Practice Pearls: Integrating PT Services into the Outpatient Wound Clinic
While many healthcare facilities provide multidisciplinary care to wound patients in 2015, few achieve the cohesion that defines a true interdisciplinary approach. What’s the difference? Multidisciplinary team members address the patient’s case from their unique professional perspective, usually with a hierarchical approach and a shared communication pattern. An interdisciplinary team, meanwhile, can articulate each staff member’s definitive purpose while simultaneously blurring those boundaries to collaborate and identify patient and family priorities to develop fluid consensus. Without carefully constructed collaboration, it may be that at times one’s professional goals are being emphasized while others may be negelected.1-3 Adapting to this mindset, especially among individuals whose professional roles have been predominately served in clinical leadership, can be difficult. However, successful outcomes are the reward to the team’s assessment of the patient and to family-identified needs. Incorporating the skill set of physical therapy into wound clinic services is paramount to achieve this. Physical therapists (PTs) can not only enhance patient outcomes, but are integral to meeting patient satisfaction, identifying and reducing potential safety issues, and maximizing revenue enhancement goals. The most impactful services PTs provide include:
- lymphedema management;
- adjunctive wound management, such as electrical stimulation, pulse lavage, diathermy, and noncontact ultrasound;
- gait evaluations after total contact casting;
- safety evaluations to identify and mitigate fall risk;
- evaluation and management of identified issues — such as range of motion, strength, and mobility — that impede moving the patient toward self-care; and
- communication with home health agencies and skilled nursing facilities regarding functional goals.
Having successfully integrated physical therapy into our own wound clinic, here are a few “lessons learned” for those clinics considering higher levels of integration:
1) Make the transition seamless.
To patients living with chronic wounds, their caregivers, and for those who may provide other transportation services, nothing can impact impressions of provided services more than the appearance of collaborative care. That said, the PT should be located within the service area and is more effective in an identified “working space” in which to provide services. This requires management cooperation between wound clinic and rehab administration.
The latter is almost always a hospital employee, whereas the wound clinic administrator varies based on the business model of the clinic. Having clinicians involved from the project start is key. Rehab and clinic administrators, the facilities team (including engineering), and clinicians must meet regularly for many months to make key decisions that result in downstream workflow enhancements. From the location of doors to the size of treatment rooms, floor types, and bathroom locations, important issues should be discussed and enacted upon together. Early and frequent clinician input is extremely valuable and cannot be substituted. Like most projects, identified budget and physical building constraints should be communicated to all stakeholders during this process, which helps assist team-building, negotiation, and collaborative skills.
2) Consider potential pitfalls in the financial structuring.
Physical therapy services in the wound clinic are typically considered a single department regardless of whether the clinic is hospital owned or has a management company affiliation. This initial budget of one full-time equivalent means the financial status of the individual and the service is separate from the rest of the clinic. When providing services that are not known to have a large profit margin but are associated with high healing rates and patient satisfaction, such as lymphedema, there are business-management skill sets for the PT to learn. In regard to lymphedema, these include monitoring of supply levels and awareness of financial issues.
A “department of one” can be culled very easily at “C-suite” levels unless preemptive discussions at this level take place. Conversely, moving a PT from an outside location into the clinic reduces the need for a physical therapy assistant (PTA) and front-desk support that would be needed in a separate location. It is unlikely, early in the process, that the expense associated with bringing in a PTA would be justified. However, utilizing an inpatient rehab department aide to set up par levels of supplies who would also be available to assist in these duties is helpful. The type of supplies needed for wound care are similar to those needed by a hospital inpatient area, so there is some similarity in product types and improved knowledge in ordering with fewer errors.
3) Allocate the appropriate space for patient referrals.
The physical therapy treatment room within a wound clinic is often a single room that does not allow for onsite access to traditional therapy equipment. Thus, when patients are in need of continued physical therapy after their wound care is complete, they need to be referred to another site that will best meet their needs. However, positive team rapport and subsequent effective patient care can result in growth of the referral base. Even though there may already have been direct marketing done regularly prior to this integration, wound clinic providers, including PTs, serve as regular “recruiters.” A more diverse referral base improves financial stability, with patient visit volumes throughout the year remaining more consistent. Planning ahead for growth, including space, personnel, and equipment can mitigate potential complications.
