1. PRESENTED BY: MATTHEW GARBER, PT, DSC, OCS, FAAOMPT PAULA PARADIS, PT, MS, DPT, MBA, MHA JON UMLAUF, PT, DPT, CSCS Integrating Physical Therapy Services in the Patient Centered Medical Home

2. Disclosures Presenters have no interest to disclose. PESG and AMSUS staff have no interest to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. PESG, AMSUS, and all accrediting organization do not support or endorse any product or service mentioned in this activity.

3. Learning Objectives Discuss the implications on access to care and quality by incorporating physical therapy services within the Patient Centered Medical Home (PCMH). Discuss the operational procedures of the Fort Belvoir Community Hospital (FBCH) PCMH Integrated Physical Therapy Clinic model. Discuss the implications on purchased care and population health by incorporating physical therapy services in the PCMH.

4. Outline Demand of Musculoskeletal Care How to access Physical Therapy (PT) Services Benefits of early access to PT Care Benefits of Embedding PT Care within a PCMH Evolution of the PCMH PT clinic at Fort Belvoir Community Hospital The Way Forward: Direct Access to PT within the PCMH

5. Escalating Demand of Musculoskeletal Care Large % PCM visits for musculoskeletal conditions  Encounter rates for musculoskeletal conditions have doubled in the last 10 years (MSMR, Apr 2013).  5 of the top 10 reasons for seeking medical care in the military are musculoskeletal (MSMR, Apr 2013). #1 Other back problems 25% of Active Duty Soldiers (~132K) are on temporary or permanent physical profiles for MSK conditions In FY14, MSK injuries accounted for 1.5 million ambulatory encounters and nearly $400M in direct patient care costs among active duty Soldiers. Medical Surveillance Monthly Report, April 2013

6. Active Duty Medical Surveillance Monthly Report, April 2015

7. Active Duty Medical Encounters (FY14) Medical Surveillance Monthly Report, April 2015

8. Non-Service Members Medical Encounters (FY14) Medical Surveillance Monthly Report, April 2015

9. Opportunity to Re-Capture Outsourced Care Non-service members accounted for over 80 million medical encounters (FY14). 89% of these encounters were outsourced Over 65 capable of using Medicare to help offset cost of outsourced care Medical Surveillance Monthly Report, April 2015

10. Non-Service Members (0-17) Medical Surveillance Monthly Report, April 2015

11. Non-Service Members (18-45) Medical Surveillance Monthly Report, April 2015

12. Non-Service Members (45-65) Medical Surveillance Monthly Report, April 2015

13. Non-Service Members (>65) Medical Surveillance Monthly Report, April 2015

14. Cost of Increasing MSK Demand on PT Services Demand > Supply = Network Deferrals/ Purchase Care

15. Non Active Duty Accounted for 84% of Purchased Care

16. Over 30% of All PT Referrals from PCMH

17. Primary Care  PCMH Improve access to primary care Improve quality Deliver more cost effective care Improve and standardize the patient experience of care Establish primary care not as a gatekeeper or a feeder system but as the foundation of a system for health

18. Steps Taken To Receive Physical Therapy Care 50 year old with back pain He is scheduled in a routine appointment within 7 days with his PCM

19. Steps Taken To Receive Physical Therapy Care PCM then decides next level of care needed Self Management Orthopedic Consultation Sports Medicine Consultation Advanced Imaging Physical Therapy Consultation

20. Steps Taken To Receive Physical Therapy Care If PCM Consults PT at initial encounter 7 days for routine + 28 Days for specialty care The MTF has met ATC standards if the patient is seen within 35 days

21. Benefits of Early Access to PT Services Low back pain is the leading reason why patients seek medical care ( MSMR, Apr 2013)  Low back pain (LBP) patients receiving early physical therapy are less likely to receive advanced imaging, additional physician visits, major surgery, lumbar spine injections and opioid medications (Fritz 2012, Childs 2015)  When LBP patients receive early physical therapy care (<14 days), total medical costs per patient is 60% lower (Fritz 2012, Childs 2015)

22. Potential Benefits of Embedding a PT within PCMH Improve access to care to PT services Ability to prioritize Acute/Sub-acute patients Improve relationship between PCMs and PTs Information Sharing between services  Participation in Huddles  Patient Handoffs  Bilateral Training Opportunities

23. Fort Belvoir Pilot: PCHM PT Clinic Started in Family Medicine (SEP 2013) Personnel = 1 PT, 1 PTA Services available to all enrollees Template change  Mostly new encounters Consult review  Acute/sub-acute prioritized into PCMH PT Clinic  Chronic patients were seen in the main PT Clinic PCM Education  Consults to include patient status (Acute, sub-acute, chronic)

24. PT Embedded Pilot Cost Outcomes One PT embedded in PCMH Sep 2013 No increase in personnel (same FTE equivalent) Over 35% decrease in network deferrals and associated cost

25. Concerns 1 PT for entire family medicine clinic (25,000 enrollees) Heavy demand = provider burnout  PT had to be rotated out every 4-6 months Not entirely patient centered  Patients were still required to call for appointment with PT  Location of care confusion Inability to provide same-day/acute appointments Limited ability to provide follow-up/hands-on treatment  Concerns on the quality of care that was being delivered

