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LECTURE

Acute Care Section Lecture: Acute Care - Our Profession’s Foundation and Its Future

Dunleavy, James PT, MS

Journal of Acute Care Physical Therapy: Spring 2011 - Volume 2 - Issue 1 - p 20-29
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INTRODUCTION

Jim Smith, President Acute Care

Section, February 11, 2011

It is now my privilege to introduce the first Acute Care Section Lecture. This lecture was developed to acknowledge and honor a member of the Acute Care Section for excellence and leadership in acute care physical therapy practice and for distinguished contributions to the Section; to provide the recipient with an opportunity to share his or her achievements and ideas with the Section’s members through a lecture presented here, at the Combined Sections Meeting; and to provide a touchstone for the profession in celebrating the role and value of acute care physical therapy.

We are honored today to have Jim Dunleavy present the first Acute Care Section Lecture. Jim Dunleavy has been a physical therapist since 1977 after graduating from the physical therapist certificate program at Columbia University College of Physicians and Surgeons. Jim practiced in numerous acute care facilities as a staff physical therapist before earning his Masters degree in physical therapy form Columbia in 1983.

His first activities in the American Physical Therapy Association were in the Hudson Valley district of the New York Chapter. There he served as treasurer, chairperson, and Director on the chapter’s board of directors. He became Treasurer of the New York Chapter for the first time in 1986, a position held twice more during his career. In addition, he currently serves on the chapter’s Finance Committee.

In 1990 he began, with his colleague Marcia Pearl, on a 2-year journey that resulted in the House of Delegates approving the creation of the Acute Care Section. Jim shepherded the Section as its president for our first 5 years. As described by one of his nominators: “In creating the Acute Care Section, Jim gave a voice to a large percentage of our professional members who understand, quite clearly, that this type of clinical practice requires the highest level of application of both foundational sciences and clinical decision-making skills. The creation of this section, and his early leadership in bringing it along, has given rise to a whole legion of professionals who continue to carry this message forward through written words, actions, and deeds.”

After that, Jim ran for the APTA’s Board of Directors in 1997, and then he was successful and was elected to the Board in 1998. He was re-elected for his second 3 year term in 2001.

After completing his 2 terms on the APTA’s Board, he was asked to return to the NY chapter where he was elected Treasurer for a third time, but after 1 year, Jim was elected President of the NY Chapter in 2006. He considers himself the luckiest chapter president ever, as, after only 2 months in office, the 25 years of hard work of so many Chapter members paid off with the adoption of direct access in New York. In addition, the chapter was able to achieve mandatory continuing education requirements and revamped the legislative agenda to move forward on issues related to high co-payments, workers compensation reform, and other improvements to the practice act.

Jim is currently a member of the APTA’s Committee on Chapters and Sections and he is a member of the Acute Care Section’s Nominating Committee. Jim has completed two years on that committee, which means that effective with his installation at our Business Meeting later this evening, Jim will become the Chair of the Nominating Committee and return to a position on the Acute Care Section’s Board of Directors.

I would like to share with you the words of one of his nominators, who wrote that “As the Section’s first President, and the namesake of the Section’s Distinguished Service Award, he was one of the first physical therapists to stand up and ensure acute care practice was recognized and had a seat at the larger table of physical therapy practice. His tenure on the APTA’s Board of Directors continued to put acute care practice on the radar of both the national association and its leaders. I have no doubt that without Jim’s leadership, at both the Section and APTA level, that acute care practice and the Section would not be where it is today.

I cannot count the number of current active members and leaders in the Acute Care Section who mention Jim’s mentorship and support playing an important role in their personal development.”

I agree with that analysis and emphasize that each of his nominators identified that Jim’s greatest contribution to our profession has been as a mentor. He has been a mentor to me, and I am confident that he has been a mentor to many in this room who are in leadership positions in the Acute Care Section or in the APTA. Jim- on behalf of all of the physical therapists and physical therapist assistants who have benefitted from your wisdom and mentoring- I thank you.

Jim’s extraordinary service to our profession has resulted in numerous awards, including the Acute Care Section’s Distinguished Service Award, which has since been re-named in his honor as “The James Dunleavy Distinguished Service Award”; the New York Chapter’s Outstanding Service to Chapter Award; and the APTA’s Lucy Blair Service Award.

Currently, Jim is the Administrative Director of Rehabilitation Services at Trinitas Regional Medicine Center in Elizabeth, New Jersey and serves as an adjunct professor in a number of physical therapy education programs in the New York area. He is married to his wife of 27 years, Mary, also a physical therapist. They have 2 daughters, Meghan and Tara.

I find it fitting that Jim is the Section’s first lecturer, as he has been the first and leading acute care physical therapist in many ways. I met Jim many years ago at a Combined Sections Meeting, when he convened physical therapists and physical therapist assistants to discuss the idea of an Acute Care Section of the APTA. As we can see, that idea had traction. His influence on our Section remains deep as we prepare to celebrate our 20th anniversary at CSM next year.

It has been my privilege to introduce this celebration of our profession and now I turn this podium over to the honorable Jim Dunleavy for his presentation “Acute Care Physical Therapy: Our Profession’s Foundation and Future.”

