The Florida Physical Therapists in Private Practice (FLPTPP) presents<br />How Physical Therapists Can Thrive Under Health...
Downloadable slide show at http://www.BulletproofPT.com<br />2<br />The Florida Physical Therapists in Private Practice (F...
Can We Do Better?<br /><ul><li>47 million uninsured Americans.
America spends more than any other country in the worlds, almost 17% of Gross Domestic Product (GDP), on healthcare.
But, America ranks #37 in Quality and Fairness according to the World Health Organization (WHO). Click the link for the 20...
Can We Do Better?<br />Downloadable slide show at http://www.BulletproofPT.com<br />4<br />
Can We Do Better?<br />Downloadable slide show at http://www.BulletproofPT.com<br />5<br />
Can We Do Better?<br />Downloadable slide show at http://www.BulletproofPT.com<br />6<br />
What is an Accountable Care Organization (ACO)? <br />The Shared Savings Program is designed to improve beneficiary outcom...
   Requiring coordinated care for all services provided to a population of people under Medicare Fee-For-Service.
   Encouraging investment in infrastructure and redesigned care processes in order to reduce the per-capita cost of health...
What is an Accountable Care Organization (ACO)? <br />Section 3022 of the Affordable Care Act that was signed into law by ...
What is an Accountable Care Organization (ACO)? <br />Risk & Reward<br />Downloadable slide show at http://www.Bulletproof...
ACO Quality Measures<br />Downloadable slide show at http://www.BulletproofPT.com<br />10<br />Five Domains<br />Patient/C...
ACO Quality Measures<br />Downloadable slide show at http://www.BulletproofPT.com<br />11<br />
ACO Quality Measures<br />Downloadable slide show at http://www.BulletproofPT.com<br />12<br />
ACO Quality Measures<br />Downloadable slide show at http://www.BulletproofPT.com<br />13<br />
ACO Quality Measures<br />Downloadable slide show at http://www.BulletproofPT.com<br />14<br />
ACO Quality Measures<br />Downloadable slide show at http://www.BulletproofPT.com<br />15<br />
ACO Quality Measures<br />Downloadable slide show at http://www.BulletproofPT.com<br />16<br />
ACO Quality Measures<br />Downloadable slide show at http://www.BulletproofPT.com<br />17<br />
ACO Quality Measures<br />Downloadable slide show at http://www.BulletproofPT.com<br />CMS is proposing to define the firs...
What is an Accountable Care Organization (ACO)? <br />Downloadable slide show at http://www.BulletproofPT.com<br />The Phy...
What is an Accountable Care Organization (ACO)? <br />Downloadable slide show at http://www.BulletproofPT.com<br />There a...
What is an Accountable Care Organization (ACO)? <br />Downloadable slide show at http://www.BulletproofPT.com<br />Prevent...
Inadequate post-discharge follow-up
Lack of coordination between inpatient and outpatient healthcare teams.</li></ul>21<br />
What is an Accountable Care Organization (ACO)? <br />Downloadable slide show at http://www.BulletproofPT.com<br />Smith e...
What is an Accountable Care Organization (ACO)? <br />Downloadable slide show at http://www.BulletproofPT.com<br />Special...
What is an Accountable Care Organization (ACO)? <br />Downloadable slide show at http://www.BulletproofPT.com<br />Imaging...
Downloadable slide show at http://www.BulletproofPT.com<br />What is an Accountable Care Organization (ACO)? <br />Imaging...
What is an Accountable Care Organization (ACO)? <br />Downloadable slide show at http://www.BulletproofPT.com<br />26<br />
What is an Accountable Care Organization (ACO)? <br />Downloadable slide show at http://www.BulletproofPT.com<br />27<br />
How to Manage a Patient Population<br />Downloadable slide show at http://www.BulletproofPT.com<br />28<br />
How to Manage a Patient Population<br />Downloadable slide show at http://www.BulletproofPT.com<br />29<br />Epidemiology<...
How to Manage a Patient Population<br />Downloadable slide show at http://www.BulletproofPT.com<br />Population health has...
How to Manage a Patient Population<br />Diagnosis<br />The process the clinician uses to move progressively from a region ...
How to Manage a Patient Population<br />Downloadable slide show at http://www.BulletproofPT.com<br />32<br />
How to Manage a Patient Population<br />How Are Physical Therapists Making Diagnoses?<br /><ul><li>Self-Rated and Physical...
Treatment Based Classification
Pathological Conditions
Psycho-Social Conditions</li></ul>Downloadable slide show at http://www.BulletproofPT.com<br />33<br />
How to Manage a Patient Population<br />Downloadable slide show at http://www.BulletproofPT.com<br />34<br />
How to Manage a Patient Population<br />ODI<br />SPADI<br />Downloadable slide show at http://www.BulletproofPT.com<br />3...
How to Manage a Patient Population<br />Downloadable slide show at http://www.BulletproofPT.com<br />36<br />
How to Manage a Patient Population<br />Downloadable slide show at http://www.BulletproofPT.com<br />37<br />
How to Manage a Patient Population<br />Clinical Decision Rules<br />Prediction of Community Acquired Pneumonia (CAP)<br /...
How to Manage a Patient Population<br />Clinical Decision Rules<br />Prediction of Community Acquired Pneumonia (CAP)<br /...
How to Manage a Patient Population<br />Clinical Decision Rules<br />Prediction of Community Acquired Pneumonia (CAP)<br /...
How to Manage a Patient Population<br />Prediction of Community Acquired Pneumonia (CAP)<br />Downloadable slide show at h...
How to Manage a Patient Population<br />Prediction of Community Acquired Pneumonia (CAP)<br />Lung Sounds: Normal<br />Lun...