26. Change 1 Added more PTs to Family Practice PCMH Clinic (DEC 2015)  Due to space limitations, providers rotated within FM PCMH Clinic  Goals: prevent provider burnout, increase quality of care 1 PT imbedded within the Internal Medicine Clinic (JUN 2014) Template change – added treatment/follow-up appointments to increased quality of care delivered Add Walk-in/acute appointments to provide care within 72 hours Allow patients to book with PT the same day at PCM encounter  Patient hand-carried slip

27. Total Consults Written & Deferred FY15 PHYSICAL THERAPY MTF FBCH Trending for FY15 – 1084 Consults Deferred Additional 36% reduction from FY14

28. Total AD Consults Written & Deferred FY15 PHYSICAL THERAPY MTF FBCH No Leaked AD Prime due to capacity for 7 months

29. Voice of the Customer: Black Belt Project “Voice of the Customer” surveys:  Likert Scale (1-5) questions on access/environment, PT experience, imaging experience  “Overall Experience” question - Net Promoter Score 179 surveys completed from main PT clinic, Family Medicine and Internal Medicine PCMH clinics with embedded PTs over three months

30. Survey Results: Net Promoter Score (NPS) Replicates the NPS methodology described in the 2003 Harvard Business Review Used widely in business based on its research- substantiated correlation between high NPS scores, company growth and customer loyalty  Results based on score received on the 1-10 scale:  Promoters: Scores 9 or 10  Passively Satisfied: Scores 7 or 8  Detractors: Scores 6 and below Industry Average: 16%  Exceptional companies: USAA, E-Bay: 75-80%  Anything above 0% considered good

31. PT Survey Results: Net Promoter Score (NPS) 179 patients surveyed (Apr-Jun15) in PCMH-based PT and main PT locations NPS Question:  “How would you rate your overall experience today with your provider on a scale of 1 to 10 with ‘1’ being the worst experience, to ’10’ being the best experience ever.” Both locations exceed industry standards for exceptional customer experience Patient Surveys - 179 total: Net Promotor Scores ClinicsTotal Surveyed Answered NPS Promotors Passively Satisfied DetractorsNPS* PCMH7238(30) 78%(8) 22%(0) 0%78% Main PT Clinic10775(66) 88%(9) 12%(0) 0%88% *NPS Industry Average 16%

32. Additional Survey Results ALL patients responded to the following statements with a 4 or 5 rating: (Scale of 1-5, with “1” being “not at all” and “5” being “absolutely”)  Confidence in PT’s knowledge  Explanation by PT on current condition  Interest and concern shown by PT  Overall satisfaction with PT  Preference to see a PT first for musculoskeletal concerns 4% of patients from PCMH clinics unhappy with wait times for initial consult with embedded PT 26% of patients surveyed referred from PCM to main PT clinic unhappy with access to care wait times  Score of “3” or less  Up to 28 days for initial PT appointment

34. HEDIS Low Back Pain Imaging Metric MEDCOM vs. FBCH

35. HEDIS Metric: Family Med vs. Internal Med

36. HEDIS Low Back Pain Imaging Metric: Analysis by Clinic Type Embedded PT

37. Intervention: Coding Go-By Clinically, providers understand the metric and are making sound clinical decisions for imaging Confusion over coding flags many providers as “inappropriate” for imaging The ED works on a “paper” record, and coders choose the ICD-9 code based on provider’s description No formal education on the metric or coding – lack of clear direction Black Belt Team developed Coding Go-By  Team Leads conducted education to all providers, including ED  Clinics initiated weekly coding reviews/checks

38. Coding Go-By Provider Handout

39. Importance of Early Access X-Ray: 155 MRI: 28 CT: 2 Over 3 times more likely to receive an MRI for back pain if seen out of network when compared to MRI numbers from our facility

40. Change 2: Move to Direct Access Initial process cumbersome and not patient- centric  PCM visit required for PT referral  May take multiple visits for PCM to refer to PT  Complicated and time-consuming process to make PT appointment Direct Access has been within the scope of practice of military PTs since the 1970s (James, 1975)

41. Evidence-Based Care: PT Skilled for Direct Intervention PTs ideally suited and trained to treat musculoskeletal conditions  Doctor of Physical Therapy degree with advanced training in differential diagnosis, appropriate imaging, and pharmacology PTs in military settings are credentialed to order imaging, refer to specialty clinics, provide profile/quarters, prescribe limited medications Diagnostic accuracy of PTs similar to orthopedic surgeons, better than non-orthopedic providers Passing score = 73% Childs JD, Whitman JM, Sizer P, Pugia ML, Flynn TW, Delitto A: A description of physical therapists’ knowledge in managing musculoskeletal conditions. BMC Musculoskeletal Disorders 2005; 6: 32.