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Figure:
Left to right: James Dunleavy & Jim Smith

LECTURE

Good evening everyone, thank you for coming. I want to begin by first thanking the Acute Care Section’s Awards Committee and the Section’s Board of Directors for selecting me to be the inaugural Acute Care lecturer. I have been awarded a number of honors during my career, but to be recognized in this manner by one’s peers is the highest honor an individual can be given. I also want to thank my family, my daughters Meghan and Tara and especially my wife, Mary, who is with me this evening. They have always been a source of strength and support, and always help to keep me grounded.

Last year, when it was announced at Combined Sections Meeting (CSM) that I was to be this year’s lecturer, I said that I hoped the talk would be one that would inspire some, make others think about new perspectives on the issues that face us and that some would disagree or even might be mad at what I was going to say. I have worked hard over the past year to achieve all these goals and now is the time to see if I have achieved those goals.

Last year I also indicated that in part, the focus was going to be on the future, a future that extends past our 2020 vision. I felt this was important because as healthcare has changed acute physical therapy will need to embrace challenges and take actions that, perhaps in the past we didn’t or were slow to respond to, but we will have to anticipate and respond proactively going forward if we are to continue to control our practice and direct our future on our own terms in acute care.

So as I began to undertake the writing this lecture, it was then that I realized just how big the challenge I had. To make it even more daunting, the changes brought on with the passage of healthcare reform over the past year has, in my opinion, upped the ante for the profession and the acute care setting in particular. In acute care, our current role in the healthcare system has been in flux, sometimes without our participation, acceptance or even our knowledge. So we enter these next years with potentially major changes in healthcare while still working our way through the changes that increasing numbers of same day surgeries, pressures related to length of stay, increased numbers of patients per bed per year, the unprecedented budgetary restraints we have and the additional but at times vague new roles we are being asked to fill. This situation is analogous to trying to cross a stream when all the rocks are moving! But as Martin Luther said, it is the challenging times that will truly test our worth.

So… what I will try to do tonight is to highlight what I feel are the key events that brought us to where we are today, how we are handling the current status of acute care practice, and what I see occurring in the coming years.

I believe we are entering one of the most challenging times not only for acute care but for the entire profession. What I also want to stress though here as well is our need in acute care, as well as every setting we practice in, to have our practice be driven by the societal need for services that we supply, and that those services are deemed by society to have value.

So, let’s see where we have been….

Our earliest beginnings were driven by the onslaught of polio in the general population in the late 1800’s, reaching far into the middle of the 20th century and especially in the military after World War I. This was the first war where levels of medical care had risen to the point where soldiers who previously would have died from their wounds were now surviving, but with varied and complex disabilities. Given the nature of these postwar disabilities, along with the level of medical knowledge of polio at the time, both these patient populations were considered in various states of “acute” medical conditions.

While I could spend most of my time here this evening on our profession’s history and how its beginnings were rooted in acute care and rehabilitation, I will leave that to all of you to review for yourself. What is important to note is that our beginnings were driven by helping the disabled and those with the debilitating manifestations of acute injury and disease. In other words, our professional beginning was born out of a societal need, and that what we could offer society for those disabilities were services that were seen to have value to society. Societal need and value. I feel we might have at some point as a profession at times perhaps forgotten that a wee bit and we need to get back to these principles as being central to our decision making and our progression as a profession.

Now during this same period of time it was also one where our relationship with the physician was one of being directed by them, being told exactly what to do, how much of it, and when. Though a few of our founding Reconstructionist/ physio/physical therapists did establish themselves as practitioners in their own right, the profession as it was known at the time was prescriptive, being directed by another profession.

So, we move forward, providing care, and in the 1920’s and 30’s and having the start of the APTA, then known as The American Women’s Physical Therapy Association. From this, the beginnings of our current professional definitions and governance structures began taking shape. Then through federal government activities and initiatives such as the Hill Burton Act in 1946, the healthcare system began to change and expand. This act provided funding for the building of modern hospitals and medical facilities. During this time, physical therapy was found to be an important, needed and valuable part of the medical services provided in healthcare facilities and so the profession expanded along with the healthcare system.

This growth continued for many years. However one part of our society was having difficulty accessing care. That group was those retired and did not have health insurance. In response to this, in 1965, the next major change in the healthcare system occurred with the passage of Medicare, with physical therapy being amended into the law in 1967. This was the first time persons over the age of 65, many of whom were retired and not covered under employer based insurances, had coverage. During this time period, the majority of physical therapy services were still being provided in hospitals and rehabilitation facilities with the majority of the physical therapists that were providing this care being under the direction of a physician prescription.

The healthcare system at this time was giving little thought to its costs, and even less thought to the efficiency in the delivery of acute care services, including physical therapy. In acute care physical therapy, patients were primarily brought to the physical therapist in their departments and their length of stay in the facility was not only a result of their medical status, but also by their functional level and, in some cases, their personal desire to stay in the facility or to go home. Physical therapy here to continued to be driven by physicians’ order and in many instances, an additional physician, and the physiatrist, who was heading up rehabilitation medicine departments, especially in large urban centers.

