How to Build a Better Physical Therapy Referral-Management Process.
To see or not to see. Physical Therapy referrals, creating the right referral process.
It seems everyone wants a physical therapy consult prior to the discharge of a patient. With diminishing resources, declining reimbursement and industry push to decrease length of stay in our acute sites, our physical therapy departments is under an increasing amount of pressure to align our department strategies with the broader acute strategy. We have seen an uptick in more and more patients, many of whom may not be an appropriate referral in the through sense. Therapists spend an over-abundant amount of time doing evaluations on patients who don’t qualify for therapy intervention.
More referrals increase volume, but lowers productivity, and prevents therapists from working with patients who truly will benefit from therapy?How do we cultivate a culture that focuses on the right interventions for the right situations? How do we build a therapy driven protocol. Have other organizations built successful protocols? Finally, how do organizations move the cultural needle to a place where these protocols are utilized?
We have been quite successful in developing protocols and embedded order sets into our electronic health record that drive the appropriate utilization of physical therapy resources in the acute care setting. This effort has been a combined project that has included physical therapy, discharge planning/case management, physicians (primarily hospitalists), and nursing. We found through a structured Lean Six Sigma project that 38% of PT referrals in the acute care setting were for non-skilled therapy and/or did not contribute meaningfully to the discharge plan. Education was done to physicians and nursing staff using case-based scenarios to help identify appropriate referrals. Care standardization protocols were developed and embedded in the EHR for populations requiring skilled PT (joint replacement, spine, stroke, etc.). These protocols/pathways were monitored for compliance and providers given feedback regarding variance to the protocol. Education was also provided regarding long-standing practices based in urban legend (e.g., “if I don’t get a PT eval and the patient falls at home after discharge I could be sued – the PT eval will prevent that”) It has been a heavy life with more work to do, but we have definitely seen progress in the right direction.
Last winter our PT also experienced increased referrals from our acute medical teams for a just in case check prior to a decision being made regarding the patients discharge. The just in case check added no value in many cases to the patients care plan or outcome. This increase in referrals appeared to be two fold a) there had been a spike in inpatient falls on medical wards b) the acute medical model meant that more than 60% of patients were being discharged within 72 hours. The medical team became increasing concerned that early discharge would also lead to increased falls at home and re-admissions. The PT team were unable to cope with the increased demand resulting in many medically well patients experiencing an increased LOS waiting for a mobility assessment and others experiencing an increased LOS due to limited access to value add interventions such as chest physiotherapy. Data on readmission rates and LOS was effective in managing the perception and concerns of the medical teams but like Sharon the most successful strategy was the implementation of standardised care protocols and a decision by the MDT at the daily journey board meeting if a request was made to deviate from the standardised protocol. The transparency of the MDT discussion was a powerful tool for team education around appropriate referrals to PT but also served as an informal, real time forum for peer review of patient management approaches across the team.