Abstract
Background and Purpose Despite legislative approval of direct access to physical therapy, other regulatory barriers and internal institutional policies often must be overcome before this practice model can be fully adopted. Few institutional initiatives have been published describing strategies designed to change policies restricting direct patient access. This case report describes steps and strategies associated with successful implementation of a direct access physical therapy model at a large academic medical center.
Case Description The process of obtaining institutional medical board and hospital authority board approval and implementing a pilot program is described. Program details, including therapist qualifications and scope of practice, the required internal training program, and program outcome assessment, are provided. The therapist scope of practice includes the ability to refer patients directly to a radiologist for plain film radiography. Early pilot program findings, including challenges faced and subsequent actions, are described.
Outcomes Reviewed patient care decisions by therapists participating in the pilot program were deemed appropriate 100% of the time by physician chart reviewers. Approximately 10% of the patients seen were referred to a radiologist for plain film imaging, and 4% and 16% of the patients were referred to physicians for pain medications or medical consultation, respectively. The pilot program's success led to institutional adoption of the direct access model in all physical therapy outpatient clinics.
Discussion Autonomy is described, in part, as self-determined professional judgment and action. This case report describes such an effort at a large academic medical center. The interdependent, collaborative relationship among physical therapists, physicians, and hospital administrators has resulted in the implementation of a patient-centered practice model based on the premise of patient choice.
Direct access, defined as “the legal right to seek and receive the examination, evaluation and intervention of the physical therapist without the requirement of a physician referral,” is core to the American Physical Therapy Association's (APTA) 2020 Vision Statement:
By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, functional limitations, and disabilities related to movement, function, and health.1
The state law first enacted allowing physical therapists such practice privileges was passed in Nebraska in 1957, and subsequent legislative activity has resulted in 48 states and the District of Columbia permitting patients to be examined by physical therapists without referral. Of these states, 44 allow provision of treatment in addition to evaluation. Advocating for more timely access to physical therapy services has been the primary impetus for such legislative action.2
In view of rapidly escalating health care costs, direct access to physical therapy may be a valuable health care strategy and resource, especially considering that most current direct access programs emphasize care for musculoskeletal conditions that are common and costly to manage. In 2004, the estimated cost for treatment of patients with musculoskeletal conditions was $510 billion (of which expenditures related to physical therapy care constituted approximately 3%–5%), the equivalent of 4.6% of the gross domestic product.3 Reduced employment rates and lost work contributed an additional $339 billion of indirect costs for musculoskeletal conditions. Researchers recently reported that from 1997 to 2005 the inflation-adjusted annual medical costs for spinal problems increased from $4,695 to $6,096 per person.4 In comparison, the mean annual physical therapy expenditures for spinal problems increased minimally, from $115 to $129, over this same time span. Radiographs, magnetic resonance imaging (MRI) scans, and medications constituted the largest proportions of total cost associated with outpatient visits. The greatest relative increase observed was for medications, increasing approximately 423% from 1997 to 2005.4 Other authors noted increases related to medical imaging and diagnostic tests,5 spinal injections,6 and increasing use of spinal fusion surgery and instrumentation.7,8 Articles dating back to the early 1970s have described outcomes, including cost of care, related to provision of physical therapy direct access care.9–11
Mitchell and de Lissovoy10 compared resource utilization and cost for physician-referral versus direct access episodes for patients with acute musculoskeletal disorders. The physician referral episodes were marked by greater rates of physical therapy claims (67%) and office visits (60%), and total claims of $2,236 per episode versus $1,004 for the direct access episodes.10 Similarly, after initiation of a direct access model for patients with low back pain, the Virginia Mason Medical Center noted decreased costs per episode of care, in part from reduced ordering of MRI scans (from 15.4% of patients to 10% within 1 year).11 With the new program, only 6% of patients lost time from work, and mean wait times for appointments dropped to 1 day.11 Similarly, Overman et al12 reported that fewer patients seen initially by physical therapists were prescribed muscle relaxants and narcotic analgesics compared with those seen first by internists (24% versus 44%, respectively). The patients seen by physical therapists reported fewer back pain episode recurrences.12 Additionally, other studies have demonstrated that physical therapists provide cost-effective, high-quality care to people with common musculoskeletal conditions.13–15 Physical therapy direct access models possess enormous potential for reducing health care costs as an alternative to high-tech medical testing and invasive interventions and for reducing the emphasis on medication therapies.
