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How physical therapists can thrive under health care (1)

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This is the slideshow I presented in Orlando, Florida to the Florida Physical Therapists in Private Practice for our Annual meeting. …

This is the slideshow I presented in Orlando, Florida to the Florida Physical Therapists in Private Practice for our Annual meeting.

We discussed Medicare Accountable Care Organizations and how private practice physical therapists can effectively compete in a vertically integrated healthcare delivery system that is trying to cut costs and increase quality.


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  • Pioneer Accountable Care Organization Model. Available at http://innovations.cms.gov/documents/pdf/Pioneer%20FSG%2005%2023%202011.pdf. Accessed 08/14/2011.Sick Around the World.Frontline. 2008. Available at http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/view/?autoplay
  • Lakdawalla, D. N., J. Bhattacharya, and D. P. Goldman, Are the Young Becoming More Disabled? Health Affairs, Vol. 23, No. 1, January/February 2004, pp. 168-176.Sturm R, Ringel J, Lakdawalla D, Bhattacharya J, Goldman DP, Hurd M, Joyce GF, Panis C and Andreyeva T. Obesity and Disability: The Shape of Things to Come. Santa Monica, CA: RAND Corporation, 2007. http://www.rand.org/pubs/research_briefs/RB9043-1
  • Overview Shared Savings Program. Available at https://www.cms.gov/sharedsavingsprogram/. Accessed 08/14/2011.Pioneer Accountable Care Organization Model. Available at http://innovations.cms.gov/documents/pdf/Pioneer%20FSG%2005%2023%202011.pdf. Accessed 08/14/2011.
  • Rosenthal MB, Cutler DM, Feder J. The ACO Rules - Striking the Balance Between Participation and Transformative Potential. NEngl J Med. 2011;365;e6:p1-3.Consequences of Risk Sharing for ACOs That Accept Two-Sided Risk.The solid blue line indicates the level of shared-savings payments to an ACO (where the line is above the x axis) or obligations to repay Medicare (where the line is below the x axis) as a function of Medicare spending for the population of patients attributed to the ACO. Shared savings are capped at 7.5% of the target, and the ACO receives 60% of any savings above the minimum savings threshold, which is 2% of the target spending level. When Medicare spending exceeds the target, the ACO is obligated to pay 60% of the excess with a similar 2% threshold for payment. Payments to Medicare for excess spending in the ACO are capped at 5% in the first year, and the cap increases by 2.5 percentage points in each of the subsequent 2 years.
  • Improving Quality of Care for Medicare Patients: Accountable Care Organizations. DHHS – CMS. April 2011. Available at https://www.cms.gov/MLNProducts/downloads/ACO_Quality_Factsheet_ICN906104.pdfCAHPS Clinician survey available at https://www.cahps.ahrq.gov/cahpskit/files/352a-4_AdultSpec_Eng_4pt_V1.pdf
  • Improving Quality of Care for Medicare Patients: Accountable Care Organizations. DHHS – CMS. April 2011. Available at https://www.cms.gov/MLNProducts/downloads/ACO_Quality_Factsheet_ICN906104.pdf
  • Smith BA. Physical Therapists’ Make Accurate and Appropriate Discharge Recommendations for Patients Who are Acutely Ill. Phys Ther. May 2010;90(5):693-703.
  • Deyo RA et al. Trends, Major Medical Complications and Charges Associated with Surgery for Lumbar Spinal Stenosis in Older Adults. JAMA. 2010; 303(13): 1259-1265. Available at http://jama.ama-assn.org/content/303/13/1259.full.pdfResults: Overall, surgical rates declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100 000 beneficiaries. Life threatening complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.95 (95% confidence interval [CI], 2.50-3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74-2.17). Adjusted mean hospital charges for complex fusion procedures were US $80 888 compared with US $23 724 for decompression alone.The problem of “rouge specialists” was discussed at the 6th Annual South Florida Conference Empowering Healthcare, Engaging Consumers of the Florida Health Care Coalition on August 10th, 2011
  • Medicare Claims Show Overuse for CT Scanning. New York Times by Walt Bogdanich and Jo Craven McGinty. Published: June 17, 2011. Available at http://www.nytimes.com/2011/06/18/health/18radiation.html
  • Chou R, Qaseem A, Owens DK, Shekelle P. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med. 2011;154:181-18. Available at http://www.annals.org/content/154/3/181.full.pdf+html
  • http://www.fiercehealthcare.com/webinars/accountable-care-pilots-lessons-learned-multi-year-demonstrations
  • http://www.fiercehealthcare.com/webinars/accountable-care-pilots-lessons-learned-multi-year-demonstrations
  • The good news for clinicians is that we can manage populations the way we have been trained to manage patients, that is, one patient at a time.
  • http://en.wikipedia.org/wiki/Population_health
  • http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Practice/Diagnosis.pdf
  • Tinetti ME et al. Shared Risk Factors for Falls, Incontinence and Functional Dependence: Unifying the Approach to Geriatric Syndromes. JAMA. 1995;273(17):pp1348-1353.
  • Tinetti ME et al. Shared Risk Factors for Falls, Incontinence and Functional Dependence: Unifying the Approach to Geriatric Syndromes. JAMA. 1995;273(17):pp1348-1353. 927 community-dwelling adults aged 72 years and greater who completed baseline and follow-up examinations.Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and co-morbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.
