The Role of Outpatient PT in Bundled Payment Programs

As a follow-up to our Fast Track session at this year’s annual AAOE conference, I wanted to revisit some key points that we discussed in regard to the role outpatient physical therapy can play in bundled payment scenarios.  Those already participating in CJR, BCPI, or other commercial bundles for total joint replacements have witnessed first-hand the trend of decreased utilization of more costly post-acute settings and a swifter conversion to outpatient therapy.  However, we want to do a little deeper dive into the role outpatient PT can play throughout the continuum of care.

PREHAB

One of the most effective tools in a total joint program is the prehab visit.  We view this as an opportunity to address concerns that the patient may not have remembered to discuss with the physician and to identify questions that perhaps the patient had not even thought to ask.  It also provides the therapist with an opportunity to capture some baseline measures as well as additional info that the referring physician may want to review as part of the risk adjustment process.  A formal prehab checklist can be a useful mechanism to make sure all relevant areas are addressed.  This checklist can also be scored and forwarded to the case navigator and the physician for review prior to surgery for patient optimization and to assist in determining the best post-acute course of action for that particular patient.

A standard prehab visit incorporates not only baseline measures and home program instruction, but it can also help to identify any home safety concerns, establish realistic patient expectations and accountability, aid in comorbidity management, and assist in educating the patient regarding the timeline following surgery.  It is also worthwhile to make sure the patient understands how to recognize signs of infection, how to manage their pain, general precautions, and who to call if they have questions.  In addition, the therapist should review any joint printed materials or online resources with the patient to make sure the patient understands where to find all of the necessary information pertaining to the joint program.  Lastly, the first post-op outpatient visit is scheduled during the prehab visit so the patient can be sure to stay on track with their protocol once they transition home.

CONVERSION TO OUTPATIENT THERAPY

After surgery, outpatient therapy should be initiated as soon as safely possible.  While there may be hesitancy among some providers to progress to outpatient therapy earlier in the post-acute phase, a quicker conversion to outpatient therapy has been shown in the literature to have considerable benefits beyond just the obvious cost savings¹.  A recent study in JAMA Internal Medicine found that among a sampling of almost 3,000 patients, discharge to post-acute care facilities fell 34% for major LE joint replacement patients while readmission rates decreased significantly in the same cohort.²  Another study in Orthopaedic Nursing revealed that in a sampling of 109 individuals who had undergone total knee replacements, patients who received home health prior to initiating outpatient therapy demonstrated no significant differences in ROM, 6-minute walk test, and KOOS scores as compared to patients who initiated outpatient therapy immediately following discharge from the hospital.  Additionally, the patients who started outpatient therapy immediately completed therapy 20 days sooner.³

Communication with care navigators can help to ensure the patient is on pace with their post-operative timeline following discharge from the hospital.  Once outpatient therapy has been initiated, patient engagement throughout the episode of care is essential to keep the patient on track with their protocol and to make sure they are meeting their goals.  Educating the patient on the front end about the course of therapy, the importance of staying consistent with therapy appointments and home exercises, and the overall long-term goals will help ensure patients will complete their plan of care with the best possible outcome.

DISCHARGE

Outpatient PT is typically the most downstream of downstream providers in the post-acute phase.  Therefore, outpatient PTs play a vital role not only in helping the patient across the finish line but also in ensuring the patient has a successful, long-term outcome.  We have talked in previous blog posts about the value of capturing outcome data, but outcomes will be especially in important in bundled payment models where decreased cost must not come at the expense of poorer outcomes.  In addition to patient perception of care questions relating to patient satisfaction and expectations, we also issue PROMs at the final visit to compare against the scores at the pre-op and initial post-op visits.  This helps to quantify the progress the patient has made from a documentation standpoint and to justify the treatment provided.  It also gives us useful information to share with payers.

The assessment tools of choice can vary from practice to practice and sometimes from provider to provider.  As the HOOS, HOOS Jr,. KOOS, and KOOS Jr. tools are included in the voluntary outcome measures that hospitals in CJR models can report, many outpatient PT clinics are incorporating these measures into their programs.  Regardless of the tools used, outcomes are a crucial component to closing the book on the patient’s course of care.  Finally, a thorough discharge visit can ensure the patient knows what activities to continue upon discharge from therapy and how to continue to progress on their own at home in order to see continued improvement in the weeks and months to come.

Hopefully, today’s blog post will challenge you to take a look at how your outpatient PT can play a larger role in bundled payment programs.  If you have any questions, don’t hesitate to drop us a line or post comments below.

1. American Hospital Association Issue Brief: Moving Towards Bundled Payment http://www.aha.org/content/13/13jan-bundlingissbrief.pdf
2. Jubelt LE, Goldfeld KS, Chung W, Blecker SB, Horwitz LI. Changes in Discharge Location and Readmission Rates Under Medicare Bundled Payment. JAMA Intern Med. 2016;176(1):115-117. doi:10.1001/jamainternmed.2015.6265
3. Warren M, Kozik J, Cook J, Prefontaine P, Ganley K. A Comparative Study to Determine Functional and Clinical Outcome Differences Between Patients Receiving Outpatient Direct Physical Therapy Versus Home Physical Therapy Followed by Outpatient Physical Therapy After Total Knee Arthroplasty. Orthop Nurs. 2016 Nov/Dec;35(6):382-390.