The new and major challenge to health care is the advent of chronic diseases. The successes of treating people with infectious diseases, the wave of the aging population, changing lifestyles, obesity, and physical inactivity have contributed to a public health epidemic of chronic diseases (ie, diabetes, stroke, Alzheimer disease, arthritis, and heart failure). Because of its personal, social, and economic impact, tackling chronic disease is the new frontier of modern medicine. Management of chronic diseases will not be solved by “magic bullets,” a surgical intervention, or the “heroics of medical rescue.” Chronic disease management requires holistic, patient-centered care, with collaborating and respectful teams of interdisciplinary providers (physicians, nurses, pharmacists, and allied health workers). These teams will coordinate care across the continuum. In addition, our current medical and public health initiatives must be prepared to address not only the medical conditions but also the social determinants of health. Atul Gawande, a surgeon and health care thought leader, wrote that health care “now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person's abilities [our emphasis].”1(p183) Individual professional and personal autonomy is not the ideal we should seek. The next generation of solutions will require new skills among physical therapists to be partners in the treatment of populations of patients across the continuum of health care settings and coach patients and families in lifestyle management and be accountable for sustaining and improving functional status.
The Centers for Medicare & Medicaid Services recently implemented bundled payments for hip and knee replacements in 67 geographic areas in the United States.2 Under this comprehensive joint replacement model, the hospital that performs the surgery will be accountable for the costs and quality of related care for the episode of care, which is from the time of the surgery through 90 days after discharge. The hospital's quality and cost performance during the episode will determine whether the hospital earns a financial reward or is required to pay Medicare for a portion of the spending above an established target. The payment structure incentivizes better coordinated care so hospitals work with physicians, home health agencies, outpatient therapists, and skilled nursing facilities to ensure that beneficiaries receive the care they need and avoidable hospitalizations and complications are reduced. Under such models of care and payments, physical therapists must practice interdependently with other colleagues and be accountable for outcomes and simultaneously help control costs. Under the new models of care and reimbursements, physical therapists will have increasing opportunities to expand their scope of practice.
Physical therapy curricula must prepare physical therapists to function in these ever-evolving health care systems and environments of accountability, and with new reimbursement models. The curricula need to engage students to develop the necessary attributes, knowledge, and skills in health leadership, policy, advocacy, and research to ensure the next generation of physical therapists can be partners to transform health care practice. For future transformative practice, physical therapy curricula need to be forward thinking and innovative. Specifically, the curricula should ensure that physical therapists: (1) manage the functional status of the rapidly growing population of individuals with complex chronic diseases; (2) provide person-centered health care in a biopsychosocial framework; (3) deliver quality of care with accountable outcomes at all levels of practice; (4) be responsive to the ever-growing financial stresses and provide the most cost-effective and efficient care; (5) work collaboratively with interdisciplinary teams to integrate research, education, and practice to create learning health systems; (6) expand the physical therapist's role in population health management; (7) be leaders and drive innovation; and (8) be self-reflective, accountable practitioners committed to self-development and lifelong learning.
The need for transformative practice and education is a national and global issue. The faculty at Macquarie University in Sydney, Australia, recognized that graduating physical therapists would need all of the skills above to be leaders in value-based health care and population management. Macquarie University developed a new program that is the only doctor of physical therapy program in New South Wales. The Macquarie program was strategically developed to systematically present the challenges of modern health care, integrate new models of care, develop outstanding clinicians, and prepare innovative leaders. The outline of the program, which is broken down into 6 semesters with 4 units per semester, is outlined in Figure 1. The program features a connected curriculum and connected learning experiences, and people are connected through innovative learning activities and strong partnerships with clinical providers, industry, and researchers.
Outline of the progressive 6-semester structure of Macquarie University's Doctor of Physiotherapy Program. The program structure outline may not be used or reproduced without written permission from Macquarie University.
