMillan lecture in PTJ. That alone got me to attend NEXT in 2010, where I heard Andrew Guccione's McMillan Lecture. That convinced me I needed to do more." Gans is a board-certified clinical specialist in orthopaedic physical therapy.

    Weyrauch advised the students in the audience: "Academics is important in physical therapist school, but you're going to have the biggest impact by doing some of those extra things you'll have the opportunity to do."

    Weyrauch presented 6 additional pieces of advice:

    • Be fearless and say "yes."
    • Understand your strengths and weaknesses.
    • Be open to and learn how to give feedback.
    • Network, network, network.
    • Develop expertise and competency
    • Be genuinely accountable and a good listener.

    The others on the panel agreed. Regarding feedback, Cunningham said, "Feedback is a great opportunity for growth."

    On networking, DeBole said: Try to connect with the right people and figure out the best way to go. Continue to connect with the people around you."

    The panel also had some advice for more experienced PTs. Gans said, "It only takes 1 person telling you to get involved. All it took was a single person to fuel my fire."

    Cunningham observed, "There are lots of opportunities in APTA. But you're all leaders in your day-to-day activities, in your own settings, and with your patients. Ask yourself: ‘How can I be better in the clinic every day?'"