During these years, up to the mid 1980s, physical therapy was considered very good business indeed for the acute care hospital. With virtually all services being paid for in acute care on a cost plus basis, which meant every time a physical therapist saw a patient in the hospital, the hospital could charge and…. get paid for those services. For our newest colleagues here this evening, that means there were no fee schedules, no DRGs, no per diem rates. Everything that was done was determined as “necessary” by the physician, and was paid for, and paid for at a price set by the facility. Needless to say, things were very good. Patients stayed in their acute care bed for weeks, with post-acute care options being a robust home care service, rehabilitation or nursing home. There were few or no sub-acute options available at the time. Resources were plentiful, profits were being made, and patients were cared for by caregivers that had more time to spend with every patient referred to them. Physical therapy though was still not seen as a key clinical decision-making service, rather it was a reactive, procedure driven, revenue-generating service, under orders from a physician.

While this was occurring in acute care, physical therapy was progressing in the legislative arena. Between 1957, when Nebraska achieved the first direct access legislation and 1984, when the start of the use of DRGs under Medicare, only 6 states had direct access. However, between 1984 and 1990 an additional 18 states achieved some form of direct access, as it became the number one priority for our profession. While this became Job #1 for the profession, in no instance that I am aware of, were state hospital regulations being reviewed or changes being proposed to align practice in acute care and other facility-based practice settings with this profession’s main objective of direct access “for all.” What’s more, direct access was being “valued” by the profession, not society, as the only true “autonomous” practice. Why was acute care not invited to the party?

I believe our profession made a classic mistake. Through a combination of our own internal shift of values, a desire for greater remuneration and professional status, we began moving outside of facility-based practice into other settings and more lucrative reimbursement structures while unconsciously jettisoning the profession’s value placed on the main practice setting for our profession’s practice and clinical training. Without planning we began to walk away from facility-based practice into these other settings. But… we forgot to tell the healthcare system and the patients in facilities around the country. It appears to me that we began to realign our values in a way that were not, for the first time, driven by the needs of all patients in all levels of infirmity. Our professional association had also moved itself in this direction through its policy, position statements, and actions. What we did was take what I would call the electrical current approach to professional growth, namely, proceed on the path of least resistance and highest financial return. Acute care was not part of that value structure. There was one big problem in all this as I see it. The decision to move out of the facility-based environment was not focused on societal values and needs. In my opinion it was self-focused. Always bad for a service profession to do and I believe devastating to the image of a healthcare provider profession in the eyes of those we serve. Now to be clear, the issue here is not the move of the provision of physical therapy services into different settings that afforded greater remuneration. That is a natural growth behavior for any profession, but we moved forward into these settings, and left the facility-based practice environment to dangle out there for itself. The best example I can give is that while our profession was pushing for direct access, no one stopped to see how direct access could be practiced in a facility-based setting. Would that, if valued, change the emphasis for state regulatory/legislative change? Would it have changed proposals for changes in Medicare regulation? If our value structure as a profession included acute care, I think it would have made a difference.

Now I referenced 1984 earlier. It is an important date in acute care practice because it was the start of the implementation of Diagnostic

Related Groups, or DRGs, as they are now known. An event, which many in healthcare see as the beginning of the end of the decision-making dominance of the healthcare system by the providers of care. In fact, the state I currently practice in, New Jersey, was the first to experiment with DRG-type reimbursement in the 1970s and is the system that the national DRG system is based on. For the first time, it was the payer, not the provider, who that had control over payments, actually dictating payment by categories of disease, and changing the role of the provider to one that only had control over the cost of the care delivered. As you can see on this chart (Figure 1), costs were dramatically reduced in response to lower reimbursement. More importantly to physical therapy, it marked the beginning of the end of cost-based reimbursement for our services in acute care. Overnight we went from a tremendous revenue center for the facility to actually being a pure cost center for the services we provided to Medicare patients.

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Figure

Coincidentally, a book named 1984 spoke about pervasive government, surveillance and even mind control. For some, the advent of diagnostic related groups I think had a similar feel. Life as we knew it in healthcare, specifically acute care, was going to change. I am old enough to remember the time well. Many were trying to predict what was going to happen… the closure of hospitals, massive layoffs and general chaos of the delivery of care to acutely ill patients. For a time, confusion and uncertainty did prevail. The acute care system though did make the seismic shift from one where the provision of care was financially incentivized to provide more services to one that required providers to take on more financial risk and to look at cost effectiveness rather than volume. Cutting costs and providing only what the patient needed rather than everything we had to offer was now the driver for every acute care facility.

So what was physical therapy’s response?

Well, in some ways, I think we panicked. Some of our colleagues could not adjust to the new realities of seeing patients for fewer visits before discharge, thinking it was “unethical” to cut back on what was then considered “necessary services”, although little in the literature supported it. It was a time when “quality” was defined by giving more care over a longer period of time. More had to be better! The definition of what the societal need for us was and our value to the healthcare system in acute care had changed -- but changed to what -- we were unsure. I believe that this upheaval led to a higher degree of job dissatisfaction in acute care. It appeared that acute care physical therapist practice was not progressive enough, not professionally satisfying enough, not cutting edge, and now our patients were leaving our care sooner than we had previously determined it to be appropriate to do and… and the care we provided generated no revenue. So some left the acute care setting, in part because they became disenchanted. In addition I feel that an additional impact on acute care was this sense of devalued status within the profession.