Despite the growing body of literature describing virtues of the direct access model, challenges and obstacles remain for establishing this practice paradigm—even in some states with laws permitting such practice. For example, in Wisconsin, a direct access law initially was passed in 1997 and then most recently revised in 2002. Yet, provision of hospital-based outpatient physical therapy services still required a physician referral. Wisconsin hospitals must meet strict Wisconsin Administrative Code guidelines, which supersede the physical therapy practice act language. Not only is the updated practice act language not reflected in the current Wisconsin Administrative Code, but the code reflects Centers for Medicare and Medicaid Services guidelines related to the provision of physical therapy services.16 We are uncertain whether all states have similar language affecting physical therapist practice, but correspondence with APTA Governmental Affairs staff provided the opinion that many states do.
The Wisconsin Physical Therapy Association (WPTA) sought the opinion of the Wisconsin Department of Health and Family Services regarding the Wisconsin Administrative Code language. The Department of Health and Family Services responded that hospitals could implement a policy, authorized by their medical staff, designating physical therapists as “allied health personnel” who could order outpatient physical therapy for patients who were not receiving Medicare or Medicaid. This opinion was consistent with HFS 124.21(4) Rehabilitation Services Order: “Physical therapy, occupational therapy, speech therapy and audiology services shall be given in accordance with orders of a physician, a podiatrist or any allied health staff member who is authorized by the medical staff to order the service.”16
Regardless of practice act and regulatory language, establishing direct access models in large hospital systems carries some unique administrative and procedural challenges. This case report describes the process leading to medical staff and hospital administration authorization of physical therapists assuming a direct access practitioner role at a large hospital—the University of Wisconsin Hospital and Clinics Authority (UWHCA), Madison, Wisconsin. In addition, the implementation of the pilot program is described. The importance of strong collaborative efforts among physical therapists, hospital administrators, and physicians is highlighted throughout the case report.
Case Description
The Institutional Initiative
The Wisconsin Department of Health and Family Services' opinion provided the mechanism to pursue adoption of the consumer direct access to physical therapist practice model. The facility's large administrative organizational structure required program approval at multiple levels, and the large number and geographical diversity of department clinical sites required a coordinated effort of multiple program staff members. The UWHCA's strategic planning model includes the University of Wisconsin (UW) School of Medicine and Public Health Executive Leadership, the UW Medical Foundation Board of Directors, the University of Wisconsin Hospital (UWHC) and Clinics Authority Board, and the UWHCA Executive Leadership Team. The Department of Orthopedics and Rehabilitation has a service line director and management team with oversight of orthopedics and rehabilitation inpatient and outpatient services. Ten outpatient therapy clinics, including general outpatient and specialty clinics such as spine physical therapy, sports rehabilitation and performance, geriatric falls, neurorehabilitation, pediatrics, and upper extremity and hand, operate in the hospital and in 4 off-site locations. The department employs more than 50 outpatient physical therapists.
Initial Step: Staff Consensus
The pursuit of “allied health” staff status at UWHCA started during a physical therapy staff meeting. Discussion occurred regarding delays and challenges associated with accessing physical therapy services. For example, a patient wanting a one-visit update to a home exercise program was required to see a physician for a referral. Therapists agreed that patient examples such as this should be brought to department administrators for discussion of current policy. Coincidently, administration had recently identified improved patient access as a major initiative in the upcoming year's department service line business plan after receiving decreased patient satisfaction reports because of access issues. The administrators agreed that it was an opportune time to pursue direct access approval. Figure 1 provides the sequence of activities leading to approval.