  • Stanton TR, Fritz JM, Hancock MJ et al. Evaluation of a Treatment Based Classification Algorithm for Low Back Pain: A Cross Sectional Study. Phys Ther 2011;91(4):pp.496-509.Cleland JA, Mintken PE, Carpenter K, Fritz JM, Glynn P, Whitman J, Childs J. Examination of a Clinical Prediction Rule to Identify Patients with Neck Pain Likely to Benefit from Thoracic Spine Thrust Manipulation and a General Cervical Range-of-Motion Exercise: Multi-center Randomized Clinical Trial. Phys Ther. 2010;90(9): 1239-1250.Whitman JM, Cleland JA et al. Predicting Short Term Response to Thrust and Non-thrust Manipulation and Exercise in Patients Post Inversion Ankle Sprain. JOSPT. March 2009;39(3):188-200.Currier LL et al. Development of a Clinical Prediction Rule to Identify Patients with Knee Pain and Clinical Evidence of Knee OA Who Demonstrate a Favorable Short-term Response to Hip Mobilization. Phys Ther, 2007;87(9):pp.1106-1119.
  • Heckerling et al. Clinical Prediction Rule for Pulmonary Infiltrates. Ann Int Med. 1990;113(9):664-670. Crackles/Rales are caused by delayed opening of alveoli in deflated regions of pathologically inflammed lung.McGee S. Evidence-based Physical Diagnosis. 2nd ed. 2007. Saunders-Elsevier.The Rational Clinical Examination: Evidence Based Clinical Diagnosis. Simel DL and Rennie D. JAMA Evidence, McGraw-Hill, 2009
  • Heckerling et al. Clinical Prediction Rule for Pulmonary Infiltrates. Ann Int Med. 1990;113(9):664-670.
  • Heckerling et al. Clinical Prediction Rule for Pulmonary Infiltrates. Ann Int Med. 1990;113(9):664-670.
  • According to clinical guidelines, the gold standard for diagnosing pneumonia is the presence of lung infiltrates indicated by chest radiography. The Centre for Evidence Based Medicine. Available at www.cebm.netNiederman DS. Recent advances in community-acquired pneumonia: inpatient and outpatient. Chest. 2007 Apr;131(4):1205-15.
  • “Although elaborate scoring systems for breath sound intensity and for wheezing have been developed they are not clearly better than the customary normal vs. abnormal dichotomization.” (p.151)The Rational Clinical Examination: Evidence Based Clinical Diagnosis. Simel DL and Rennie D. JAMA Evidence, McGraw-Hill, 2009
  • The LR is used to assess how good a diagnostic test is and to help in selecting an appropriate diagnostic test(s) or sequence of tests.A LR greater than 1 produces a post-test probability which is higher than the pre-test probability. An LR less than 1 produces a post-test probability which is lower than the pre-test probability. The Centre for Evidence Based Medicine. Available at www.cebm.net
  • McGee S. Evidence Based Physical Diagnosis, 2nd Ed. 2007. Saunders/Elsevier.
  • Christensen C. The Innovator’s Prescription. 2009. McGraw-Hill The Survivor. Forbes Magazine. March 14, 2011.
  • Conn VS et al. Interventions to Increase Physical Activity Among Healthy Adults. Am J Pub Health. 2011; 101(4): 751-758. Meta-analysis of 358 reports of 99,011 patients. Effect size equal to 496 ambulatory steps per day.
  • Conn VS et al. Interventions to Increase Physical Activity Among Healthy Adults. Am J Pub Health. 2011; 101(4): 751-758. Meta-analysis of 358 reports of 99,011 patients. Effect size equal to 496 ambulatory steps per day.
  • Moerman DE. Deconstructing the Placebo Effect and Finding the Meaning Response. Ann Int Med. 2002;136: 471-476.
  • Weschler ME et al. Active Albuterol or Placebo, Sham Acupuncture or No Intervention in Asthma. N Engl J Med. July 2011;365: 119-126.Moerman DE. Deconstructing the Placebo Effect and Finding the Meaning Response. Ann Int Med. 2002;136: 471-476.Blackwell et al. Demonstration to Medical Students of Placebo Responses and non-drug factors. Lancet. 1972;1:1279-82.Cobb et al. An Evaluation of Internal Mammary Artery Ligation by a Double Blind Technic. N Engl J Med. 1959;260:1115-8.
  • Ingram D, Fell N, Cotton S, Elder S, Hollis L. Patient Preference, Perceived Practicality, and Confidence Associated with Physical Therapist Attire: A Preliminary Study. 2011.HPA Resource / HPA Journal: 11(2); ppJ2-J8.
  • Ingram D, Fell N, Cotton S, Elder S, Hollis L. Patient Preference, Perceived Practicality, and Confidence Associated with Physical Therapist Attire: A Preliminary Study. 2011.HPA Resource / HPA Journal: 11(2); ppJ2-J8.
  • Ingram D, Fell N, Cotton S, Elder S, Hollis L. Patient Preference, Perceived Practicality, and Confidence Associated with Physical Therapist Attire: A Preliminary Study. 2011.HPA Resource / HPA Journal: 11(2); ppJ2-J8.
