Physical therapists, will be able to avoid the 2016
2.0% PQRS penalty by reporting at least 3 individual
measures via claims or registry for 50% or more of
eligible Medicare patients in the 2014 reporting
increase the number of PQRS quality measures that
providers must report either via claims or registry
from 3 to 9 to qualify for the 0.5% bonus payment in
eliminate the option to report on measures groups
To identify, develop, endorse, implement, and
advance quality measures in PT and the settings
where PTs practice.
To advance payment models that promote the
value of PT.
To identify, develop and implement public policy
and payment initiatives that advance the role of
the PT in disease management, prevention and
To improve access to PTs by the elimination
of regulatory, legal and payment policy
To eliminate referral for profit in PT
To advance policy that ensure a qualified
workforce in PT to meet the public need for
health care services.
Increase funding for rehabilitation research
Extended Scope of Practice
Full PT Scope of Practice
Individual Scope –personal
Advanced Scope of Practice: A role that is within
the currently recognized scope of practice for
that profession, but that through custom and
practice has been performed by other
professions. The advanced role may require
additional training as well as significant
professional experience and competency
▪ Australian Physiotherapy Association
Extended Scope of Practice-:A role that is outside
the currently recognized scope of practice and one
that requires some method of credentialing
following additional training, competency
development and significant professional
experience, as well as legislative change.
Australian Physiotherapy Association
The summit sought to share international
experiences in developing and implementing
policy direct access and advanced practice in
A post Summit working group addressed key
questions involving direct access and advanced
scope of practice and strategies to move this
Collaboration with other stakeholders
(including other PTs, HCPs, researchers,
Understanding of purpose of ESP (patient
centered, profession specific, health care
Measurements of success exist
Importance of public recognition
Rising health care costs, problems with
access to care, and physician shortages
leading to new models of care.
Physiotherapy as key provider for services for
Natural to move to advanced/extended SOP.
2005 : supplementary prescribers.
▪ “Voluntary partnership with medical practitioner and eligible supplementary
prescriber to implement an agreed patient specific written clinical management
plan with the patients agreement”
▪ Need counter signature
August 2013: Independent prescribing by physiotherapists.
“..independent prescribing is prescribing by a practitioner responsible and
accountable for the assessment of patients with undiagnosed or diagnosed
conditions and for decisions about the clinical management required, including
▪ Eligible: Advanced practitioners and additional training
▪ Wide range of medicines
*Department of Health (2006) Improving Patients’ Access to Medicines – A Guide to
Implementing Nurse and Pharmacist Independent Prescribing within the NHS in
England, London, DH
Non Medical Prescribing Pathway.
Identified large increases in demand for health
care, equity of access, financial sustainability,
workforce shortages and a fragmented health
system as challenges facing Australia.
PTs considered as primary contact practitioners.
Recently approved by the Minster of Health
Desmeules, et al (2012) Systematic Review: Assess effectiveness of PT’s in APP
“The new roles include role enhancement and role substitution related to
traditionally performed medical or controlled acts, such as: communicating a
diagnosis, triaging potential surgical candidates, ordering diagnostic imaging
or laboratory tests, and prescribing/injecting medication.”
▪ “emerging evidence suggests that physiotherapists in APP roles provide
equal or better usual care in comparison to physicians in terms of
diagnostic accuracy, treatment effectiveness, use of healthcare resources,
economic costs and patient satisfaction. There is a need for more
methodologically sound studies to evaluate the effectiveness APP care.”
Desmeules F, Roy JS, MacDermid JC, Champagne F, Hinse O, Woodhouse LJ. Advanced practice physiotherapy in
patients with musculoskeletal disorders: A systematic review. BMC Musculoskelet Disord. 2012;13:107-2474-13107. doi: 10.1186/1471-2474-13-107; 10.1186/1471-2474-13-107.
Is prescribing medication a direction we should
(want) to take in the United States?
Requirements to practice in ESP (professional and
post- professional education, experience, etc.)
