Physical therapists (PTs) "are in the perfect position to be involved in primary care," according to John Heick, PT, DPT, PhD, but to make the most of the opportunity, PTs need to understand the current primary care landscape and its potential for the future.
That was the aim of "Primary Care Roles of Physical Therapists: A Perspective" presented on June 23 at the APTA NEXT Conference in Boston. Heick was joined by 6 other presenters—Steven Ambler, PT, DPT, MPH; Hadiya Green PT, DPT; Andwele Jolly, PT, DPT, MBA, MHA; Marie Johnson, PT, PhD; Ivan Matsui, PT; and Brian Young, PT, DSc—for a multifaceted look at primary care and the PT. The presenters were part of the team involved in creating a new APTA perspective paper on the topic. The session, with its attention to the here-and-now practicalities of the issue, provided important context for a later Rothstein Roundtable discussion focused on the future of PTs in primary care.
Green began by providing background for the subject, pointing out that the idea that PTs could play a part in primary care is "not a new concept," but one that has received increased attention from APTA and its House of Delegates. In response, the association has begun to investigate and identify not just the roles of PTs in primary care teams, but which PT services may qualify as part of primary care delivery systems and the opportunities for integrating these ideas into practice, education, and research.
Heick continued the context by describing primary care's history, which began with the need to treat the wounded overseas during World War I, and took formal shape when the US embraced the primary care model in the 1960s. The PT's role in primary care came later, when states began to create direct access provisions. According to Heick, the potential connection to primary care followed naturally, if for no other reason than that musculoskeletal conditions are the second most common reason for visits to the emergency department (ED) and account for 25%-28% of ED visits overall.
PT education's part in primary care was covered by Johnson, who described how the curriculum evolved during the expansion of outpatient physical therapy in the 1970s and 1980s. That growth led to more focus on physical therapy as a doctoring profession, including the move toward the DPT and in the inclusion of not-always-explicit primary care concepts in educational guidance such as the Commission on Accreditation in Physical Therapy Education's evaluative criteria. There is more work to be done to increase primary care content, Johnson pointed out, including introducing opportunities for PT residencies in primary care.
In some ways, the US military may provide insight into the future of primary care education in PT programs, explained Young, a Lieutenant Colonel in the US Air Force. Young presented an outline of the Army-Baylor DPT curriculum plan, which incorporates a significant amount of direct access concepts into its program. The result: PTs well-acquainted with an expanded role in primary care, with outcomes data finding no adverse effects among 472,000 direct access PT visits—which included PTs ordering imaging and prescribing medications.
But gains aren't just being made in the military, explained Matsui, who serves on the faculty for Kaiser Permanente's Northern California Graduate Education program. Kaiser has been including PTs as primary care providers among its 21 hospitals across Northern California since the mid-1990s, when PTs were embedded in Kaiser-run clinics. Since that time, the program has shifted away from the embedding concept and toward a more consultative role for PTs, Matsui explained, where the PTs are asked to provide insight on the appropriateness of specialty referrals, special tests or imaging, injections, and work modification.
Jolly focused on payment issues, noting that while the current Affordable Care Act (ACA) does not include PTs in the list of primary care providers, the value-based care programs arising from the ACA could change that. Expanded direct access to PTs would lead to lower utilization, fewer invasive interventions, shorter wait times, greater efficiencies, better patient education, and more appropriate diagnostic strategies—all of which would contribute to the "triple aim" of health care reform to lower costs, better the patient experience, and improve the health of populations, Jolly said. But, he added, there are a host of barriers to be addressed, including reimbursement issues, certification requirements, agreement on a diagnostic classification system, and malpractice and liability considerations.
Ambler wrapped up the session by reminding the audience that the barriers are worth overcoming, because PT involvement in primary care represents a true benefit to society. He explained that expanded PT direct access in primary care settings would lead to greater coverage of underserved areas, a more diverse workforce, and an enrichment of the primary care body of knowledge, thanks to the unique perspective the PT brings to the table.
APTA members can go online to read “A Perspective—Exploring the Roles of Physical Therapists on Primary Care Teams,” the association’s new perspective paper on primary care. (Log in to apta.org and look under Hot Topics Related to PT Scope of Practice on the Scope of Practice webpage.)