  • Ingram D, Fell N, Cotton S, Elder S, Hollis L. Patient Preference, Perceived Practicality, and Confidence Associated with Physical Therapist Attire: A Preliminary Study. 2011.HPA Resource / HPA Journal: 11(2); ppJ2-J8.
  • The Six Sources of Influence (p.78), Influencer: The Power to Change Anything. Patterson et al. 2008, McGraw-Hill, NY.
  • Tousman S. Patient Engagement: Building Effective Self-Management. 6th Annual South Florida Conference Florida Health Care Coalition. August 10, 2011.Teaching Tip Sheet: Cognitive Dissonance. American Psychological Association. Available at http://www.apa.org/pi/aids/resources/education/dissonance.aspx
  • Patient Centered Primary Care Collaborative webinar. ACOs: What is all the noise about? July 13th, 2011. Available at http://pcpcc.net/webinar/acos-what-all-noise-about .Doctors respond very well to data that shows INDIVIDUAL (not aggregated) practice variation. These 12 primary care docs were from the SAME PRACTICE and this slide prompted important conversations AMONG DOCTORS that changed their prescribing behaviors and lowered costs. Payers and policymakers should take heed when attempting to influence physicians’ decisions.
  • A Novel Plan Helps Hospital Wean Itself Off Pricey Tests.Fuhrmans V. WSJ. January 12, 2007
  • 2009 PT Benchmark Report. HCS Consulting. Available at www.HCSConsulting.com
  • Stavrinaki K. The Health Story Project: Clinical Narrative and Structured Data in the EHR: Venus and Mars live in Harmony with CDA4CDT. AHIMA Conference, October 2009
  • SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms), is a systematically organized computer processable collection of medical terminology covering most areas of clinical information such as diseases, findings, procedures, microorganisms, pharmaceuticals etc. It allows a consistent way to index, store, retrieve, and aggregate clinical data across specialties and sites of care. It also helps organizing the content of medical records, reducing the variability in the way data is captured, encoded and used for clinical care of patients and research.
  • The Rational Clinical Examination: Evidence Based Clinical Diagnosis. Simel DL and Rennie D. JAMA Evidence, McGraw-Hill, 2009
  • Hippisley-Cox J, Coupland C. Development and validation of risk prediction algorithm (QThrombosis) to estimate future risk of venous thromboembolism: prospective cohort study. BMJ 2011; 343:d4656. doi: 10.1136/bmj.d4656 Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. AHRQ. August 2008. Available at http://www.ahrq.gov/qual/vtguide/
  • Sixth Annual HealthGrades Patient Safety in American Hospitals Study. April 2009. Available at http://www.healthgrades.com/business/img/PatientSafetyInAmericanHospitalsStudy2009.pdf
  • Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. AHRQ. August 2008. Available at http://www.ahrq.gov/qual/vtguide/
  • Hart DL et al. Effect of Fear Avoidance Beliefs of Physical Activities on a Model That Predicts Risk-Adjusted Functional Status Outcomes in Patients Treated for a Lumbar Spine Dysfunction. JOSPT 2011;41(5):pp.336-345.Calley DQ, Jackson S, George SZ. Identifying Patients Fear-Avoidance Beliefs by Physical Therapists Managing Patients with Low Back Pain. JOSPT. 2010:40(12):pp.774-783.
  • Waddell G et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic LBP and disability. Pain 1993; 52(2): 157-168.
  • Haggman S, Maher CG, Refshauge KM. Screening for Symptoms of Depression by Physical Therapists Managing Low Back Pain. Phys Ther. 2004; 84:1157-1166.Nemececk D. Integrating Behavioral Health and Primary Care. 6th Annual South Florida Conference Empowering Healthcare, Engaging Consumers of the Florida Health Care Coalition on August 10th, 2011
  • Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and co-morbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.
  • http://www.apta.org/PQRS/ (APTA log-in required)
  • Improving Quality of Care for Medicare Patients: Accountable Care Organizations. DHHS – CMS. April 2011. Available at https://www.cms.gov/MLNProducts/downloads/ACO_Quality_Factsheet_ICN906104.pdf
  • Direct Access: A Check List for Physical Therapist Clinicians. American Physical Therapy Association. Available at http://www.apta.org/DirectAccess/ClinicianChecklist.
  • Leading Health Indicators for Healthy People 2020: Letter Report. March 2011. Institute of Medicine. Available at http://www.iom.edu/Reports/2011/Leading-Health-Indicators-for-Healthy-People-2020.aspx
  • Transcript

    • 1. The Florida Physical Therapists in Private Practice (FLPTPP) presents
      How Physical Therapists Can Thrive Under Health Care Reform
      August 20-21, 2011
      Orlando, Florida
      Tim Richardson, PT
      TimRichPT@BulletproofPT.com
      Downloadable slide show at http://www.BulletproofPT.com
      1
    • 2. Downloadable slide show at http://www.BulletproofPT.com
      2
      The Florida Physical Therapists in Private Practice (FLPTPP) presents
      Armin Loges, PT
      Chris Mulvey, PT
      Tim Richardson, PTDiane Hartely, PTEric Douglass, PTRobert Dragan, PT Stephen Trinque, PTTom Zeller, PTTricia Trinque, PT
    • 3. Can We Do Better?