Having said that, those of us that did stay took a step back and began to look for opportunities for physical therapy practice to thrive in the acute care setting. In New York City, for example, I saw an opportunity to eliminate the middleman. New York had, and may still have, the largest number of physiatrists of any state in the nation. Having an additional physician arbitrarily having to see a patient before I did seemed to me to be very costly, and frankly disparaging to my skills and the skills of my colleagues. In addition, I questioned the societal need for this arbitrary referral process and whether it provided any value to the care of the patient. So, in the new era of DRGs, I began a study on the time of referral to the time the physiatrist saw the patient and from there, to the time the physical therapist finally saw the patient. The delay was long enough to clearly make a case that this arbitrary referral process did not improve care, while it did increase costs at a time when acute care facilities were looking for any way to cut costs and to move patients faster through the acute care bed. I was able to use the new system of reimbursement to eliminate that required referral so that physical therapists could deal directly with the referring physician, cutting the time from referral to start of PT services by 2 days. This was the first time a physical therapist in any major teaching hospital center in New York City was able to see the patient directly upon a referral from any physician. Interestingly, one of the physiatrists, when told of the change, came over to me and asked, “So what is my role now?” I told her that she and her colleagues had to answer that one for themselves. This is just one example of how those of us in acute care took what was a great challenge to our practice and found an opportunity not only for better patient care but to advance the position of the profession in the healthcare system. From practice expansion in cardiology, pulmonary, intensive care, neurology, and the emergency room -- we didn’t turn our backs on acute care patients and walk away when the “smart money” said we should leave, but the devaluing by some of the acute care setting within the profession continued.

As the pressure to decrease the length of stay increased, the development of new practice settings such as the sub-acute environment and expansion of hospital-based outpatient services continued to fragment the healthcare system and the profession. In acute care we were now having to set goals not only for the time they were under our care, but also prognosticate what level of care was required for the rest of the episode of care. This would have not been so bad if we only had the valid, reliable tools to prognose effectively the ultimate functional status of the patient. These additional demands placed on us for decision making was something that frankly, many of us were not educated to do and in some cases shied away from. This inability for many to move forward into these decision-making roles I feel has hurt us mightily and something I will make suggestions for change for later in my talk. So while all these changes were occurring in acute care practice, we continued to struggle for meaningful recognition within our profession. But that was about to change…

In 1990 at the Annual Conference in Anaheim, Marcia Pearl and I were attending a session on acute care practice being presented by the staff of Cedars Sinai Hospital in Los Angeles. It was an excellent presentation by their staff. But, as we looked around the room we realized that we were surrounded by a couple hundred colleagues. The room was packed. We were amazed at how many people were attending this lecture, at a national conference… on acute care. We saw right there that there was a need for a new source of information, education and networking for the acute care clinician within the association. So, after the lecture, Marcia and I did what everybody does when they feel they have a great new idea but is unsure of what to do about it… we went to sit by the hotel pool and ordered some adult beverages and discussed our ideas some more!

There we talked about a new organization for the acute care clinician. We first thought we should do a special interest group, never thinking we could do a full section. Well, we later found out that there was no such thing as a national special interest group at the time, so as our discussions continued it was clear that what we were moving towards what was to be a commitment to embark on the 2-year journey that resulted in the 1992 House of Delegates in Denver to unanimously vote to approve the then called the Acute Care/Hospital Clinical Practice Section--the word “Hospital” having being inserted into the name upon request of the then Administration Section. During the journey, one of the key events, and frankly I think the funniest, occurred when I had to send out the petitions to all the components to be signed. As the deadline neared for petition submission, I was called to jury duty and was assigned to what turned out to be a 7-day trial. The only way I was going to make the deadline was to get help with the mailing of the petitions. So, thanks to my fellow jurors, during our lunch breaks they helped fold petitions and stuff the envelopes!

So, the section was born from the need for the acute care clinician to have a defined place in our professional association and to feel they were valued by their colleagues. It gave the acute care setting a defined voice and a mechanism to advance their clinical practice. It was home for the acute care clinician.

In addition to being the leadership voice of the acute care clinician, the Section has also served as a source of APTA leadership, with both myself and Mary Sinnott (who was the first actual officer of the section) having been elected to the APTA Board of Directors. I cannot emphasize enough the importance of the Section to continue to enhance its leadership role within the Association. The changes in the healthcare system will demand it. The acute care setting will be in a position to be a major player in forging new interdependent structures in healthcare and rehabilitation--if we take up the opportunity.

I believe we are now at a crossroads in acute care practice. There are pressures for increased efficiencies, need for faster discharges, higher acuity levels of patients, but with fewer colleagues to meet the acute care delivery needs. Estimates of vacancies of acute care physical therapy positions have been as high as 30% in some areas. In New Jersey alone it is almost 21%. As I have mentioned earlier, we have seen growth in other practice settings, certainly an increase in earning potential being part of the equation. My concern is that as a profession we have to a degree taken the position that we just assume that we will always have acute care physical therapy, or worse, if we do not have it… well that’s ok as well. Others are also under the misconception that: “Hey why worry, it’s mandated to have PT in hospitals right?” I am afraid that this is an example of us not shedding our passive approach to being involved in the political processes of our states.