4) Implement the “support” staff.
Tasks such as clinician and patient scheduling, insurance copay coordination, and required authorization/referral record keeping should be supported by front-desk staff. There could be some challenges in operationalizing this when a management company is participating with a hospital in providing services. However, these are not insurmountable. These tasks are often taken for granted in a traditional outpatient, therapy-only clinic. This includes checking for insurance nuances, addressing payer-specific requests, and assuring reauthorization for subsequent visits is achieved.
Copays are an interesting dynamic. Customers may perceive that they are in one suite and thus anticipate paying one copay. Visibly posting information on copays and offering personal, face-to-face communication on this subject can improve patient satisfaction and assure better understanding on the part of the patient.
Since provider, facility, and therapist copays and fees are prescribed by the individual’s insurance, it is important to verify benefits for the patient prior to initiating care and communicate those results of the inquiry to staff members and patients. Patients requiring wound care visits with or without hyperbaric treatments as well as therapy services must be assessed on an individual basis. Meeting as an interdisciplinary group helps to determine plans of care and patients’ clinical needs to promote an effective strategy agreed upon by all clinical staff members, whether or not a financial strain on the patient exists.
5) Beware of barriers preventing development of the interdisciplinary team.
Not all inpatient and outpatient hospital electronic health records (EHRs) will integrate well with wound management EHR software. Adding a PT to the wound clinic can exacerbate these challenges. As therapy services must meet certain documentation requirements not found in wound EHR software, PTs must learn how to access, if only for read-only purposes, multiple EHR systems.
As some requirements for PT documentation and billing are not routinely supported by niche EHRs, hospital outpatient therapy departments (including lymphedema) have little choice but to use the hospital-based/rehab EHR. An example includes the PT use of Medicare-mandated claims-based outcomes reporting, often referred to as “G” codes.
Therapists must use these codes to document functional status at defined times during the episode of care. To use an EHR that does not support G codes would equate to lost reimbursement for the therapy provided. Thus, in one facility, some patient care information can be found in one EHR (provider, nurse, hyperbaric visits) and some can be found in another EHR (therapy visits). Alternate communication strategies must be used to assure that all wound clinic staff members are fully engaged in the patient’s plan of care.
Selecting the PT with the “right fit” can be challenging. In addition to the skills needed to perform well clinically, per scope of practice, candidates should possess a skill set that includes experience in working closely with other disciplines as well as autonomy in therapy practice. While working well in an interdisciplinary team setting requires a sense of confidence among one’s peers, the knowledgeable therapist will also feel comfortable seeking resources to bridge the gap in the billing and regulatory areas, as well as clinically at times.
Should the therapist have a clinical question or policy-related concern, there should be availability among staff members to consult. Information needs to flow both ways, especially if the hospital-based wound clinic uses a management company because these employees will have information related to updates of practices and/or policies.
Additionally, there are usually separate meetings and specific communication methods inherent with this management structure. Care must be taken to support inclusivity, not exclusivity, when possible. Identifying these and other barriers to optimal team functioning are usually a work in progress, but are not insurmountable. Overall, integrating a hospital employee into an environment of all non-hospital employees benefits the patient with improved communication and improved referral patterns. With advanced planning, this integrated model can be successful for both patients and staff members. n
Elizabeth Warner is director, rehabilitation services, at Bristol (CT) Hospital. Catherine T. Milne is co-owner of Connecticut Clinical Nursing Associates, Bristol.
References
1. Scarborough P. Understanding your wound team: Defining unidisciplinary, multidisciplinary, interdisciplinary and transdisciplinary team models. WoundSource. 2013;16:7-8.
2. Stefanacci S, Spivak B. Looking ahead to issues affecting geriatric care in 2014. Ann Long-Term Care. 2013; 21(12):46-50.
3. American College of Wound Healing and Tissue Repair and The Angiogenesis Foundation. Patient-Centered Outcomes in Wound Care. Accessed online: https://www.angio.org/wp-content/uploads/2013/10/Wound_Care_White_Paper.pdf.
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