      • 47 million uninsured Americans.
      • 4. America spends more than any other country in the worlds, almost 17% of Gross Domestic Product (GDP), on healthcare.
      • 5. But, America ranks #37 in Quality and Fairness according to the World Health Organization (WHO). Click the link for the 2008 PBS Frontline documentary Sick Around The World.
      Downloadable slide show at http://www.BulletproofPT.com
      3
    • 6. Can We Do Better?
      Downloadable slide show at http://www.BulletproofPT.com
      4
    • 7. Can We Do Better?
      Downloadable slide show at http://www.BulletproofPT.com
      5
    • 8. Can We Do Better?
      Downloadable slide show at http://www.BulletproofPT.com
      6
    • 9. What is an Accountable Care Organization (ACO)?
      The Shared Savings Program is designed to improve beneficiary outcomes and increase value of care by:
      • Promoting accountability for the care of individual Medicare fee-for-service beneficiaries.
      • 10. Requiring coordinated care for all services provided to a population of people under Medicare Fee-For-Service.
      • 11. Encouraging investment in infrastructure and redesigned care processes in order to reduce the per-capita cost of healthcare.
      Eligible providers, hospitals and suppliers may participate in the Shared Savings Program by creating or joining an Accountable Care Organization, also called an ACO. The ACO is expected to transition to population-based payment arrangements
      Downloadable slide show at http://www.BulletproofPT.com
      7
    • 12. What is an Accountable Care Organization (ACO)?
      Section 3022 of the Affordable Care Act that was signed into law by President Barack Obama on March 23, 2010 requires the Centers for Medicare and Medicaid Services (CMS) to establish a Shared Savings Program to facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service beneficiaries and reduce unnecessary costs. 
      Downloadable slide show at http://www.BulletproofPT.com
      8
    • 13. What is an Accountable Care Organization (ACO)?
      Risk & Reward
      Downloadable slide show at http://www.BulletproofPT.com
      9
    • 14. ACO Quality Measures
      Downloadable slide show at http://www.BulletproofPT.com
      10
      Five Domains
      Patient/Care Giver Experience
      Care Coordination
      Patient Safety
      Preventative Health
      At-risk Population/ Frail Elderly
    • 15. ACO Quality Measures
      Downloadable slide show at http://www.BulletproofPT.com
      11
    • 16. ACO Quality Measures
      Downloadable slide show at http://www.BulletproofPT.com
      12
    • 17. ACO Quality Measures
      Downloadable slide show at http://www.BulletproofPT.com
      13
    • 18. ACO Quality Measures
      Downloadable slide show at http://www.BulletproofPT.com
      14
    • 19. ACO Quality Measures
      Downloadable slide show at http://www.BulletproofPT.com
      15
    • 20. ACO Quality Measures
      Downloadable slide show at http://www.BulletproofPT.com
      16
    • 21. ACO Quality Measures
      Downloadable slide show at http://www.BulletproofPT.com
      17
    • 22. ACO Quality Measures
      Downloadable slide show at http://www.BulletproofPT.com
      CMS is proposing to define the first quality performance period as beginning January 1, 2012, and ending December 31, 2012.
      For the first year of the Shared Savings Program, CMS proposes to set the quality
      performance standard at the reporting level.
      18
    • 23. What is an Accountable Care Organization (ACO)?
      Downloadable slide show at http://www.BulletproofPT.com
      The Physician Group Practice (PGP) Demonstration was the first pay-for-performance initiative for physicians under the Medicare program.
      Billings Clinic, Billings, Montana
      Dartmouth-Hitchcock Clinic, Bedford, New Hampshire
      The Everett Clinic, Everett, Washington
      Forsyth Medical Group, Winston-Salem, North Carolina
      Geisinger Health System, Danville, Pennsylvania
      Marshfield Clinic, Marshfield, Wisconsin
      Middlesex Health System, Middletown, Connecticut
      Park Nicollet Health Services, St. Louis Park, Minnesota
      St. John’s Health System, Springfield, Missouri
      University of Michigan Faculty Group Practice, Ann Arbor, Michigan
      19
    • 24. What is an Accountable Care Organization (ACO)?
      Downloadable slide show at http://www.BulletproofPT.com
      There are three primary ways for an ACO to achieve savings on the care of the assigned Medicare population:
      Reducing emergency room visits and hospital inpatient admissions.
      Reducing the provision of specialty care for the assigned Medicare patient population
      Reducing the provision of imaging and other special tests
      20
    • 25. What is an Accountable Care Organization (ACO)?
      Downloadable slide show at http://www.BulletproofPT.com
      Preventing Avoidable Hospital Re-admissions
      Preventable readmissions can occur because of...
      • Inadequate discharge planning
      • 26. Inadequate post-discharge follow-up
      • 27. Lack of coordination between inpatient and outpatient healthcare teams.
      21
    • 28. What is an Accountable Care Organization (ACO)?
      Downloadable slide show at http://www.BulletproofPT.com
      Smith et al reported on the discharge recommendations of 40 physical therapists treating 762 patients at a large, acute care hospital. Smith wanted to see how often the therapists’ recommendations were followed.