The content and delivery of the final year of the program are the most innovative and most likely to prepare the next generation of physical therapists to be innovators and leaders in transformative practice. The faculty developed a Leadership, Policy, and Advocacy course to run alongside current courses in advanced physical therapist practice, advanced research training, and business management and law. The Leadership, Policy and Advocacy course introduces health policy and health care reform issues that: (1) drive health system redesign, (2) demand a new scope of clinical skills, and (3) relate to the development of leadership skills for transformative practice. Conceptually, the course is based on Health LEADS Australia: the Australian Health Leadership Framework3 (Fig. 2) and Fuda's 7 metaphors for leadership transformation.4 The 7 metaphors are fire, snowball, master chef, coach, mask, movie, and Russian dolls. Information about these metaphors is available in his text4 and online.5 This course is all about the future; every module highlights the changing health systems and the growing need for population health management and emphasizes how physical therapy is adapting and, more importantly, how the discipline needs to continue to transform.
Health LEADS Australia: the Australian Health Leadership Framework. Reprinted with permission from Health Workforce Australia, 2013.3
There are several consistent concepts reinforced in this course that are necessary for transformative practice. These concepts include: (1) population health management; (2) development of independent practitioners who can lead and function in interprofessional teams; (3) coordination of care across the different health care sectors; (4) ability to differentiate between patients with complex conditions who need different levels of health care to improve functional status (eg, those who may need physician services) and patients with noncomplex conditions who only need physical therapy; (5) anticipated changes in health care funding; (6) ability of frontline practitioners to identify, collect, and analyze data and generate information to guide their practice and establish value-based services for patients, payers, and the public; (7) continuous quality improvement programs; (8) inequalities in health care and promotion of equal access to preventative health and health care; (9) presentation of relevant contemporary professional issues or health reform issues (both nationally and internationally) that will directly influence and offer opportunities and challenges for physical therapist practice and practice of other health professions; and (10) utilization of the Health LEADS Australia framework to prepare a workforce to develop a “health system that is equitable, effective, and sustainable.”
In this course, the Macquarie University faculty successfully engage physical therapist students as active participants and debaters in health care transformation. The course includes 3 highly innovative and integrated full-day workshops, which showcase physical therapy excellence in education, practice, and research. These workshops involve a morning of student health policy debates, followed by a presentation by a clinical specialist, and, finally, a presentation by a distinguished researcher. Students are required to submit reflections on the presentations by the clinical specialist and distinguished researchers with recommendations about how they will use their learning to enhance their future physical therapist practice. All final-year students are involved in each showcase, with one group debating, another group peer marking the debates, and the third tutorial group managing the event. The debate topics are carefully selected to reflect current health policy and advocacy issues. For example, past topics have been: (1) research is too much about breakthrough and not enough about follow-through; (2) physical therapy, as a profession, should not lobby with other health care professions; (3) the Australian Medical Association has too much power over health care; (4) the current Australian Standards for Physiotherapy6 stifle innovation; (5) health funds should provide rebates for physical therapist–led health promotion and preventive health programs; (6) self-reported outcomes are more valuable for the clinician than objectively measured outcomes; (7) cultural competency should be emphasized more than clinical skills in physical therapy programs; and (8) physical therapists should be able to prescribe and coordinate a Medicare-funded chronic disease management plan.
Within the Leadership, Policy, and Advocacy course, students also are engaged in policy development and advocacy in partnership with the Australian Physiotherapy Association. Students are required to critique one of the association's position statements and submit a revised statement based on latest evidence. The best revised position statements are forwarded to the association for use by the policy development team. Students have frequently demonstrated more innovative ways to communicate the association's position, with a considerable proportion submitting infographics.
The course assessments are structured to evaluate content and to promote lifelong, self-directed learning, reflection, and career planning. Guest lecturers who are renowned leaders in physical therapy and health care are invited to share their career journey with students. Networking is promoted by encouraging and supporting students to identify and approach professional mentors who match their career aspirations. Students are overwhelmingly positive about the Leadership, Policy, and Advocacy course, scoring it 4.2/5, and, as one student reported, it provided a “thought-provoking and interesting perspective of the overall physical therapy/health industry.”
Conclusion
The Macquarie University physical therapist students are prepared for the future to adapt to emerging health care needs, find innovative solutions, and redesign health systems in Australia and globally. The Leadership, Policy, and Advocacy course developed by the Macquarie University faculty could serve as a useful model as we redesign courses and curricula to prepare physical therapist students to be innovative and accountable health care providers nationally and globally.
Footnotes
Both authors provided concept/idea/project design, writing, and consultation (including review of manuscript before submission). Professor Dean provided data collection and data analysis.
- Received November 30, 2015.
- Accepted December 6, 2015.
- © 2016 American Physical Therapy Association
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