A severe pneumonia was identified in Wuhan, Hubei Province, China, in December 2019. The World Health Organization subsequently confirmed that the underlying cause was a novel coronavirus (COVID-19) on January 12, 2019, which was declared a pandemic on March 12, 2019. Although the morbidity and mortality rates related to COVID-19 infection have surpassed seasonal influenza, survivorship of COVID infection is a common outcome. The role for physical therapists to ameliorate functional compromise related to COVID-19 crisis is still crystallizing for the acute and post-acute settings. Yet, it is not too early to consider how physical therapists can prepare for and cope with disruptions in our ability to provide care. Epidemics and pandemics are not unanticipated, rather they occur repeatedly throughout history and are expected events that require planning to prevent and reduce the impact.1 Preparing for disruptions now is not only relevant for current and future disease outbreaks, but further disruptions in care related to climate change and other natural disasters should be expected and can further contribute to infectious disease outbreaks.
In recognition that dynamic and complex problems cannot be addressed simply, we propose several strategies for physical therapists to adapt to a post-COVID medical system through clinical processes, research priorities, and policy. These strategies are organized by a social–ecological approach to health. The social–ecological model of health consists of at least 4 nesting levels of influence. The intrapersonal domain comprises individual knowledge, attitudes, beliefs, and values. The interpersonal domain involves the impact of relationships between a given individual and people in their immediate environment, including family members, friends and other peers, and health care practitioners. Major interventions at the intrapersonal and interpersonal domains can involve the efforts of individual clinics and clinical practices. The community domain of the model involves influences from civic structure, design, government, and community norms. The societal domain includes cultural, religious, legal/regulatory, and political institutions' influence on health.2 Major interventions at the community and societal levels involve our collective advocacy for laws and policies. Clinical and health services research can inform strategies targeting these levels of the social–ecological model. This model can be used to organize physical therapists' strategic responses to create beneficial adaptations in health services for the post-COVID world (Fig. 1).
CLINICAL LEVEL STRATEGIES (INTRAPERSONAL AND INTERPERSONAL DOMAINS)
The COVID-19 pandemic has disrupted clinical care for physical therapists around the world. These disruptions have taken the form of rapid transitions to telehealth, reduced caseloads, and clinic closures. Although many of these changes are prudent, temporary, and likely in the best interests for both patients and clinicians, there are negative consequences. Patients who do not get the type or amount of care they need may experience ongoing pain, activity limitations, and participation restrictions due to these interruptions. Providers are experiencing financial challenges, and those still performing in-person patient care may increase the risk of COVID-19 exposure for themselves and their patients. As with so many health conditions, the impact of these disruptions are not experienced similarly across patients, providers, regions, and countries. Existing structural inequities in health and health care result in these negative consequences varying by income, race, education, availability of transportation, and geographic location, among other social determinants of health.3
Social risk factors drive increased mortality in disadvantaged groups directly from chronic noncommunicable diseases (NCDs),3 and the increased NCD prevalence among disadvantaged groups also widens existing health inequalities during infectious disease outbreaks by increasing host susceptibility. With this knowledge, physical therapists and health care organizations can assess patients for social risk factors using publicly available tools4,5 and develop local partnerships and referral sources6 for patients and clients with social risk factors to begin addressing social risk factors at the individual level. In addition, physical therapy (PT) organizations at the local and national levels may begin to develop consensus around strategic plans to address the social risk in their governmental advocacy efforts. These strategic plans could serve to coalesce the values used to advocate for equitable opportunities for physical activity and other healthful behaviors at the societal level.
Physical therapists can contribute to overall health system readiness for infectious disease outbreaks through their work in health promotion to reduce population susceptibility. Chronic NCDs and multimorbidity in wealthy, middle-income, and lower-income countries have generally overtaken infectious disease as a substantial driver of disease burden worldwide.7 Noncommunicable diseases not only contribute to the burden of disease and costs to individuals, populations, and health systems on their own but also to susceptibility and severity of infectious disease.8,9 Indeed, the interaction between NCDs and infectious disease susceptibility has led to the characterization of NCD management by national health systems as a litmus test for health service strength.8 As a result, many of the same mechanisms for service delivery and communication developed to measure and manage NCDs also can be helpful in the events of infectious disease outbreaks. Continuing and adapting health promotion and disease/injury prevention efforts to maintain or expand the reach of these efforts during service disruption are important roles for physical therapists.