This was brought into focus to me last year when I was president of the NY Chapter. I was asked by a member for the citations, regulations etc. that mandate physical therapy be available to acute care patients. As we reviewed Medicare, state hospital regulations etc. it was clear that there really was no legal/regulatory sources that stated we must exist in the acute care setting. Now, what is more frightening was the reason why this member was asking. Their hospital administration was asking to see if savings could be found by drastically diminishing or eliminating the service altogether. So, at least in New York, those supposed guarantees may not be so ironclad. Now I do not bring this up to strike fear into the acute care physical therapy community. I bring it up to emphasize our need to demonstrate our value with acute care patients and the healthcare provider community and not to rely on tradition or what “always was” as a reason for being. The value we bring has tangible benefits, both for the patients and in measurable financial ways to the healthcare system. There are other factors such as best practice standards for one that would seem to insure our services will be maintained, I believe again that societal need and the value society and the healthcare system holds for our services will be the driver for future paradigms of our practice in the acute care environment. We have to be open to new business relationships in acute care and other facility-based settings. I believe that as the healthcare system changes, so to will our business relationships with facilities at which we are currently in employed relationships.

I want to now turn for a moment and talk a bit about acute care’s current role in clinical education.

With the decreased numbers of therapists, and the time pressures placed on us in acute care, the training of our colleagues has been affected. What we face now is a profession that has more and more of its newest members never having seen an acutely ill person, much less obtaining the foundation to be able to identify and know what to do if they have a patient experiencing an acute medical episode in an outpatient or other setting. How can we talk about wanting to be considered primary care practitioners and at the same time not meet our responsibility to society to produce practitioners that have a well-rounded clinical experience? This must change.

So, I have spoken so far on where we came from and where we are now. I believe that the profession’s position right now absolutely is screaming at us collectively to stop and smell the coffee and look for new ways, new paradigms of care. There is so much we need to do -- so what does the future hold?

We are about to experience some major changes in our healthcare delivery system, with the advent of health care reform that was passed last year. Although it has come under fire recently, with some state courts having ruled parts or all of the law unconstitutional, while other courts have ruled it to be well within the constitution’s tenets, only time will tell what will happen, but one thing is sure, change has already started. Much is being written and questions raised such as “What will the new system look like?”; “Who will get paid?”; and “How will that payment be made?”; “Will this result in fewer facilities?”; “Will there be fewer staff positions?”; “It looks like I will lose my job!”

I am struck by the “déjà vu” moment that these questions bring. They sound very familiar. They sound like the questions being asked in 1984 and the start of the cost-sharing era of DRGs and the commercial insurer’s per diem payment structures. They also sound familiar to those heard again in the late 1990s with the onslaught of managed care and the Balanced Budget Act. But there are some differences this time around. For example, there is an additional question being raised now, one that is being asked by private practitioners and their fear that the proposed new organizations will decrease their access to patients. While change is always nervous and unsettling, I believe they have the potential of proving to be advantageous for acute care physical therapy, the profession, even private practice, if we embrace new definitions of practice environments and are open to new types of business relationships. But whether we have the vision and the courage to be proactive and not wait for the change to happen to us will determine the future for physical therapy in acute care and the potential for expansion of private practice structures into acute care physical therapy.

The health care reform law calls for a change in the structure of how healthcare is paid for and incentivizes greater coordination of services, meeting quality benchmarks, all with an emphasis on primary medical care and prevention. While initially it will still call for fee for service payment, alternatives are being explored. The new structures will try to align the agendas of physicians, hospitals and other providers to coordinate care for a defined population. These organizations, called “accountable care organizations” will take many forms. If they are able to provide care in their system below a predetermined benchmark cost, the difference between that decreased cost and the benchmark will be shared between Medicare/Medicaid and the ACO. These performance benchmarks will be clinically based in the areas of cardiac, pulmonary, diabetes and other more common diseases. It will also look to control the costs of care for the time period 30 days before and 30 days after their acute care episode as well. These ACO models will be able to come online with Medicare as of October 2011 for a 3-year period. While these will be considered demonstration projects, it is clear by the activity of the healthcare provider community that they perceive these structures as the best way to maximize reimbursement, coordinate care thus decreasing costs, and enhancing patient outcomes going forward. Demonstration projects are being set up and others are underway to explore different scenarios for the payment of services to these new entities as well.

As I mentioned, these structural changes will take many different forms. The new law does not dictate the type of structure nor is it expected that the regulations, when completed, will severely box in facilities and providers into the same structure. Some may have the physicians as employees of the facilities especially primary care physicians, while others would create different types of gain sharing between the hospitals and the physicians. A telling statistic--today, in the US, one out of every six physicians is already employed. But with the emphasis on primary care, the number of physicians needed may not meet the demand as recent data suggests that only 1 in 11 medical students are interested in primary care. I know in speaking with our residents it appears that as many who say they want to go into clinical practice also say they do not, and from a discussion I had with a faculty member of a local medical school in my area I was surprised to hear that today’s MD degree is being looked at by some in corporate America as the new MBA, with some with new MD degrees looking to cash-in in the corporate world. But even with these projected structural changes and physician perspectives on their careers, it appears that the extent to which these changes will occur will be based, at least in part, on the local will of the medical community and what they will want to do and how much risk they want to take. I can see a myriad of organizational structures and relationships being created, with all of them being designed to decrease cost while standardizing care and applying best practice principles.