Order of approval and implementation activities.
Direct Access Initiative Proposal
We developed the action plan knowing that approval was needed from the chair of the Department of Orthopedics and Rehabilitation, the hospital's fiscal, legal, and risk management departments, the hospital's Medical Board, and finally the Hospital Authority Board. Multiple sources, including APTA, WPTA's Autonomous Practice Task Force, and published literature, provided supporting information. Relevant literature included studies describing results associated with direct access service models9–12,17 and publications describing long-standing models, including the military and Kaiser Permanente in northern California.18 The APTA's Data, Evidence, and Research Supporting Direct Access to Physical Therapist Services2 contains multiple papers describing a historical overview of direct access history, patient safety, cost-effectiveness, and quality-of-life outcomes associated with direct access models. The WPTA task force provided resources developed by Amery Regional Medical Center, the first Wisconsin facility to grant physical therapists “allied health” status. Considering most physicians and the administrators outside our department were unaware the direct access model existed and was legal in Wisconsin, the resources provided valuable background information.
A 2-page Executive Summary was created, providing: (1) an overview of the Wisconsin Physical Therapy Practice Act, including the extra direct access step required for hospital-based physical therapy; (2) names of other large institutions that had implemented a similar practice model; (3) UWHCA's business plan initiative to deploy resources at all levels to eliminate inappropriate patient care delays and promote patient choice; (4) evidence of direct access cost-effectiveness; and (5) proposed outcome measures for program assessment. The proposed outcome measures would allow for later analyses, comparing data of patients seen by physical therapists with versus without physician referral. The information collected would include: (1) number of new patients seen; (2) average number of visits per episode of care; (3) average duration (in weeks) of episodes of care; (4) patient functional outcomes per episode of care, using department standard outcome measures; (5) patient adverse events; and (6) resource utilization such as continuation of physical therapy services beyond the initial visit, referral of patients to physicians and other health care providers for consultation, and direct referral of patients to the radiology department for plain film radiography and equipment orders (eg, orthotics, durable medical equipment).
The Executive Summary was presented to selected department clinic supervisors and physicians for review and feedback and then to the chair of the Department of Orthopedics and Rehabilitation, an orthopedic spine surgeon. Agreeing with the need for improved patient access to services, he provided valuable advice on how to proceed through the hospital's administrative channels and produced a letter of support for all future meetings.
The Executive Summary then was sent to the UWHCA legal and risk management departments for review. No objections were raised, with the following provisos: (1) policies and procedures are in place to ensure that physical therapists are functioning within their scope of practice and refer or seek medical assistance when needed, and (2) physical therapists are not functioning independently (ie, they are functioning under the general supervision of physicians). The institution's definition of general supervision includes the availability of physicians for consultation and a periodic chart audit of selected cases. Other health care providers (eg, physician assistants, nurse practitioners) employed by the UWHCA work under these provisos.
An Oversight Committee made up of department administrators, physical therapists, and physicians was established to ensure: (1) broad representation of primary stakeholders for program development and (2) ongoing program assessment, with quick resolution of issues as they arose. The Oversight Committee may be dissolved eventually as the program becomes established, with the standard departmental quality, safety, and competency assessments assuming oversight. An initial committee action was to develop a practice model including therapist qualifications, with an application process and a scope of practice. Therapist qualification included any one or more of the following 5 requirements, followed by successful completion of the UWHC direct access training: (1) APTA American Board of Physical Therapy Specialties current certification in a relevant practice area (Orthopaedic Certified Specialist for therapists practicing in an orthopedic setting), (2) completion of an APTA-credentialed residency or fellowship program in a relevant practice area, (3) an advanced academic degree with a clinical emphasis, (4) advanced clinical practice training (based on quality, emphasis, and extent of practice experience or a certain number of continuing education units), and (5) UWHCA Advanced/Expert Clinical Practice Level per the institution's professional advancement and recognition program. Once practicing in this model, therapists must maintain the advanced competency status, as determined by the department's annual staff performance review process, and be current on all institutional safety, educational, and internal training offerings.