Promoting self-management skills is an important part of physical therapist practice and an example of how we can build resiliency and reduce susceptibility in our patients. This moment underscores the importance of helping patients develop self-management skills so they can cope with health care and social disruptions. The burden of musculoskeletal pain and NCDs does not diminish when immediate needs shift to infectious disease, and it is possible the burden of disease may increase as people recover from COVID-19 or as the health care disruptions limit typical care and support systems for people with NCDs.10 Physical therapists must adapt practice patterns to consistently and effectively promote self-management skills in our patients, including behavioral strategies, building self-efficacy, and adopting lifestyle modifications. The Chronic Care Model emphasizes productive provider–patient interactions to promote self-management, but the extent to which formal chronic care models11 or other standardized self-management trainings12 are used in rehabilitation and by physical therapists is unknown. Integrating these programs with physical therapist practice or linking clinics with existing evidence-based programs in the community13 may be an important way to foster improvement in health outcomes despite disruptions in care.
Physical therapists must develop and implement new models of care and change practice patterns to accommodate disruptions while still retaining value (Fig. 1). Expanded direct access by physical therapists can offload the primary health care system to address patients with COVID-19. Practice act restrictions related to required timeframes for follow-up with a physician should permanently be suspended, to best leverage the safe and effective ability of physical therapists to engage in consumer direct access. Developing this capacity in a manner that is conducive to physical distancing also may include advancing knowledge and implementation of telehealth, electronic health, and mobile health models of care.14 At the time of this writing, many physical therapists are making these changes in an ad hoc manner due to the COVID-19 pandemic. To implement best practices with these different models of care in a sustainable way, physical therapists must establish guidelines and standardization, training, and quality assurance with outcomes assessment before the next major disruption. Telehealth and eHealth education and resources currently exist in limited areas, but these will need to be expanded at both entry-level education and postprofessional level.15
In parallel with clinician-focused strategies to develop effective and efficient decentralized care models, health services research must be undertaken to determine whether new practice patterns provide value and are financially sustainable from a payment perspective. New practice models must provide high-quality care and retain or enhance the value provided by traditional in-person care. As such, stronger priority must be placed on clinical and health services research in PT to examine the adoption of new models, barriers and facilitators to implementing new models, diagnostic accuracy, content of care, practice alignment with clinical practice guidelines and evidence, clinical and cost outcomes, and equity of care.16 Outcome registries (such as the PT Outcomes Registry), administrative databases, and clinical trials are strategically important tools for these efforts.
POLICY LEVEL RESPONSES (COMMUNITY AND SOCIETAL DOMAINS)
Further upstream, physical therapists and advocacy organizations can strengthen national health responses by engaging in primordial prevention strategies to minimize future interruptions in PT and other health services for patients (Fig. 1). This may take the form of advocating for changing policies that create barriers to patients' ability to receive care when needed. In some countries, such as the United States, lack of health insurance, inadequate health insurance, or excessive costs being shifted to patients in the form of high deductibles, copayments, or coinsurance is a major barrier to receiving PT care in general17 and during a pandemic. In addition, employer-based health insurance may be lost along with the loss of a job, causing an unexpected barrier to pay for health services. Physical therapists' advocacy for policies that expand health insurance coverage to all residents and include adequate rehabilitation care within this coverage may be an important objective that strengthens the health care system.
The sustainability of efforts to adopt new practice models will also rely on advocacy efforts at the state and national levels to ensure health policy changes that allow access to new models of care provided by physical therapists and for payment parity with traditional methods of care delivery. Rapid changes in health policy surrounding telehealth with the COVID-19 pandemic suggest enduring policy change is both possible and needed. Health services research will also be vital during these changes to inform the outcomes of different policies and implementation strategies. Ongoing research efforts will be needed to examine how future policy changes impact access, timing, equity, affordability, quality, and safety of care.
