Putting the PT in Hospital: Direct Access in Acute Care

Physical therapy is a relatively new profession—although its origins can be traced back to Hippocrates in 460 BC. And it has quite the interesting history. In the US, many healthcare practitioners used physical therapy techniques to help patients during the polio epidemic of 1916. Then, according to this US Army Medical Department page and this slide deck by Aaron Keil, PT, DPT, OCS, it was World War I—which the US entered in 1917—that really propelled the profession forward in this country. In an effort to help restore function to a growing number of injured soldiers—many of whom had lost limbs—the US Army trained and deployed a fleet of reconstruction aides.

Back on the homefront, physical therapy in hospitals really began in 1918 with Mary McMillan, who treated patients in the Walter Reed Army Hospital in DC. Without official clinic space, McMillan provided physical therapy to patients in hospital wards and led group exercise programs on the hospital’s porch (you can find a photo of one of her group sessions on this page). Later that same year, Walter Reed established the first US hospital-based physical therapy clinic. Fast forward to today, and direct access to physical therapy care is transforming hospital acute care settings—or at least beginning to. But, the profession has had to grow a lot in the interim.

Historically, physical therapists have been adjunct healthcare professionals.

Not everyone was on board with the development of this new profession: according to the above-cited Army resource, “Many medical officers were skeptical of the values claimed for physical therapy, but reconciled themselves to what they termed an intruder in the medical profession, feeling that it was a passing fad.” It was not, but physicians continued to dominate the profession—serving as gatekeepers between patients and physical therapists: “Some medical officers were so incredulous that the only patients they would entrust to physical therapists were those whose condition could not possibly be impaired by the application of the new therapeutic measures.” According to the above-cited presentation deck, in 1937, the American Physiotherapy Association's goal was simply to “cooperate with and work only under the prescription of members of the medical profession.”

The vision for physical therapists has changed.

While cooperation with the rest of the medical community is still key, the industry’s education standards and goals have changed considerably. In 2000, the APTA unveiled its 2020 vision statement, which says that by 2020, doctors of physical therapy will provide physical therapy to consumers who “have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function, and health.”

In fact, the APTA’s latest vision statement is much more all-encompassing.

In 2013, the APTA announced a new overarching vision statement: “Transforming society by optimizing movement to improve the human experience.” However, the organization stated that “the values of Vision 2020 remain significant to the successful fulfillment of the new vision.” In other words, physical therapists must continue to not only own their role as doctoral level medical professionals, but also objectively demonstrate the value they provide to their patients. And now that at least some form of direct access is available in all 50 states, physical therapists have a broader scope of influence to ensure the rest of the medical community—and patients themselves—recognize that value.

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Hospitals are now relying on PTs.

As WebPT’s Brooke Andrus explained in this blog post, “evolving payment incentives are holding hospitals more accountable for what happens to patients post-discharge.” That’s why, she says, “many hospitals have adjusted their inpatient discharge planning process to encourage better patient success rates once those patients return home”—by incorporating physical therapists into the patient’s discharge plan of care, for example. However, some hospitals are taking things a step further by incorporating physical therapists into acute care settings. For example, the Cape Cod Hospital in Provincetown, Massachusetts has staffed its emergency department with PTs to better identify patients’ functional issues, prevent safety oversights, and transition patients to the next step in their care progression.

That’s because PTs can positively impact a number of important metrics.

According to Andrus, because a large portion of the patients who present at the Cape Cod Hospital are at least 55 years old, many are at a greater risk for falls and have trouble performing “normal activities of daily living (ADLs)—two issues that fall smack dab in the middle of the rehab therapy wheelhouse” and, if unaddressed, have the potential to land patients right back in the hospital. Thus, it makes sense—in terms of improving clinical outcomes and patient satisfaction as well as reducing costs associated with extended hospital stays and readmissions—for physical therapists to practice in the ER.

Research supports the benefits of having PTs in the acute care setting.

Per the Academy of Acute Care Physical Therapy, recent research supports the benefits of physical therapy in the acute care setting:

• One study “found that when the recommendations about discharge made by the physical therapist were not followed, patients were 2.9 times more likely to be readmitted to the hospital.”
• Another study found that stroke patients who received “early and intensive” physical therapy had better mobility outcomes.
• Yet another study demonstrated that “physical-therapist led exercise improved function, reduced sedation,” and decreased the length of stay in both the ICU and the hospital for patients with acute respiratory failure.

According to this Cape Cod Hospital press release, the National Institute of Health (NIH) concluded that “patients who are seen by a physical therapist while in the hospital typically spend fewer days there.” Furthermore, NIH researchers said that “taking it one step further and bringing physical therapy to patients while they are still in the emergency room can be even better.”

With direct access, hospitals are beginning to encourage patients to see PTs first.

Earlier this year, the Frances Mahon Deaconess Hospital in Montana published a piece announcing that their patients “may self-refer themselves to physical therapy services, therefore bypassing the need for an extra physician appointment.” According to the press release, the benefits of this are twofold: 1) it’s “easier for the patient,” and 2) “research suggests that in appropriate cases, allowing direct access to physical therapy can lower healthcare costs, reduce requirements for diagnostics imaging, and provide more expeditious resolution of the patient’s symptoms.”

Other countries have already seen positive results.

While this type of setup is still relatively new in the US, Andrus said in this post that “in many countries outside of the US, hospital-based direct access to physical therapy is much more commonplace—and thus much more culturally accepted.” She uses the example of a London-based hospital that found a significant increase in patient satisfaction after “staffing its walk-in center with PTs and nurse practitioners.” In fact, “90% of patients report[ed] that they would likely return to the center rather than access care elsewhere.”

The case for direct access is clear.

According to Keil’s presentation, two of the most common objections to direct access have to do with “Patient Safety” (i.e., “are PTs adequately trained?”) and “Financial[s]” (i.e., will it cost too much or will services become overutilized?). However, it appears that PTs are adequately trained to not only identify neuromusculoskeletal issues, but also refer patients out when those patients’ conditions fall outside of the PT scope of practice. In fact, Keil reports that “liability insurance has not increased at all as a result of implementation of direct access.” And numerous studies have demonstrated that early access to physical therapy leads to better outcomes and patient satisfaction as well as reduced costs, medications, imaging, and sessions. According to Keil, the case for direct access has been well made. Now, hospital policies and payers need to catch up—which means PTs have some some work to do.

But, making it happen in your organization may take some investigative work.

To make the case for direct access in your organization, Keil recommends doing some “fact finding” first—specifically, researching:

• the language in your state’s practice act and your hospital’s policies;
• payer reimbursement policies; and
• case studies of similar institutions that have implemented direct access.

(Next, Keil suggests that PTs make the case for being able to order radiologic imaging studies—but that’s another discussion for another day. If you’re interested in learning more, definitely check out the slide deck from Keil’s presentation here.)

According to the Frances Mahon Deaconess Hospital announcement, as of January of 2017, Montana was only one of 18 states with fully unrestricted direct access. However, as more of these programs demonstrate success—and legislation in other states begins to catch up—we can expect to see even more acute care settings taking advantage of the benefits of direct access to physical therapy. Ultimately, this type of progression will enable PTs to intercept more patients who are good candidates for therapy at their healthcare entry point. And we all know the benefits of first-line physical therapy intervention for patients with neuromusculoskeletal conditions—especially compared to surgery and injections.

How do you think direct access to physical therapy will change the nature of the acute care setting? Tell us your thoughts in the comment section below.