An interesting new study caught my attention recently. In “Effects of Hospital-Based Physical Therapy on Hospital Discharge Outcomes Among Hospitalized Older Adults With Community-Acquired Pneumonia and Declining Physical Function,” Kim and colleagues1 described how inpatient physical therapy did not seem to change physical function as measured by the Katz ADL Index at hospital discharge, yet did seem to have the effect of lowering 30-day readmission rates in older persons with pneumonia. Through what they posit are “delayed and spillover effects”1,p177 of inpatient physical therapy, their study population showed persistent benefits from their hospital-based physical therapy, even after being discharged home. The researcher in me immediately started wondering how to measure these effects, how to capture the “magic” of the physical therapy these patients received. In the study, only direct time spent with patients in physical therapy was captured, not what interventions were performed. Beyond the basic questions about interventions and their intensity, I was curious about other, more intangible possibilities. Was it the patient education on the need for mobility? Was it the self-efficacy patients gained by increasing their activity and performing functional tasks/training in the hospital? Was it more coordinated discharge plans? Was it effective use of the interprofessional team? My mind started designing methodologies for future studies that might capture these effects.
This got me thinking about the value provided through the early provision of physical therapy. There has been a long-standing disconnect between how hospital administration views our services, namely a cost center, versus how many practicing clinicians see their work, as providing value to the overall health care of their patients. I, as I am sure many of you, have gnashed my teeth and pulled my hair when discussions of productivity arise. It is a difficult discussion on the best of days. The ever-present fallacy of “productive time” is equated to “billable time” (which in and of itself is somewhat ridiculous in the arena of diagnostic-related groups and bundled payments), an equation that misses much of what acute care physical therapists do for their patients. Multiple studies describing what and how of acute care physical therapists' work clearly show how communication, including documentation and interprofessional communication during rounds, decision making and clinical reasoning, and discharge planning play a large role in effectively managing acute care patients.2–5 Yet, these important aspects are not captured in our direct patient care minutes, which is frequently the only measure of our productivity. How can we convince administration that they should not be worried we are spending inordinate amounts of time twiddling our fingers or lounging about eating bon-bons when we are not in a patient's room delivering hands-on interventions, but rather that we are working in interprofessional teams, dissecting and sharing information, and making key decisions that add value to the patient's overall health?
After laughing off the mental image of acute care therapists lounging about in a posh staff room, wasting time and waiting for referrals so the hands-on physical therapy interventions can start, I recalled the real question. How much of our supposed “nonproductive time” is actually, truly productive? Or as the Acute Care Section's Task Force on Productivity/Value is currently asking, how much of that “nonbillable” or “nonproductive” time is adding value?6 This paradigm shift, from viewing our services as a cost center where we need to account only for the minutes spent in direct patient care to a value-added model where multiple factors of our entire patient–therapist interaction can be captured over a variety of metrics aimed at showing the value we add to the patient's overall health care, is key. As this important Task Force moves their work forward over the next 6 to 12 months, I am interested to see how it might intersect with the Kim et al1 findings. What currently uncaptured, undescribed, and undefined “magic” in acute care physical therapy adds value? How can we better describe these factors? How can we further share with payers, administrators, and patients that our value may include more than direct patient care and very well can lead to “delayed and spillover effects”1, p 177 that continue to benefit our patients, even after they are discharged from the hospital? I encourage you to watch for updates from the Acute Care Section's Task Force on Productivity/Value, as their work is at the forefront of this area of practice management. I know I will be keeping an eye out and my mind open to new possibilities.
Sharon L. Gorman, PT, DPTSc, GCS, FNAP
President, Acute Care Section
1. Kim SJ, Lee JH, Han B, et al. Effects of hospital-based physical therapy on hospital discharge outcomes among hospitalized older adults with community-acquired pneumonia an declining physical function. Aging Diseases. 2015;6(3):174–179.
2. Masley PM, Havrilko C-L, Mahnensmith MR, Aubert M, Jette DU. Physical therapist practice in the acute care setting: a qualitative study. Phys Ther. 2011;91(6):906–919.
3. Gorman SL, Wruble-Hakim E, Johnson W, et al. Nationwide acute care physical therapist practice analysis identifies knowledge, skills, and behaviors that reflect acute care practice. Phys Ther. 2010;90(10):1453–1467.
4. Smith M, Higgs J, Ellis E. Physiotherapy decision making in acute cardiorespiratory care is influenced by factors related to the physiotherapist and the nature and context of the decision: a qualitative study. Aus J Physiother. 2007;53(4):261–267.
5. Jette DU, Grover L, Keck CP. A qualitative study of clinical decision making in recommending discharge placement from the acute care setting. Phys Ther. 2003;83(3):224–236.
6. Task Force on Productivity/Value, Acute Care Section-APTA. Position Statement on Value vs. Productivity Measurement in Acute Care Physical Therapy. AcutePT website. http://c.ymcdn.com/sites/acutept.site-ym.com/resource/resmgr/files/2014-11_productivity_value_b.pdf
Published 2014. Accessed June 11, 2015.