Even with policy changes, lack of infrastructure and financial distress may disrupt the ability to receive high-speed internet access, and thus access to telehealth. Physical therapists' promotion of policies to ensure equitable access to broadband internet should occur alongside our advocacy for extended telehealth privileges and payment. This is needed to ensure our patients have the infrastructural and financial means to access these alternate models of care.18 For example, our patients will benefit from physical therapists supporting broadband internet as a common good that is necessary for modern health care delivery models, similar to how we expect roads and transportation infrastructure to reach our patients who require home health PT.
The COVID-19 pandemic has created numerous challenges of our patients, our profession, and our society. This viewpoint proposed a multilevel framework for strategic priorities, informed by the social–ecological model of health, to start conversations that can set an agenda to strengthen our health care systems and profession in the face of future disease outbreaks. These conversations may be transferable to other potential sources of health service disruptions, such as those related to climate change. The ongoing situation related to COVID-19 remains complex, dynamic, and difficult. Early reflection on our current experiences can only benefit our patients and our society in both the short-term and the long-run.
1. Brandt AM, Botelho A. Not a perfect storm—Covid-19 and the importance of language. N Engl J Med. 2020;382(16):1493-1495.
2. Golden SD, Earp JA. Social ecological approaches to individuals and their contexts: Twenty years of health education & behavior health promotion interventions. Health Educ Behav. 2012;39(3):364-372.
3. Di Cesare M, Khang YH, Asaria P, et al. Inequalities in non-communicable diseases and effective responses. Lancet 2013;381(9866):585-597.
4. Rethorn ZD, Cook C, Reneker JC. Social determinants of health: If you aren't measuring them, you aren't seeing the big picture. J Orthop Sports Phys Ther. 2019;49(12):872-874.
5. Andermann A. Screening for social determinants of health in clinical care: Moving from the margins to the mainstream. Public Health Rev. 2018;39:19.
6. Andermann A, Collaboration C. Taking action on the social determinants of health in clinical practice: A framework for health professionals. CMAJ. 2016;188(17-18):E474–E483.
7. GBD 2017 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1859-1922.
8. Kostova D, Husain MJ, Sugerman D, et al. Synergies between communicable and noncommunicable disease programs to enhance global health security. Emerg Infect Dis. 2017;23(13):S40-S46.
9. Kostova D, Chaloupka FJ, Frieden TR, et al. Noncommunicable disease risk factors in developing countries: Policy perspectives. Prev Med. 2017;105S:S1–S3.
10. Wilkinson JP, Chipungu E. Between Scylla and charybdis: Delivery in the setting of obstructed labour. BJOG. 2020.
11. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: Translating evidence into action. Health Aff (Millwood). 2001;20(6):64-78.
12. Lorig K, Ritter PL, Plant K. A disease-specific self-help program compared with a generalized chronic disease self-help program for arthritis patients. Arthritis Rheum. 2005;53(6):950-957.
13. United States Centers for Disease Control and Prevention. Self-Management Education: Learn More. Feel Better. 2018. https://www.cdc.gov/learnmorefeelbetter/
. Accessed April 8, 2020.
14. World Health Organization. WHO Guideline: Recommendations on Digital Interventions for Health System Strengthening. Geneva, Switzerland: World Health Organization; 2019.
15. Lee AC, Davenport TE, Randall K. Telehealth physical therapy in musculoskeletal practice. J Orthop Sports Phys Ther. 2018;48(10):736-739.
16. Rundell SD, Goode AP, Friedly JL, Jarvik JG, Sullivan SD, Bresnahan BW. Role of health services research in producing high-value rehabilitation care. Phys Ther. 2015;95(12):1703-1711.
17. Freburger JK, Carey TS, Holmes GM. Physical therapy for chronic low back pain in North Carolina: Overuse, underuse, or misuse? Phys Ther. 2011;91(4):484-495.
18. Perzynski AT, Roach MJ, Shick S, et al. Patient portals and broadband internet inequality. J Am Med Inform Assoc. 2017;24(5):927-932.