      The therapists’ discharge recommendations were followed 83% of the time. There was a mismatch in PT recommendation and patient discharge location in 124 of 743 cases .
      When the therapists’ recommendations were NOT followed, the patients were 2.9 times MORE likely to be readmitted than when the recommendations were followed.
      The hospital had an 18% 30-day re-admission rate, which is consistent with the literature.
      22
    • 29. What is an Accountable Care Organization (ACO)?
      Downloadable slide show at http://www.BulletproofPT.com
      Specialist Costs
      23
    • 30. What is an Accountable Care Organization (ACO)?
      Downloadable slide show at http://www.BulletproofPT.com
      Imaging Costs
      Overutilization of CAT scans:
      Double billing the Medicare program
      24
    • 31. Downloadable slide show at http://www.BulletproofPT.com
      What is an Accountable Care Organization (ACO)?
      Imaging Costs
      25
    • 32. What is an Accountable Care Organization (ACO)?
      Downloadable slide show at http://www.BulletproofPT.com
      26
    • 33. What is an Accountable Care Organization (ACO)?
      Downloadable slide show at http://www.BulletproofPT.com
      27
    • 34. How to Manage a Patient Population
      Downloadable slide show at http://www.BulletproofPT.com
      28
    • 35. How to Manage a Patient Population
      Downloadable slide show at http://www.BulletproofPT.com
      29
      Epidemiology
      The branch of medical science dealing with the transmission and control of disease and the mathematics of the collection, organization, and interpretation of numerical data, especially the analysis of population characteristics by inference from sampling.
    • 36. How to Manage a Patient Population
      Downloadable slide show at http://www.BulletproofPT.com
      Population health has been defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”
      It is an approach to health that aims to improve the health of an entire population.
      One major step in achieving this aim is to reduce health inequities among population groups.
      Population health seeks to step beyond the individual-level focus of mainstream medicine and public health by addressing a broad range of factors that impact health on a population-level, such as environment, social structure, resource distribution, etc.
      An important theme in population health is importance of social determinants of health and the relatively minor impact that medicine and healthcare have on improving health overall.
      From a population health perspective, health has been defined not simply as a state free from disease but as "the capacity of people to adapt to, respond to, or control life's challenges and changes“.
      30
    • 37. How to Manage a Patient Population
      Diagnosis
      The process the clinician uses to move progressively from a region of low clinical certainty to a region of high clinical certainty.
      In low probability conditions, screening tests are used to generate diagnostic possibilities and to “rule out” improbable conditions.
      In high probability conditions, diagnostic tests are used to confirm, or “rule in” likely conditions.
      Both testing and treatment carry risk.
      Downloadable slide show at http://www.BulletproofPT.com
      31
    • 38. How to Manage a Patient Population
      Downloadable slide show at http://www.BulletproofPT.com
      32
    • 39. How to Manage a Patient Population
      How Are Physical Therapists Making Diagnoses?
      • Self-Rated and Physical Characteristics
      • 40. Treatment Based Classification
      • 41. Pathological Conditions
      • 42. Psycho-Social Conditions
      Downloadable slide show at http://www.BulletproofPT.com
      33
    • 43. How to Manage a Patient Population
      Downloadable slide show at http://www.BulletproofPT.com
      34
    • 44. How to Manage a Patient Population
      ODI
      SPADI
      Downloadable slide show at http://www.BulletproofPT.com
      35
    • 45. How to Manage a Patient Population
      Downloadable slide show at http://www.BulletproofPT.com
      36
    • 46. How to Manage a Patient Population
      Downloadable slide show at http://www.BulletproofPT.com
      37
    • 47. How to Manage a Patient Population
      Clinical Decision Rules
      Prediction of Community Acquired Pneumonia (CAP)
      Temperature > 100.04o
      Pulse > 100bpm
      Crackles/Rales on auscultation
      Decreased breath sounds on auscultation
      No asthma
      The clinician assigns one point for each of the findings that is present.
      Downloadable slide show at http://www.BulletproofPT.com
      38
    • 48. How to Manage a Patient Population
      Clinical Decision Rules
      Prediction of Community Acquired Pneumonia (CAP)
      Prevalence of Pneumonia in Primary Care = 2%
      Downloadable slide show at http://www.BulletproofPT.com
      39
    • 49. How to Manage a Patient Population
      Clinical Decision Rules
      Prediction of Community Acquired Pneumonia (CAP)
      Prevalence of Pneumonia in the Emergency setting = 8%
      Downloadable slide show at http://www.BulletproofPT.com
      40
    • 50. How to Manage a Patient Population
      Prediction of Community Acquired Pneumonia (CAP)
      Downloadable slide show at http://www.BulletproofPT.com
      41
    • 51. How to Manage a Patient Population
      Prediction of Community Acquired Pneumonia (CAP)
      Lung Sounds: Normal
      Lung Sounds: Crackles/Rales
      Lung Sounds: Wheezing
      Downloadable slide show at http://www.BulletproofPT.com
      42
    • 52. How to Manage a Patient Population
      Prediction of Community Acquired Pneumonia (CAP)
      ...compared with...