The scope-of-practice statements included: (1) practice according to APTA's Standards of Practice for Physical Therapy,19 Code of Ethics,20 and Guide for Professional Conduct21; (2) practice according to established UWHCA department standards, regulations, and clinical pathways; (3) provision of care per the Wisconsin Physical Therapy Practice Act and Rules and Regulations, including practice requirements 448.56 (4) (Duty to refer: A physical therapist shall refer a patient to an appropriate health care practitioner if the therapist has reasonable cause to believe that symptoms or conditions are present that require services beyond the scope of physical therapy) and 448.56 (1a) (Responsibility: A physical therapist is responsible for managing all aspects of the physical therapy care of each patient under his or her care); and (4) provision of timely and appropriate referral of patients to the radiology department for plain film imaging studies. The only scope-of-practice item representing a new patient care responsibility was “timely and appropriate referral of patients to the radiology department for plain film imaging studies.”
Therapists interested in direct access practice were to provide the Oversight Committee with a cover letter of intent, a description of their qualifications, and a résumé. Once approved, the therapists began the internal training program. Once completed, the above proposal was taken to outpatient physical therapy clinic staff meetings for feedback and discussion.
Direct Access Model Approval
Prior to presenting the model to the Medical Board (18-member board made up primarily of hospital physicians) for a vote, we met individually with half of the Medical Board members to present the Executive Summary and practice model, the department chair's letter of support, steps taken to ensure patient safety, and the required training program and to discuss any issues of concern. The potential for over-utilization of therapy services without physician oversight was the only issue raised (one physician). This issue was addressed by noting the availability of 6 years' worth of benchmark data (per therapist) describing average number of patient visits over average number of weeks and patient functional status at the initial visit and at discharge. Therefore, administration would note a marked deviation from the norms. Critical to gaining Medical Board members' backing were having the department chair's letter of support and emphasizing that, except for referring patients directly to the radiology department for plain films, therapist practice responsibilities would be no different than when seeing patients via a physician referral. In addition, providing a historical overview including the number of states having adopted direct access since 1957, Wisconsin's 20-year direct access history, and the military's long track record with the lack of evidence describing adverse events and complaints filed against therapists allayed concerns that we were implementing a new and untested practice model.
A PowerPoint presentation was prepared for the Medical Board meeting, including: (1) an overview of the Executive Summary, (2) a description of the proposed model, and (3) the list of physicians and hospital administrators who participated in developing the model. The Medical Board unanimously approved the proposal and then moved the presented model and necessary “allied health” language to the Hospital Authority Board as a proposed hospital bylaw change. The Hospital Authority Board unanimously approved the proposal, a culmination of 7 months of activity.
Required Direct Access Training Program
The UWHCA program, developed by physical therapists and physicians, is based, in part, on training modules developed for the military and Kaiser Permanente direct access models.18 The program emphasizes clinical “red flag” recognition, suggesting a physician consultation is warranted, and plain film indication guidelines recognizing when to refer patients to the radiology department. The referring criteria for plain films were developed jointly with department orthopedists and radiologists based on current evidence22–27 and existing departmental guidelines. The training program includes required readings, lecture and discussion sessions, and a patient case series take-home assignment, followed by group discussion. The take-home assignment consisted of 10 patient case vignettes, which were variations of published cases,28,29 and therapists were asked to respond to the questions presented in Figure 2. Therapists, with an Oversight Committee physician, met to present the cases and discuss plans of care. Upon successful completion of the program, therapists were allowed to practice in the direct access model. Per the hospital's policy, the House and Medical Staff Affairs Office assigned each therapist a provider number necessary for referring patients directly to the radiology department. All therapists noted value in participating in the educational training program. For some therapists, the result was an increased comfort level in seeing patients without physician referral, especially referring patients for plain film imaging. This level of comfort encouraged early program participation.