So as all this change and gearing up for this new system begins, the following question needs to be raised--have we in physical therapy looked at what is coming and, as a profession, how this will impact us? As of this writing, our colleagues in private practice have been actively looking at accountable care organizations (ACOs) impact on their access to patients. Right now they have a real issue because physical therapy is not mentioned in the health reform law as a profession that can be a provider active in an ACO model. While this oversight in the law will have little impact on facility-based practitioners as far as employment is concerned, it will have an impact on diminishing new market opportunities for both private practitioners and facility-based practitioners. Now there is an upcoming think tank being sponsored by Emory University and APTA scheduled in March looking at how the profession should move forward. They will be discussing these changes in healthcare structure while applying what was learned at the PASS Conference two years ago. I am registered to attend this, but this is only a one-day event in a think-tank format. We need more dialogue on all levels of the profession along with a central repository of information about what is happening in order for us to make good common sense decisions about our practice. This issue can be a great opportunity for the profession to break down the what I call “label silos” that practice settings have put themselves into and deal with this as a professional issue in all settings, in all components of the association. Acute Care Section membership and the profession as a whole will be looking to the APTA for this type of leadership and assistance. I believe that the Acute Care Section can be an important leader here.

In acute care practice, we are still primarily in employed positions. While the new payment structures probably will not change the terms of payment for physical therapy in acute care, it brings us potential opportunities to explore different financial relationships with facilities, if we choose to take an active role and some risk. I am aware that the APTA is working hard on how to include us as one of the providers that can be part of an ACO and hopefully they will be successful. I want us to consider though, that when we are included, just what the possibilities are.

Let’s ask ourselves the following questions:

  • What if: Exploration of alternative compensation relationships with facilities and physical therapy results in more cost-effective care while increasing the coordination of care across the pre-, intra- and post-acute care hospital segments of a patient’s episode of care?
  • What if delivery models can be developed that can include our private practice colleagues in order to meet the physical therapy needs of the covered lives that the ACOs will be responsible for? A system of delivery that is driven by patient need and cost accountability, not professional control?
  • What if new delivery models for acute care physical therapy are created that credit the profession for meeting various facility and provider pay for performance measures, and in so doing, increase the remuneration to the acute care physical therapy practitioner?

But again we must make this now a part of the dialogue of the section and the profession quickly; otherwise, we might lose a great opportunity for practice expansion, standardization of service across settings and an enhanced position for the profession within the healthcare system. Hey… how about an ACO just for the rehabilitation needs of persons that provides services at all levels of the continuum - acute care, sub-acute and acute rehab, home care and outpatient? This Rehab ACO then contracts or aligns with other ACOs? Imagine the cost savings, and the enhanced clinical outcomes for each patient if this concept can be melded into these new structures.

In order to achieve these opportunities I believe strongly that our profession needs a vibrant, progressive, politically and financially savvy acute care practice setting to meet the profession’s goals. Not only the goals associated with the changing structure of care but the profession’s goals in the areas of education, practice and research related to what we want the physical therapy practitioner to look like in 2020 and beyond.

Nowhere else but in acute care can our profession develop better its role as a valuable leader in an ever interdependent healthcare system. Those of us in acute care must be active participants outside our departments, not behave as technical services and “just staff” waiting to be told what to do. Each one of us, along with our physical therapy colleagues in all other settings, need to be active participants in the clinical direction of our profession in these new models of care. I believe there are other things that acute care leadership can do now to assist our colleagues to explore possible alternatives in care delivery and, equally as important, redefine our role in clinical practice.

I would like now to delineate some of the things I feel we need to do to position ourselves for the future. One that can be very bright for us and that will reach way past 2020, but we have to act now.

I have mentioned previously broad areas of our profession, namely practice, education and research. Let us now look at these areas and see what the possibilities are for each area of acute care, and what I feel needs to be done.

Our role in the acute care environment has changed in terms of emphasis. While we continue to treat and provide direct patient care, we also make decisions on the prognosis of our patients that determines their future through the process of triage. What are these decisions based upon? How do we determine, from a functional standpoint which patient should go to acute or subacute rehab, home care, perhaps straight to outpatient services, or even no rehab services at all? Unfortunately, many of these decisions are based on tradition or based solely on the socioeconomics of the patient. We need to do better here. I call upon the section to develop research questions surrounding these clinical decisions and support the development of research to answer these questions through either funding of this research through the Foundation for Physical Therapy or the development of a research fund within the section for this purpose. The just published new research agenda for the profession has many elements that focus activity in the area of studying our professional decision making. These decisions that we make every day about people’s future need to be based on researched decision-making algorithms, not tradition. Other areas of research, such as in the treatment of specific patient populations including patients in intensive care units and other specialty units needs to be supported and expanded. These are the most costly and resource intensive areas of a hospital. If we can impact the cost of care while assisting in moving patients to a less costly level of care faster, we will provide a needed service to patients while providing tremendous value to the healthcare system.