How to Manage a Patient Population<br />Prediction of Community Acquired Pneumonia (CAP)<br />...compared with... <br />Do...
How to Manage a Patient Population<br />Derive Sn, Sp, +LR, -LR with a 2x2 table<br />Need Pneumonia numbers<br />Download...
How to Manage a Patient Population<br />Downloadable slide show at http://www.BulletproofPT.com<br />45<br />
Downloadable slide show at http://www.BulletproofPT.com<br />46<br />
Disruptive Innovation<br />Downloadable slide show at http://www.BulletproofPT.com<br />“The business models of health are...
Disruptive Innovation<br />Downloadable slide show at http://www.BulletproofPT.com<br />48<br />
Disruptive Innovation<br />Downloadable slide show at http://www.BulletproofPT.com<br />49<br />Non-physician professional...
How Physical Therapists Can Drive Better Outcomes<br />Exercise is generally NOT harmful. Power training.<br />Increased, ...
How Physical Therapists Can Drive Better Outcomes<br />Hurt ≠ Harm. <br />Emotional/Mental factors may drive 30-55% of mus...
How Physical Therapists Can Drive Better Outcomes<br />Adequate physical activity is linked with important health outcomes...
How Physical Therapists Can Drive Better Outcomes<br />Behavior Change Assumptions<br />Education<br />Knowledge<br />Beha...
How Physical Therapists Can Drive Better Outcomes<br />Behavioral interventions MORE effective than educational interventi...
Self-monitoring
Feedback – Functional Scales
Consequences/rewards
Exercise prescription
Cues</li></ul>Downloadable slide show at http://www.BulletproofPT.com<br />54<br />
How Physical Therapists Can Drive Better Outcomes<br />Goals<br />Do single leg standing x 30sec. three times per day to i...
How Physical Therapists Can Drive Better Outcomes<br />Educational/cognitive interventions LESS effective at promoting phy...
How Physical Therapists Can Drive Better Outcomes<br />“Medical Theater” <br />Real treatment effects/outcomes due to some...
How Physical Therapists Can Drive Better Outcomes<br />What drives outcomes in addition to the intended treatment?<br />Dr...
How Physical Therapists Can Drive Better Outcomes<br />“Medical Theater”<br /><ul><li>Albuterol vs. Sham Acupuncture for A...
Branded Analgesics for Headache (1981)
Red pill vs. Blue Pill for Mood Alteration (1972)
Internal Mammary Artery Ligation for Chest Pain (1959, 1960)</li></ul>Downloadable slide show at http://www.BulletproofPT....
How Physical Therapists Can Drive Better Outcomes<br />“Medical Theater”<br />Downloadable slide show at http://www.Bullet...
How Physical Therapists Can Drive Better Outcomes<br />“Medical Theater”<br />Downloadable slide show at http://www.Bullet...
How Physical Therapists Can Drive Better Outcomes<br />“Medical Theater”<br />Downloadable slide show at http://www.Bullet...
How Physical Therapists Can Drive Better Outcomes<br />“Medical Theater”<br />Downloadable slide show at http://www.Bullet...
How Physical Therapists Can Drive Better Outcomes<br />Health Coaching<br />Hotspots by AtulGawande, MD featuring Jeffrey ...
How Physical Therapists Can Drive Better Outcomes<br />The Six Sources of Influence<br />Downloadable slide show at http:/...
Downloadable slide show at http://www.BulletproofPT.com<br />66<br />How Physical Therapists Can Drive Better Outcomes<br ...
Lectured the students: “Use Condoms!” – didn’t work
Had college students make an educational video to teach high school students about protected sex.
Technique worked.
80% of the college students bought condoms immediately and the amount of condoms purchased was greater than a control group.
Technique known as Cognitive Dissonance.</li></li></ul><li>Downloadable slide show at http://www.BulletproofPT.com<br />67...
Critical Pathways of Care: <br />Starbucks/Aetna Saves Money, Improves Outcomes<br />Downloadable slide show at http://www...
Costs and Productivity<br />Downloadable slide show at http://www.BulletproofPT.com<br />69<br />
Structured Data<br />Structured data is another way of referring to data that is entered into a specific field as opposed ...
Structured Data<br />Downloadable slide show at http://www.BulletproofPT.com<br />71<br />
Structured Data<br />Downloadable slide show at http://www.BulletproofPT.com<br />72<br />
Structured Data<br />Downloadable slide show at http://www.BulletproofPT.com<br />73<br />
Structured Data<br />Downloadable slide show at http://www.BulletproofPT.com<br />74<br />
Structured Data<br />Downloadable slide show at http://www.BulletproofPT.com<br />75<br />
Structured Data<br />Downloadable slide show at http://www.BulletproofPT.com<br />76<br />
Structured Data<br />Downloadable slide show at http://www.BulletproofPT.com<br />77<br />
Structured Data<br />Downloadable slide show at http://www.BulletproofPT.com<br />78<br /><ul><li>Which structured data po...
Which structured data point is predictive of future disablement?
Which structured data point demonstrates Medical Neccesity for Physical Therapy to initiate a PT POC or to exceed the PT C...
Structured Data<br />Downloadable slide show at http://www.BulletproofPT.com<br />80<br />
Downloadable slide show at http://www.BulletproofPT.com<br />81<br />Decision Rules<br />CAGE Rule for Alcoholism Screenin...
10% of those who drink have alcohol problems that adversely affect their lives and their families lives.
The mortality rate of those who drink 6 or more drinks per day is 50% than matched controls.
Alcohol is a major factor in suicides, homicides, violent crimes and motor vehicle accidents.
Physicians are about to recognize, without decision aids, only about half of the problem drinkers they encounter.
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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.

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
  • How physical therapists can thrive under health care (1)

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