Patient case vignette assignment.
Pilot Program
Once the Hospital Authority Board had approved the program and the selected therapists had completed the training program, the model was initiated in 2 specialty clinics (spine and sports rehabilitation clinics, with 2 therapists from each clinic providing the services). Operationally, specific direct access patient care slots were identified on therapists' schedules on days when physicians were physically on-site. If these slots were not filled with direct access patients, within 24 to 48 hours from that day, other patients were scheduled.
To promote awareness of the direct access program, presentations were made to staff members who field patient calls, including reception desk staff and other personnel (eg, nurses, physician assistants) working in the spine and sports rehabilitation clinics. For example, the spine clinic nurse manager routinely screens patients calls and determines whether patients need to see a surgeon immediately. If an urgent surgeon visit is not indicated, options for nonsurgical management, now including provision by physical therapists, would be presented. Scenarios were described where direct access recommendations would not be appropriate (ie, patients covered by Medicare or Medicaid). In addition, letters describing the new practice model were sent to patients previously seen by the 4 direct access therapists.
One issue that quickly arose was pain medication, a potential need when seeing patients with acute conditions. The Wisconsin Physical Therapy Practice Act states that therapists cannot prescribe medications. The Oversight Committee decided that if a patient had been seen previously by a physician for a condition, the physician would be contacted regarding the prescription. For patients not seen, their primary care physician would be contacted. After 6 months, the program was evaluated for: (1) patient utilization of direct access opportunities, (2) hospital reimbursement, (3) obstacles encountered by therapists (eg, when referring patients for plain films, arranging for provision of pain medication, accessing physician assistance when patient health concerns were identified), and (4) physical therapist plan-of-care decision making.
Evaluation of Pilot Program
Despite letters to patients who had been seen previously and extensive intradepartmental and interdepartmental communications, approximately 33% to 50% of the designated direct access patient scheduled slots were used. Most patients who had been seen previously were informed of the direct access option by local clinicians; very few patients called the scheduling desk directly. The need to develop a comprehensive, system-wide marketing plan quickly became evident. The internal marketing plan included: (1) meeting with primary care clinic (PCP) managers and presenting the new program, (2) describing the program in the institution's newsletter and its Web site (eg, creating a “Did you know … ” feature), (3) creating printed materials (brochures and posters) for reception areas and PCP entranceways, and (4) distributing flyers as part of the employee Wellness and Ergonomic Injury Reduction Program and to fitness club members. External marketing efforts included contacting local media for news features and high school coaches and athletic directors to promote the program, as well as attending health fairs. A review of hospital reimbursement revealed that reimbursements for patients billed with direct access rates were consistent with those for patients seen via a physician referral.
Eighty-one patients were seen during the pilot program. The Table summarizes the degree to which the participating therapists initiated other health care services. A physician consultation was initiated for approximately 30% of the patients. Of the 13 patients referred for health management issues other than plain films and pain medications, 1 patient was referred for possible deep venous thrombosis and another patient was referred for exacerbation of ankylosing spondylitis. A majority of patient referrals were for nonurgent orthopedic-related consultations (eg, further testing for suspicion of a glenoid labral tear or knee meniscus tear). Therapists noted that initiating the referrals took time, but not more time than when therapists initiated consultations for patients referred by a physician. As the program becomes more widespread, allowing for more data to be collected, an in-depth analysis can be done regarding the institutional impact the direct access program has had.
Summary of Pilot Program Findings (N=81 patients)
A physician from the spine and sports rehabilitation clinics reviewed randomly selected charts for the 4 therapists and reported findings to the Oversight Committee. The chart review included responding to the following questions:
-
Was the patient appropriate for direct access? Why or why not?
-
Would the patient have benefited significantly from medication therapy?
-
Did the patient exhibit “red flags” that were not adequately addressed?
-
Was a radiology consultation requested by the therapist? If so, was it justified?
-
Under what circumstances should the patient have been referred to a medical doctor or doctor of osteopathy?