42. Evidence-Based Care: Direct PT Intervention Evidence for Direct Access to PT A Systematic Review: Direct Access vs. Physician Referred PT ( Ojha, 2014) 8 articles, level 3-4 evidence (Grade B-C) Statistically significant, clinically meaningful across studies  Superior satisfaction and outcomes  Lower costs  Fewer visits  Less imaging and medication  Fewer additional non-PT appointments  No evidence of harm

43. Steps Taken To Receive Physical Therapy Care 50 year old with back pain He is scheduled in a routine appointment within 7 days with his PCM

44. Direct Access PT PT decides next level of care needed Orthopedic Consultation Sports Medicine Consultation Advanced Imaging PCM Consultation

45. Change 2: Process for Direct Access for PTs

46. PT in PCMH Results Overview Cost Quality Access Embedded PT Pilot SEPT 2013 Savings of $1M network cost FY13-FY14 35% reduction in network deferrals Added 2 nd PT to Internal Medicine – JUN 2014 Combined improved HEDIS measure: 75 th percentile Internal Medicine only HEDIS measure: 90 th percentile Direct Access PT Pilot MAY 2015 Improved access to PT: 7-10 days Improved patient satisfaction

47. References 1.Armed Forces Health Surveillance Center. Signature Scars of the Long War. MSMR. 2013 Apr;20(4):2-4. 2.Armed Forces Health Surveillance Center. Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, U.S. Armed Forces, 2013. MSMR. 2014 Apr;21(4):2-14. 3.Armed Forces Health Surveillance Center. Ambulatory Visits Among Members of the Active Component, U.S. Armed Forces, 4.2014. MSMR. 2015 Apr;22(4):18-24. 5.Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary Care Referral of Patients With Low Back Pain to Physical Therapy: Impact on Future Health Care Utilization and Costs. Spine. 2012: 37(25):2114-2121. 6.Childs JD, Fritz JM, Wu SW, et al. Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. BMC Health Services Research. 2015: 15:150. 7.American Physical Therapy Association: Direct Access to Physical Therapy Services Overview. Available online at http://www.apta.org/StateIssues/DirectAccess/Overview/ 2012./ 8.Benson CJ. Schreck RC. Underwood FB. Greathouse DG. The role of Army physical therapists as nonphysician health care providers who prescribe certain medications: observations and experiences. Physical Therapy. 75(5):380-6, 1995 May. 9.Byles SE, Ling RS: Orthopaedic Out-patients – A Fresh Approach. Physiotherapy 75. 435-437, 1989 10.Daker-White G, Carr AJ, Harvey I, Woolhead G, et al. A randomized controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. 11.Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am. 1998; 80(10):1421- 1427. 12.Greathouse DG, Schreck RC, Benson CJ. The United States Army physical therapy experience: evaluation and treatment of patients with neuromusculoskeletal disorders. J Orthop Sports Phys Ther. 1994; 19(5):261-266. 13.Hattam P, Smeatham A. Evaluation of an Orthopaedic Screening Service in Primary Care, Clin Perform Qual Health Care. 1999; 7: 121-124 14.Health Providers Service Organization, in a March 22, 2001, letter to the American Physical Therapy Association, on file. 15.James JJ, Stuart RB: Expanded Role for the Physical Therapist: Screening Musculoskeletal Disorders. Phys Ther 55. 121-132, 1975 16.Mitchell JM, de Lissovoy G. A comparison of resource use and cost in DA versus physician referral episodes of physical therapy. Phys Ther. 1997; 77(1):10-18. 17.Overman SS, Larson JW, Dickstein DA, Rockey PH: Physical Therapy Care for Low Back Pain: Monitored Program of First-Contact Nonphysician Care. Phys Ther 68. 199-207, 1988 18.Pew Commission Urges Increased Action to Cut U.S. Physician Supply. PT Bulletin. Page 10; November 6, 1998 19.Primary Care: Practice Opportunities for the Future; Orthopaedic Practice Vol 12;2:00 p.9 20.Weale AE, Bannister GC: Who Should See Orthopaedic Outpatients- Physiotherapists or Surgeons? R Coll Surg Eng (Suppl) 1995; 77: 71-73 21.Zigenfus GC. Yin J. Giang GM. Fogarty WT. Effectiveness of early physical therapy in the treatment of acute low back musculoskeletal disorders. Journal of Occupational & Environmental Medicine. 42(1):35- 9, 2000 Jan. 22.Childs JD, Whitman JM, Sizer P et al. A description of physical therapists’ knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord 2005; 6: 32. 23.Moore JH, Goss DL, Baxter RE, DeBerardino TM, Mansfield LT, Fellows DW, et al: Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopaedic surgeons, and nonorthopaedic providers. J Orthop Sports Phys Ther 2005; 35: 67-71. 24.Moore JH, McMillian DJ, Rosenthal MD, Weishaar MD: Risk determination for patients with direct access to physical therapy in military health care facilities. J Orthop Sports Phys Ther 2005; 35: 674-8. 25.Ojha HA, Snyder RS, Davenport TE. Direct Access Compared With Referred Physical Therapy Episodes of Care: A Systematic Review. Phys Ther J 2014; 94: 14-30.

48. Questions?

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