To do this I would also suggest the Acute Care Section partner with our colleagues in the Research Section and others to undertake these new and valuable research questions for our profession. I think that the American Hospital Association along with state hospital groups would also be very interested in partnering in these research activities that would lower the costs for its member facilities.

Now, as part of this new concept of an acute care clinical research agenda, we need to also look at how we utilize the pain relieving techniques we possess as a profession, but adapt them for use at the bedside. As pain level has become a vital sign, we have many tools that we can use to reduce pain that can decrease the use of more expensive and functionally degrading medications. Many of these, including physical agents, as well as manual therapeutics to name just two, seem to be valued only in the outpatient arena. Why are they not utilized at the bedside? Perhaps tradition? Money? Efficiency? Or, is it the underlying pressure to “move them out” that alters our focus of clinical goals in a way that emphasizes function only? In actuality this function only approach may cost the facility even more money in some instances, as pharmaceuticals have become the key runaway cost for acute care hospitals. We need to show how we can impact that cost.

I would also urge the Section, in the strongest possible way, to take a leadership role in the application of the findings of the Physical Therapy and Society Summit Conference held in January 2009. We must build on the work of that conference, as I believe it has been the most valuable meeting of our colleagues in a very long time. It produced a look at our profession and its future, with input from many outside the profession that will prove invaluable to us.

My dear colleagues, acute care is THE practice setting that has been and will continue to be the profession’s best demonstration of the characteristics of a truly interprofessional practice environment. It is this experience that our profession will need to rely on going forward in the coming years.

Now we are inundated with best practices, guidelines and such in an attempt by others to determine what is best care. My dear colleagues I believe it is time that we focus on the practice of acute care physical therapy. The Section needs to establish the criteria for and a mechanism to recognize best practice, not only for the individual but also for centers as a whole in the acute care environment. I would like to see the use of the fine work done by the Section on the analysis of practice for an individual physical therapist and use that as the basis for criteria for measuring best practice on a facility basis. Criteria can be developed in the areas of intensive care, neurology, orthopedics, cardiopulmonary, pediatrics just to name a few. Exactly how can we expect to compete when we do not have a measurement tool that determines the level of performance that defines a great acute care physical therapy service? I urge the Section to pursue the development of these criteria. Recognition of these “centers of excellence,” as well as the measures that define the best individual practitioner, provides the profession with a measurement that all acute care practices can measure itself against. This can contribute to the decrease in the variability of our practice, and it gives ammunition to the leadership in acute care practices to assist them in not only protecting their practice but expanding it and, to show the public and the health care system that we are serious in our aspirations to best practice principles.

As I mentioned earlier, our new health care system may bring opportunities for us. To help facilitate our capturing of these opportunities, I would ask the Acute Care Section to be the catalyst for intraprofessional and interprofessional discussion through sponsoring multi-section/professional forums that invite chapters and individual members to participate to be able to share and update information on physical therapy care in multiple practice settings as these changes occur. Imagine also a presentation here at CSM where we take one patient, and thru the application of best practice principles take them through the continuum of physical therapy care. These types of educational opportunities are essential if we are to be prepared to meet the changing structures that are coming in the near future. I am convinced that acute care can be an invaluable asset to these new organizations if we can take the lead in educating ourselves and others through using these educational opportunities to better the lives that we serve because we must pursue the concept that the most cost effective care is that care that meets the patient’s reasonable goals, using resources at the intensity needed to reach the patient’s reasonable goals.

Now I want to talk a bit about another aspect of education, and more specifically what I am most concerned about--that is clinical education. The variability of the clinical education experiences that our newest members of our profession receive is unacceptable. I see a pivotal role for the acute care section here as well. We need to set a goal of having the clinical education facility criteria developed by the Clinical Instructor Education Board many years ago, criteria that are currently voluntary become mandatory. Can acute care environments partner with schools and hold themselves to these standards? I see no reason from the acute care side of the equation why we cannot. How can we face society and say we are turning out a uniform product that meets uniform performance criteria when the system we train them in has no consistency in it at all? We owe this to our newest colleagues and society. I hope that acute care leadership will take a lead in moving towards establishing these criteria as a mandatory item for all settings that take students.

Now there is another, and perhaps more controversial aspect of clinical education that I would like to mention. I believe, “That every physical therapy and physical therapist assistant student be required prior to graduation, to have at least one of their clinical experiences in acute care.” How can we think that we can be an entry to the healthcare system when we are training our best and brightest in a way that they cannot possibly meet the needs of society? By not having seen or treated a single medically ill human being we run the risk of being perceived by the rest of the medical community as not having the “creds,” as my daughters say, to be a valued member of the healthcare team? How would they know what their role is or what to do? How do they identify signs and symptoms? While we teach these aspects of our practice very well in the classroom, we fail to give our newest colleagues the clinical experience to apply that knowledge in all instances and, we do not place an emphasis on it. Recently, one of our outpatient staff attended a continuing education course where she took an impromptu survey of the attendees. She asked whether those in the outpatient setting took blood pressures / pulses on their patients. Our staff member was the only one who raised their hand. If we are truly to be an interdependent and valuable practitioner within these new health care structures, we must have the experience of treatment and decision making that only acute care practice can provide.