      Downloadable slide show at http://www.BulletproofPT.com
      43
    • 53. How to Manage a Patient Population
      Derive Sn, Sp, +LR, -LR with a 2x2 table
      Need Pneumonia numbers
      Downloadable slide show at http://www.BulletproofPT.com
      44
    • 54. How to Manage a Patient Population
      Downloadable slide show at http://www.BulletproofPT.com
      45
    • 55. Downloadable slide show at http://www.BulletproofPT.com
      46
    • 56. Disruptive Innovation
      Downloadable slide show at http://www.BulletproofPT.com
      “The business models of health are frozen in the hospital and the doctors’ office. The path to fixing the system is to disrupt those models.”
      Clayton Christensen
      The Innovator’s Prescription
      There are really three business model under one roof in the hospital:
      Precision medicine that can be “Routinized”. The goal is to identify areas where automation of repetitive tasks can improve care and save costs. Example: Total Knee Replacements.
      Intuitive medicine that requires highly trained specialists using costly diagnostic testing machines to discover the best treatment approach. Example: Gregory House, MD.
      Empirical medicine is the costly trial-and-error realm of chronic disease management. Christensen predicts an increase in patient autonomy, self-diagnosis and self-care choices. The rise of social networks will feature prominently in this realm. Example: Outpatient Physical Therapy.
      47
    • 57. Disruptive Innovation
      Downloadable slide show at http://www.BulletproofPT.com
      48
    • 58. Disruptive Innovation
      Downloadable slide show at http://www.BulletproofPT.com
      49
      Non-physician professionals, like Registered Nurses, Physical Therapists and Physicians Assistants, will tend to disrupt the business practices of primary care physicians
      Primary care physicians will tend to disrupt the business practices of specialist physicians
      Specialist physicians
    • 59. How Physical Therapists Can Drive Better Outcomes
      Exercise is generally NOT harmful. Power training.
      Increased, self-directed activity is essential to reducing disability.
      Promote activity: walking, yoga, running, lifting, resistance programs, Zumba, Pilates, gardening, golf, fishing.
      Downloadable slide show at http://www.BulletproofPT.com
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    • 60. How Physical Therapists Can Drive Better Outcomes
      Hurt ≠ Harm.
      Emotional/Mental factors may drive 30-55% of musculoskeletal outcomes.
      Behavioral training more important than Cognitive training
      Downloadable slide show at http://www.BulletproofPT.com
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    • 61. How Physical Therapists Can Drive Better Outcomes
      Adequate physical activity is linked with important health outcomes…
      Reduced cardiovascular disease
      Type 2 diabetes
      Some cancers
      Future falls risk
      Osteoporotic fractures
      Depression
      Physical function scores on standardized self report measures
      Downloadable slide show at http://www.BulletproofPT.com
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    • 62. How Physical Therapists Can Drive Better Outcomes
      Behavior Change Assumptions
      Education
      Knowledge
      Behavior Change
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    • 63. How Physical Therapists Can Drive Better Outcomes
      Behavioral interventions MORE effective than educational interventions.
      • Goal setting/contracting
      • 64. Self-monitoring
      • 65. Feedback – Functional Scales
      • 66. Consequences/rewards
      • 67. Exercise prescription
      • 68. Cues
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    • 69. How Physical Therapists Can Drive Better Outcomes
      Goals
      Do single leg standing x 30sec. three times per day to improve balance.
      Cues
      First thing in the morning do single leg standing x 30sec. in the kitchen while the coffee percolates.
      Downloadable slide show at http://www.BulletproofPT.com
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    • 70. How Physical Therapists Can Drive Better Outcomes
      Educational/cognitive interventions LESS effective at promoting physical activity
      Targeting knowledge, attitudes or beliefs
      Mass media (vs. individualized instruction).
      Train-the-trainer models (vs. staff providing interventions directly to patients).
      Idiosyncratic provider interventions (vs. standardized recommendations).
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    • 71. How Physical Therapists Can Drive Better Outcomes
      “Medical Theater”
      Real treatment effects/outcomes due to some aspect of the medical intervention other than the physiologic effect. NOT a placebo!
      “A placebo is a substance or procedure…that is objectively without specific activity for the condition being treated…”
      Downloadable slide show at http://www.BulletproofPT.com
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    • 72. How Physical Therapists Can Drive Better Outcomes
      What drives outcomes in addition to the intended treatment?
      Dress: The white coast and stethoscope
      Language: Medical jargon based in Latin
      Diagnosis and Expectation: The effect on functional status over time of a diagnosis of “disc degeneration”
      Cost: More costly medical treatments have a higher cost and a higher perceived benefit
      Color: Blue pill vs. Red pill study by Blackwell
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    • 73. How Physical Therapists Can Drive Better Outcomes
      “Medical Theater”
      • Albuterol vs. Sham Acupuncture for Asthma (2011)
      • 74. Branded Analgesics for Headache (1981)
      • 75. Red pill vs. Blue Pill for Mood Alteration (1972)
      • 76. Internal Mammary Artery Ligation for Chest Pain (1959, 1960)
      Downloadable slide show at http://www.BulletproofPT.com
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    • 77. How Physical Therapists Can Drive Better Outcomes
      “Medical Theater”
      Downloadable slide show at http://www.BulletproofPT.com
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    • 78. How Physical Therapists Can Drive Better Outcomes
      “Medical Theater”
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    • 79. How Physical Therapists Can Drive Better Outcomes
      “Medical Theater”
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    • 80. How Physical Therapists Can Drive Better Outcomes
      “Medical Theater”
      Downloadable slide show at http://www.BulletproofPT.com
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    • 81. How Physical Therapists Can Drive Better Outcomes
      Health Coaching
      Hotspots by AtulGawande, MD featuring Jeffrey Brenner, MD
      New Yorker magazine article
      Frontline “Hotspotters” Video
      Downloadable slide show at http://www.BulletproofPT.com
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    • 82. How Physical Therapists Can Drive Better Outcomes
      The Six Sources of Influence
      Downloadable slide show at http://www.BulletproofPT.com
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    • 83. Downloadable slide show at http://www.BulletproofPT.com
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      How Physical Therapists Can Drive Better Outcomes
      How to Persuade your Patient
      • Stone et al attempted to change college student sexual protection behavior.
