"Now faith is the substance of things hoped for, the evidence of things not seen."
Hebrews 11:1
My first job in 1992 had me working with Mike, a physical therapist who would pray with his patients.
At the time I had no religion training and I didn't know quite what to make of Mike's non-traditional efforts to care for his patients.
Mike didn't pray with every patient, just those that seemed receptive and who needed that extra bit of inspiration to keep going and get better.
In 1992 neither Mike nor I had much knowledge of Medicare payment policy and so he would bill the patient for his time spent in prayer.
Today, of course, I realize that since prayer doesn't meet the criteria for physical therapy skilled services it shouldn't be paid for by Medicare or any third-party payer.
I tell this story because in 2006, Medicare spent $3.06 billion dollars on outpatient physical therapy services with no evidence that the services were any more skilled than Mike's prayer.
Now, maybe we all need a bit more prayer. I certainly pray more now than I did in 1992.
But, when we are talking about evidence of skilled decisions, we need to provide evidence that physical therapists' decisions matter.
Otherwise, we are no better (and no worse) than...
- massage therapists
- athletic trainers
- personal trainers
- 'kinesiotherapists'
Current efforts to improve physical therapists' decision-making tools come from several sources...
- The Physician Quality Reporting Initiative (PQRI) - a much lambasted project begun in July 2007 to measure performance among healthcare providers. The project is cuurently establishing a baseline of over 100 variables that will gauge the health and function of Americans on such measures as falls risk, medication usage, pain, incidence of diabetic foot, body mass index and more.
- Developing Outpatient Therapy Payment Alternatives (DOTPA) - kicked off in September 2007 with data collection set to begin in May 2009 this project aims to reduce the impact on setting (eg: home health, outpatient clinic, hospital) as a driver of payment.
- OPTIMAL scale is one of the current professional consensus, Medicare-recommended outcomes tools for outpatient physical therapy. OPTIMAL is a broad outcomes measure that will enable the aformentioned 'apples-to-apples' comparisons.
OPTIMAL is meant to be paired with a condition/disease specific measure such as the Lower Extremity Functional Scale, the Neck or Back Disability Index, etc.
Yes, that means you may need to administer two seperate outcome scales to each patient.
Other professional consensus, Medicare-recommended outcome tools are the Activity Measure for Post Acute Care (AM-PAC) and the Focus on Therapeutic Outcomes (FOTO) - The American Physical Therapy Association (APTA) provides continuing education on Medical Necessity and Medicare payment policy on a regular and convenient schedule.
An encyclopedic resource on documenting skilled physical therapy services is the APTA's Defensible Documentation for Patient/Client Management - The Diagnosis Dialogs that are attempting to find descriptors (or labels) for physical therapists to describe the results of our clinical examination and evaluation. The descriptors/lables would be...
"standardized anatomical, physiological or functional terms that concisely describe the condition or syndrome of the human movement system."
- Edward's decison-making model shows how physical therapists decisions (and diagnoses) are different, complementary and equally important with physicans' diagnoses.
- Bulletproof Physical Therapy Notes and Charts is my own effort to improve written decision-making through what I call competency-based compliance, that is, the intersection of evidence-based practice with Medicare payment policy.
I've been working on Bulletproof for about two years and I have a book due out Summer 2009.
The DOTPA project plans to develop two pen-and-paper outcome measures based on ambulatory status (walking and non-walking). The universal use of these outcomes measures will enable an 'apples-to-apples' comparison of patient outcomes across various settings.
I haven't seen Mike in 10 years and I don't normally pray with my patients. I'm glad, however, that he showed me his example of patient care.
He showed me that his care, by his prayer, could be distinguished from his skill.
Hopefully, all physical therapists have stories of our care that may not show up on paper. There may be no evidence.
"Faith proves to the mind, the reality of things that cannot be seen by the bodily eye."
But now, we have new tools that can show our skill. We can justify the next $3 billion dollars spent on outpatient physical therapy. We can have evidence of the things we see in physical therapy.
What are your stories?