-
Did the number of therapy sessions and treatment duration seem appropriate for the condition?
-
If adverse events were noted, did the therapist take appropriate action?
The reviewing physicians determined the therapists made appropriate decisions of referring or initiating treatment in 100% of the reviewed cases. Subsequently, the Oversight Committee decided to open the direct access model to all outpatient clinics and thus remove the necessity of having physicians on-site when therapists were seeing patients. The group deemed it adequate for physicians being available for telephone contact.
Discussion
Years of intense lobbying by APTA and its components to promote state practice act changes have led to direct patient access to physical therapy services being available in a majority of states. With emphasis on removing existing access restrictions in many of these states and gaining access in the few remaining states, little organized effort has occurred related to developing institutional and organizational strategies promoting the implementation of this practice model. As noted previously, the UWHCA direct access effort was in response to the Wisconsin Administrative Code language for hospitals, language that may not be in effect in all states. Even in these states, however, direct access may be prohibited or restricted by internal policies set forth by institutions and third-party payers, illustrating that passage of direct access laws may be just the initial step in fully implementing this model of health care delivery.
Despite the long-standing success of the military direct access program9,18 and the previously described potential benefits to health care delivery, there has not been widespread institutional adoption in the public sector. Although the literature provides descriptions of direct access program implementation in a large health maintenance organization system and veterans hospital, as well as in military hospitals,18 to our knowledge this is the first case describing establishment of such a model in a large academic medical center. Requiring approval from a large board of physicians and numerous administrators (unfamiliar with current physical therapy laws and education and practice standards), although unique compared with private practice settings, is not unlike the decision-making processes found within insurance companies, smaller hospitals, and large corporations. Strategies promoting widespread approval of the direct access model are paramount to the potential positive impact on health care quality and costs being realized. Once approval is gained, other challenges exist in many practice settings that must be met for this practice model to have its full impact.
Establishing a direct access program does not guarantee patients will fully utilize this entry point to the health care system, as evidenced by our initial low numbers of scheduled appointments. At institutions such as UWHCA, the sheer size can be an obstacle. More than 80 primary care and specialty physician clinics scattered geographically are all potential patient entry points into our system. In these clinics, medical assistants, nurses, nurse practitioners, and physician assistants field calls and triage where patients are to be seen. Educating these practitioners, along with the clinic managers, provided logistical challenges. Scheduling the clinic meetings and subsequent travel was time-consuming, and after the initial contact, follow-up periodic reminders that direct access to physical therapy existed were needed. Complicating the process for practitioners triaging the patient telephone calls was that some patients' health plans (ie, Medicare and Medicaid) required a physician referral, so asking questions regarding patients' health plans was necessary.
Besides the internal challenges associated with utilization, lack of public awareness of and familiarity with the direct access option to physical therapy also is a factor. For decades, when patients called our clinics, they were told a physician referral was needed, the referral-based model being the only model previously experienced. A comprehensive marketing plan can facilitate the necessary wide-range “educational initiative,” with the hope that word-of-mouth informing of family members and friends will ensue. The process for direct access programs becoming routine and common knowledge in the public's eye can take time. This challenge provides an opportunity for APTA and its components to work with institutions of all types to develop effective marketing plans.
The successful implementation of direct access models may result in a shift of patient volume from one institutional cost center to another, leading to a potential conflict for those triaging patient calls. Attempting to keep medical providers' schedules full could lead to patients appropriate for physical therapy being triaged instead to physicians, nurse practitioners, or physician assistants. The Virginia Mason Medical Center report described the need to shift hospital resources in response to changing practice patterns once direct access was initiated. The hospital's state-of-the-art chronic pain center ended up treating fewer, but more complex, patient cases, resulting in 15 of the clinic's medical staff leaving.11 Reallocation of financial and staff resources may need to occur in large institutions before the positive impact of the direct access model can be fully appreciated.