      • 84. Lectured the students: “Use Condoms!” – didn’t work
      • 85. Had college students make an educational video to teach high school students about protected sex.
      • 86. Technique worked.
      • 87. 80% of the college students bought condoms immediately and the amount of condoms purchased was greater than a control group.
      • 88. Technique known as Cognitive Dissonance.
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      How Physical Therapists Can Drive Better Outcomes
    • 89. Critical Pathways of Care:
      Starbucks/Aetna Saves Money, Improves Outcomes
      Downloadable slide show at http://www.BulletproofPT.com
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      How Physical Therapists Can Drive Better Outcomes
    • 90. Costs and Productivity
      Downloadable slide show at http://www.BulletproofPT.com
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    • 91. Structured Data
      Structured data is another way of referring to data that is entered into a specific field as opposed to free text in a chart note.
      60% of the narrative note data is lost to the EMR.
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    • 92. Structured Data
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    • 93. Structured Data
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    • 94. Structured Data
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    • 95. Structured Data
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    • 96. Structured Data
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    • 97. Structured Data
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    • 98. Structured Data
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    • 99. Structured Data
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      • Which structured data point is more predictive of the outcome?
      • 100. Which structured data point is predictive of future disablement?
      • 101. Which structured data point demonstrates Medical Neccesity for Physical Therapy to initiate a PT POC or to exceed the PT Cap using the –KX modifier?
    • Structured Data
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    • 102. Structured Data
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    • 103. Downloadable slide show at http://www.BulletproofPT.com
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      Decision Rules
      CAGE Rule for Alcoholism Screening
      • An estimated 100 million Americans drink alcohol.
      • 104. 10% of those who drink have alcohol problems that adversely affect their lives and their families lives.
      • 105. The mortality rate of those who drink 6 or more drinks per day is 50% than matched controls.
      • 106. Alcohol is a major factor in suicides, homicides, violent crimes and motor vehicle accidents.
      • 107. Physicians are about to recognize, without decision aids, only about half of the problem drinkers they encounter.
      • 108. Physicians are even LESS likely to identify, without decision aids, alcohol problems in women and elderly people.
    • CAGE Rule for Alcoholism Screening
      Downloadable slide show at http://www.BulletproofPT.com
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      Decision Rules
      “Have you ever felt you ought to cut down on your drinking?”
      “Have people annoyed you by criticizing your drinking?”
      “Have you ever felt bad or guilty about your drinking?”
      “Have you ever had a drink (eye opener) first thing in the morning to steady your nerves or get rid of a hangover?”
    • 109. Downloadable slide show at http://www.BulletproofPT.com
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      Decision Rules
      CAGE Rule for Alcoholism Screening
    • 110. Decision Rules
      Downloadable slide show at http://www.BulletproofPT.com
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      HINTS to Diagnose Stroke in Acute Vestibular Syndrome (vertigo, nystagmus, nausea, head motion intolerance, unsteady gait)
      • Normal Horizontal Head Impulse Test
      • 111. Nystagmus in different gaze positions
      • 112. Test of Skew with prism crossover test of ocular alignment
      Prevalence of Stroke: 25% of dizzy patients in the emergency setting are experiencing a stroke.
      HINTS is Head-Impulse, Nystagmus, Test-of-Skew.
       
    • 113. Decision Rules
      Downloadable slide show at http://www.BulletproofPT.com
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    • 114. Decision Rules
      DVT risk and prevalence is increasing.
      DVT and Pulmonary Embolism (PE) is “the most common preventable cause of hospital death in the United States”.
      2 million Americans develop DVTs every year and 200,000 die of the associated PE.
      Each year, over 25,000 people in England die from venous thromboembolism developed in hospital.
      Downloadable slide show at http://www.BulletproofPT.com
      Screening for Deep Vein Thrombosis
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    • 115. Decision Rules
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      Screening for Deep Vein Thrombosis
      87
    • 116. Decision Rules
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      Screening for Deep Vein Thrombosis
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    • 117. Active cancer? 
      Bedridden recently >3 days or major surgery within four weeks? 
      Calf swelling >3cm compared to the other leg? 
      Collateral (non-varicose) superficial veins present? 
      Entire leg swollen?
      Localized tenderness along the deep venous system? 
      Pitting edema, greater in the symptomatic leg? 
      Paralysis, paresis, or recent plaster immobilization of the lower extremity 
      Previously documented DVT? 