Professional “schizophrenia” (roles/levels within
Communication (internal and external to the
Relationships to other HCP
New: Entering body orifices to mange pelvic
conditions, ordering diagnostics ultrasound,
administering a substance by inhalation, ordering
Future: setting or casing fractures or joint
dislocations, prescribing medication, ordering lab
tests, ordering care in hospitals
One person’s advanced is another’s entry
Is it time to define PT around the world?
What makes us US?
Data exists supporting direct access or
patient self referral (cost, safety)
Communicate and Consult
Purpose of direct
access should be in
terms of societal
mission and be person
Need for standardized terminology (patient self
referral vs. direct access)
Global communciation of advances in DA
Global consideration need to be adapted to
regional and local jurisdictions.
Setting specific variations in DA(public vs.
private, variations in practice settings)
Department of Practice driven survey with 1800 members from 9 selected
chapters with varying degrees of direct access.
Although slightly more than half of the respondents report seeing patients
without referral, the percentage of direct access patients in practice
settings in these chapters is small.
Physical therapists in private practice settings are much more likely to see
patients via direct access than those in other settings.
Employer requirements that all patients have a referral appear to
impose a significant barrier to direct access. This requirement exists in
all types of practice settings but is especially prevalent in both inpatient
and outpatient hospital-based settings.
A large percentage of respondents indicated a need for resources to help
them remove hospital/institutional restrictions to direct access.
Importance of Value based research:
Efficiency and effectives of care
Measures of quality
Boxes with black surrounds indicate actual case data inputs – other boxes are derived estimates
Ease of squatting increase by 20% points
The role of the PT in global healthcare
International “standardization” for PT
education, practice, and policy (regulation).
EBP relation to policy development.
PT role in health care policy development
Opportunities for advancement and innovation
dependent upon unique environments that are
influenced by national social and health care system,
health care worker availability, and local facilities.
Need to convince internal and external stakeholders
of the role, value and effectiveness of physical therapy
Collaborative and interprofessional models tended to
be highly successful.
Access to care was an important factor in all countries
Practitioner malaise: resistance to change practice
Data extremely important; so to are patient ‘stories’
Physicians working Map, accessed November 5, 2012 from World Mapper website:
HIV prevalence Map, accessed November 5, 2012 from World Mapper website:
Diabetes prevalence: accessed November 5, 2012 from World Mapper website:
Addressing a need
Singapore: PTs in ICU and critical care areas do
not require physician referral for PT
▪ SARS outbreak was driver
Chartered Society regarding extended scope
practitioner and prescription rights.
“New service models including self-referral to
allied health professional services such as
musculoskeletal physiotherapy, have improved
patient outcomes and satisfaction and reduced
demand elsewhere in the system. “
Various educational standards within
Freedom of movement legislation:
If there is a shortfall in the entry level education
and attestations of competency of an applicant
from another member state:
▪ A compensatory measure must be offered.
▪ Have we defined explicitly the educational requirements
for direct access (first contact practitioners)?
PASS took place February 27-28, 2009,
The PASS was designed as an invigorating
experience and created a highly interactive
environment that allowed rich, insightful
discussion in five topic areas:
education - professional preparation,
health care access, systems and funding,
Paradigm Shift to physical therapists as an
integral part of a collaborative,
multidisciplinary health care team that has
the health care consumer as its focus.
Technology: Information technology,
integrated data systems, robotics,
prosthetics tissue engineering, Imaging
Value of PT to stakeholders (consumers)
Prevention and Wellness
Innovative practice models needed
Providing secondary prevention services in a disease
Improving physical therapy outcomes by incorporating
evidence into practice in an integrated health care setting
Providing consulting services in a primary prevention model
Providing care in a hospital emergency department
Providing outpatient services in a setting that incorporates
evidence in practice to decrease costs and improve outcomes
Providing care to large numbers of patients in an
Providing health promotion services to groups
Providing services in an urban, academic medical
center emergency department
Providing direct access services in an academic
medical center out-patient clinic
Providing services to individuals in a military outpatient setting
Emergency Departments / Urgent Care
Triage for musculoskeletal patients
Public health role
What needs changing?
How will you lead your profession?