Now there is something else that I believe will be required in order to meet this clinical education goal. I believe that there needs to be as part of a re-dedication of the acute care practice setting to high quality clinical education that we should abandon of the old “one clinical instructor per physical therapy student” model of clinical education. It is inefficient, costly and does not ensure a better educational experience. I would also ask my colleagues to look at their tables of organization and explore paid clinical experiences with their local DPT programs. In these changing financial times, we cannot expect the government to begin to subsidize clinical education for physical therapy. We have to figure out ways to do it ourselves. Acute care can be, and should be, the center of the clinical educational experience for our profession. This will also help students to offset their just ridiculously high debt load for their physical therapy training by paying these students a reasonable percentage of what a full time “attending” physical therapist would be paid. Acute care needs to do whatever it can to lower the debt load of our newest colleagues.

Another area of topical concern is the APTA’s Governance Review currently underway. I believe it holds opportunities for the Acute Care Section and sections as a whole. In the recently released recommendations I was pleased to see a number of things that paralleled suggestions I had made during the governance review process. The Acute Care Section was founded on the overarching principle that… well… nothing is sacred! For example, the Acute Care Section was the first, much to the chagrin of some of the more “experienced” section program chairs, to dare to hold platform presentations at CSM and to present research posters in a way that are more educationally rewarding for our colleagues. We also were the first to try to have shared special interest groups with other sections. We didn’t know and to a degree, didn’t care, that we shouldn’t do this. We did it because the needs of our members required it. By some views, the thought of “shared special interest groups” in actuality buttresses the argument that perhaps the labeling of our sections needs to be more aligned with our practice. Everyone seemed then and now to an extent to be stuck with practice labels and process labels that serve more as barriers to learning rather than clarifying areas of practice. We saw early on in our sections’ activities the issues that all these labels within our professional association brought with them. They were more and more placing information, critical clinical information, into exclusive “silos” that members had to pay to get into. These “silos” of educational content, seemed to us to be counter to what the membership needed to move forward. The Acute Care Section is based on this premise of no siloed information and I urge the section to review the recommendations in the governance review as they pertain to the sections. As a newly appointed member of the governance task force on sections whose task it will be to further refine the recommendations for section governance, I urge you to give me your perspectives on the recommendations and to ask the section to support those recommendations that enable more members to gain more information on practice issues and clinical education while not being restrained by the barriers caused by labels and additional dues payments. To meet the goals of 2020 and beyond the practitioner of today and tomorrow needs the educational content from all the sections. If we can achieve this, it will align the structure of the association with how we practice.

With the potential of new health care delivery structures, the profession has to be as flexible as possible to respond to these changes. We need to “go back to the future” and do whatever we need to do to establish direct access in the acute care setting. With the July 2010 clarification by Medicare allowing the state laws and regulations to define whether we can order/access patients without a referral in the acute care setting we now need as a section to send the message to our colleagues in APTA’s national and chapter leadership that this is a major goal for the section and the profession. Currently only 2 states, Florida and Iowa, have specific language in their practice acts that act as barriers to direct access in acute care. The other states need from our professional association/section more directed “how to” messages to navigate the change to having acute care be a direct access environment. The Acute Care Section, I believe, can be a critical component in this by assisting states, through serving as a clearing house for state hospital/facility regulations as they pertain to physical therapy practice and promote demonstration project activities in the states to show the safety and cost effectiveness of direct access in the hospital setting. The section can also serve as a place for discussions and forums on direct access and practice privileges in acute care and what are all the possible barriers to achieving these goals.

So while we have come a long way, we have much to do.

Tonight I have spoken about our history. How the profession was born from the needs and values of society and how acute care practice grew based on meeting those needs and doing so with valued services. While the systems and structures may change, it will be required of us as a profession to supply services to society based on societal needs and values, not our needs and values. It is also required of us to supply services in all settings that are meeting the needs and values of the healthcare system as well. I am confident that through the section and the active participation of its members, acute care physical therapy will be an important leader in how physical therapy deals with the system changes that lie ahead for us. Through research, innovation of practice delivery and seizing opportunities in new business relationships within acute care, and an enhanced commitment to the education of both of ourselves and our newest colleagues, I am confident that the acute care setting will grow and continue to be a vital practice setting for physical therapy. To quote Vince Lombardi:

“The difference between a successful person and others is not a lack of strength, not a lack of knowledge, but rather a lack in will.”

We have to embrace the changes that are coming, in the context of what society needs and values from physical therapy, and exhibit the courage and will to change. In so doing, acute care practitioners and the profession will be influential leaders in healthcare well past 2020.

My dear colleagues it has been my great personal honor to present the inaugural acute care lectureship lecture. Thank you again for this most remarkable recognition you have given me this evening.

February 11, 2011

© 2011 by Lippincott Williams & Wilkins, Inc.