      Alternative diagnosis to DVT as likely or more likely?
      Downloadable slide show at http://www.BulletproofPT.com
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      Decision Rules
      Screening for Deep Vein Thrombosis (DVT)
    • 118. Downloadable slide show at http://www.BulletproofPT.com
      90
      Decision Rules
      Screening for Deep Vein Thrombosis (DVT)
    • 119. Test Question: “Do you believe that you should not do any activities that make your pain worse?”
      Downloadable slide show at http://www.BulletproofPT.com
      Decision Rules
      Screening for Fear Avoidance Beliefs
      In one study of 80 patients, George estimates the population prevalence of elevated fear avoidance behaviors to be 37.5%.
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    • 120. Downloadable slide show at http://www.BulletproofPT.com
      The largest single, modifiable factor affecting worker and our patients’ outcomes may be the psychosocial factor.
      As stated by Waddell...
      “…fear of pain and what we do about it may be more disabling than pain itself.”
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      Decision Rules
      Screening for Fear Avoidance Beliefs
    • 121. Downloadable slide show at http://www.BulletproofPT.com
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      Decision Rules
      Screening for Fear Avoidance Beliefs
    • 122. Downloadable slide show at http://www.BulletproofPT.com
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    • 123. Decision Rules
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      Screening for Depression
      • Prevalence of acute depression is 25% in Americans.
      • 124. Depressed patients 3x more likely to be non-adherent with their medical treatment.
      • 125. Of the world’s ten leading causes of disability, five are psychiatric/addictive conditions.
      • 126. With appropriate treatment, 80% of people with depression will recover fully.
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      Decision Rules
      Screening for Depression
      Ask your patient these questions:
      “During the past month, have you often been bothered by feeling down, depressed or hopeless?”
      AND
      “During the past month, have you often been bothered by little interest or pleasure in doing things?”
    • 127. Downloadable slide show at http://www.BulletproofPT.com
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      Decision Rules
      Screening for Depression
      Prevalence of acute depression is 25% in Americans.
      Prevalence of chronic depression is 6.7% in Americans
    • 128. Decision Rules
      Physician Quality Reporting System
      Health Information Technology: Adoption/Use of Electronic Medical Records (#124)
      Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy: Neurological Evaluation (#126)
      Diabetic Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Evaluation of Footwear; Preventive Care and Screening (#127)
      Body Mass Index (BMI) Screening and Follow-up (#128)
      Documentation and Verification of Current Medications in the Medical Record (#130)
      Pain Assessment Prior to Initiation of Patient Treatment (#131)
      Falls: Plan of Care (measure #154)
      Falls: Risk Assessment (#155)
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      The Affordable Care Act makes a number of changes to the Physician Quality Reporting System, including authorizing incentive payments through 2014 and requiring a penalty, beginning in 2015 for professionals who do not satisfactorily report.
    • 129. Decision Rules
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      Physician Quality Reporting System
      In addition, physical therapists are eligible to report on a measures group related to back pain. If a physical therapist elects to participate based on this measures group, he or she must perform all the measures in this group. The back pain measures include:
      • Back Pain: Initial Visit (measure #148)
      • 130. Back Pain: Physical Exam (measure #149)
      • 131. Back Pain: Advice for Normal Activities (measure #150)
      • 132. Back Pain: Advice Against Bed Rest (measure #151)
      “Several of the proposed ACO quality measures align with those used in other CMS quality programs, such as the Physician Quality Reporting System...”
    • 133. Decision Rules
      Ottawa Rules for Ankle Fracture Following Trauma
      Downloadable slide show at http://www.BulletproofPT.com
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    • 134. Decision Rules
      Ottawa Rules for Knee Fracture Following Trauma
      Downloadable slide show at http://www.BulletproofPT.com
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    • 135. Decision Rules
      Screening for Spinal Fracture
      Downloadable slide show at http://www.BulletproofPT.com
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    • 136. Decision Rules
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      Cancer Screening in Lower Back Pain
    • 137. How Physical Therapists Can Do Better
      Downloadable slide show at http://www.BulletproofPT.com
      Clinical Decision Support Tools
      • Move away from “asking permission” from the physician to “making recommendations” to the physician.
      • 138. Knowing when not to treat is as important as knowing when to treat.
      • 139. Maintain a list of health professions to refer patients to when indicated.
      • 140. Maintain a high “index of suspicion” for pathology
      • 141. Collect baseline data. Create systems. Push down data collection to every person in the clinic.
      • 142. Standardize your Examination. Screen low AND high risk populations.
      • 143. Find patterns.
      • 144. Follow-up
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    • 145. How Physical Therapists Can Do Better
      Downloadable slide show at http://www.BulletproofPT.com
      Population Health
      Address population health through behavior and active exercise programs. Some possibilities might include:
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    • 157. How Physical Therapists Can Do Better
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      • ACOs may lower costs, improve quality
      • 158. Physical therapists can address population health
      • 159. Physical therapists can address behavioral health
      • 160. Physical therapists may need to alter patients’ and physicians’ expectations
      • 161. Structured Data is a new type of documentation
      • 162. Clinical Decision Rules are a “Technological Disruptor” in Health Care...
      ...if we use them!
    • 163. Thank You
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