The UWHC direct access program requirements raised some issues among the physical therapy staff. Although not required by Wisconsin statutes, a decision was made to implement an application process for practicing in this model and requiring successful completion of the direct access training program. Some of the more recent therapist graduates expressed frustration being unable to practice in this model due to not meeting the established requirements—a requirement not present if they practiced in non–hospital-based practice environments. We explained to therapists (and administrators) that our process was consistent with long-standing models developed in other large institutions (the military and Kaiser Permanente), models demonstrating very positive outcomes to date.18 The process eased concerns expressed by some hospital administrators and physicians, who noted the variety of degrees held by therapists (BS, MPT, MSPT, and DPT) and questioned what this meant in terms of practice capabilities. The discussion included the impact of DPT professional degree programs evolving, possibly including residency-like clinical educational models,30 and how comfort levels of new graduates practicing in direct access environments might be enhanced. The Oversight Committee agreed the application requirements would be revisited in the future.
With all challenges come opportunities and the potential for positive far-reaching changes. The meetings with individual hospital administrators and Medical Board members as preparation for the formal board approval meetings presented us with excellent opportunities to educate administrators and physicians regarding the evolving nature of physical therapist practice. Follow-up meetings with specific physician groups to describe the program afforded the occasion to emphasize the model's goal is not to promote therapists' practicing independent of, or in isolation from, physicians. Instead, the goal is interdependent practice and patient-centered care, as described by Johnson and Abrams—care marked by therapists working collaboratively with patients, other practitioners, and payers.31 Therapists initiating a consultation for 30% of the patients during the pilot program provided good examples of the nature of collaborative practice afforded by the direct access model. The public marketing program allows us to not only promote the direct access model but also describe the variety of services physical therapists can provide. Taking full advantage of these opportunities requires cooperation among institutions of similar organizational designs, as well as cooperation between APTA and its components. This cooperation will help ensure appropriate resources being developed and disseminated, encourage efficiency, limit reinventing of the wheel, and promote a consistent message being provided to the public.
Summary
Consumer choice and timely patient access to the appropriate practitioner were the impetus for obtaining UWHCA administrative approval of and implementation of the direct access model. The initiative's success was facilitated by: (1) APTA and WPTA resources and (2) relevant published research, combined with the institution's administrative commitment to improve patient access coinciding with physical therapists' readiness to redesign their practice model. This administrative case illustrates the importance of communication, collaboration, advanced planning, and consensus building to organizational change of this nature. Program evaluation over time will reveal the institutional impact this model has had. Previous studies provide us with comparison markers, including: (1) patient, therapist, and physician satisfaction; (2) patient functional status at initial visits and outcomes at discharge; (3) number of visits over number of weeks per episode of care; (4) cost per episode of care; (5) utilization of radiology services; and (6) numbers of and reasons for referrals of patients to physicians and other practitioners. Publication of such direct access data from different health care delivery systems (eg, urban versus rural hospitals, private practice clinics, the military) may identify different issues and outcomes that influence institutional policy decisions, staffing models, therapist educational training, and government approval of direct access legislative initiatives.
Footnotes
-
All authors provided concept/idea/project design. Dr Boissonnault and Dr Badke provided writing and data collection and analysis. Ms Powers provided consultation (including review of manuscript before submission).
-
The authors thank all of those whose dedication and commitment led to the development and implementation of the physical therapy direct access program at the University of Wisconsin Hospital and Clinics: David Bernhardt, MD, Dan Enz, PT, Karl Fry, PT, Ellen Heiser, RN, Kris Jensen, PT, Jenny Kempf, PT, James Leonard, DO, Julie Sherry, PT, Marc Sherry, PT, Kip Schick, PT, Kristen Traino, PT, and Thomas Zdeblick, MD.
-
Portions of the article were presented at PT 2009: Annual Conference and Exposition of the American Physical Therapy Association; June 10–13, 2009; Baltimore, Maryland.
- Received August 11, 2008.
- Accepted August 30, 2009.
- © 2010 American Physical Therapy Association
References
Issue highlights
