Physical Therapy Information: Could It Reduce Hospital 30-Day Readmissions?

The voice of physical therapy is absent in the assessment of hospital Medicare readmission risk. Physical therapy functional assessments are involved in decisions to discharge to home or to inpatient rehabilitation, but physical therapy findings are missing for gauging readmission risk. Thirty-day readmissions are a vital factor in hospital reimbursement.¹ Does omitting physical therapy information make a difference?

What does physical therapy information offer to readmission risk assessment? Physical therapy provides a unique information-bearing relationship in the hospital setting.² It involves hands-on, personal treatment often delivered by the same individual or team, which is an increasingly rare component in fragmented, technology-driven health care delivery. This often daily, personal care provides an anchoring bond in the setting of rapid, frequently remote, medical care. Physical therapy can offer a healing relationship in the context of acute loss as patients seek to restore function and self-esteem. Because this treatment involves the same small team of physical therapists, some patients will share their personal concerns regarding their efforts to adjust to their losses and related uncertainty. This shared information and insight gained by the physical therapy team could inform treatment planning and readmission risk. Who knows their risks better than the patients themselves? This understanding is not big data, but it is personal and actionable information.

We reviewed the 2012–2014 medical literature using the search terms “physical therapy” and “patient readmission” both separately and together. We then searched the discovered articles for the descriptor “physical therapy” or “physical therapist.” These terms did not appear, except in one article written by a team of physical therapists in Toronto whose focus was discharge readiness, not readmission risk.³

To understand current tools used to monitor readmission risk, it is helpful to consider the Rothman index, a widely used quantitative measure of medical acuity.⁴ It involves 26 risk variables, such as temperature, pulse oximetry, and pulse rate, plus a 12-point nursing assessment. The Rothman index has predictive validity for readmission risk as well as transfer to a higher level of care.⁵ There is, however, no mention of physical therapy findings among these variables.

The American College of Surgeons conducted a study to assess readmission risk after lower extremity bypass procedures.⁶ Again, there was no mention of physical therapy information in this study.

A Cochrane Review published in 2013 reviewed the effectiveness of routine discharge planning versus individualized discharge plans as reflected in outcomes, including reduced readmissions.⁷ Twenty-four randomized studies were analyzed. Individualized plans provided superior results. Physical therapy findings were never mentioned in this review.

What is missing when physical therapist input is left out? Of paramount importance is the insight into the patients' experience shared with physical therapists that could inform discharge planning and readmission risk. To capture that information, a narrative from the physical therapy team might be useful. This narrative would focus on the patients' perceptions of the dangers they face. Some of their concerns might be predictable, such as fear of falling or impending death. Others—such as despair, apprehension about an abusive relationship, or something as ordinary as tripping on the family pet—might be amenable to intervention, thus reducing readmission risk. Quantitative scores from screening tests cannot capture the patients' experience as narratives can.

In addition, physical therapy narratives could reveal patients' views of what has meaning for their lives. These sources of meaning, such as family relationships, serve as a guide to what might motivate patients to maximize recovery and minimize readmission risk, whereas the fears could identify obstacles to optimal recovery. Physical therapists also could provide relevant information such as mobility and balance observations. Mobility is a potent predictor of readmission risk.⁸ This knowledge could aid discharge planning and related readmission risk reduction.

There is heuristic value in studying how physical therapy information might be useful for reducing 30-day readmissions. For example, closely examining who gets physical therapy and who does not with given diagnoses might shed light regarding the impact of physical therapy actions and information on 30-day readmission. For purposes of systematic data collection, the physical therapy narrative might feature pull-down lists of structured texts to describe patient motivations and concerns. If so, what would the structured texts contain? Which components of those texts might be correlated with 30-day readmission risk? In addition, how might mobility and balance predict early readmission?

The relevance of physical therapy information and involvement is not restricted to discharge. For example, socioeconomic status, diagnosis, and caregiver support influence early readmission risk and can be identified at admission. Might these factors point to early physical therapist involvement in these cases? If so, which aspects of physical therapy might be the most beneficial?

The physical therapist perspective regarding patients can augment the Rothman index and similar quantitative tools designed to measure readmission risk. Not all patients receive physical therapy during their hospital admissions. Patients with cardiovascular disease, especially those with congestive heart failure and those who have undergone surgery for orthopedic conditions, do routinely receive physical therapy. They constitute groups known to have high readmission risk.

There are quantitative tools to measure and mitigate readmission risk. The voice of physical therapy is missing in this process. Does this omission matter? We think it does. Physical therapy does contribute to patient education and discharge planning and can contribute to reducing readmission risk through narrative plus quantitative data such as mobility and balance.

• © 2014 American Physical Therapy Association