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PT on the Run

Running for Boston
by Michael Kelley

In the fall of 1993, at the ripe old age of seven, I followed my older brother to Portage Park a couple blocks from our house to our grade school's cross country team practice. In what I'm sure was a pretty pathetic effort, I ran my mile around the park as fast as my little legs could carry my 4-foot-and-change, 50-something-pound body. From that day forward, I was hooked. As humans we are by nature social creatures. We seek out others and find a place where we fit in -- a community to belong to. Me, I'm a member of the running community, and I will be until the day I die.

It was about a year ago that my community came under attack as two explosions rocked the finish of the 2013 Boston Marathon. Growing up, I remember the news coverage of the Oklahoma City bombing, the shootings at Columbine, and of course the attacks on 9/11. While they were all tragedies in their own right, the attacks on Boylston Street that Monday morning really got to me. For me, this wasn't just an attack on Boston or even the nation as a whole. No, to me, this was an attack on my community -- this was an attack on my people. The night of the attacks, my sister (also an avid runner) and I took part in a "Unity Run" in Chicago; one of many happening all over the country. Throughout the short 30-minute jog, I kept thinking to myself, "Us runners, this is what we do. When we feel pain, we push through it. When we get injured, we keep going. And when one of us falls, the rest of us are there to pick that person up."

In the aftermath of the attacks, my other community stepped up in a big way. The medical teams at the various hospitals performed flawlessly. Physical and occupational therapists in conjunction with prosthetists and orthotists have helped the hundreds of injured get back on their feet. I was reading some of the many stories online about the victims' rehab progress and it was honestly hard to hold back the tears. In one article an emergency room nurse from one of the hospitals in Boston said, "No one who made it to a hospital that day died. That's pretty remarkable." Indeed it is and the countless hours that the rehab professionals have put in (many pro bono including free prosthetic legs, outpatient PT, and use of gym equipment) has really been inspiring.

The 2014 Boston Marathon is next Monday. Amid unprecedented security, some 36,000 runners will line up to race back to Boylston Street, thousands of whom raced last year but couldn't finish because of the attacks. And me? Come Monday night I'll be out again on the streets of Chicago running. Running for Boston. Running for my community. Running for my people.

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Can You Describe Your Dizziness?
by Michael Kelley

We've all seen it before... a patient comes into your hospital or clinic complaining of the dreaded "dizziness." It's been said that dizziness is one of the most difficult subjective symptoms to diagnose because it can be caused by such a wide variety of physiologic and even psychological issues. I personally have seen patients with a primary complaint of dizziness who have had cardiac issues, neurologic issues, psychological issues, musculoskeletal issues, renal issues, and the list goes on!

A few weeks ago, I attended a CE course on another potential cause of dizziness... the vestibular system. Now I remember learning about the vestibular system in PT school, but we practiced our Dix-Hallpike tests and Epley maneuvers on our classmates, who clearly did not have vestibular disorders. So needless to say, when I started my job, I didn't feel comfortable treating actual patients. I had never worked with a vestibular patient on any of my clinical rotations in school, so they were sort of a foreign population to me. The course I took was well organized and thorough. I can honestly say I enjoyed the class, the presenters, and re-learning the vestibular system as well.

Since the class, I've had the opportunity to work with a couple of vestibular patients who have been admitted to the hospital with "dizziness." While my diagnostic skills need some improvement, I feel pretty comfortable performing the various positioning tests and treatment positions as well. We are fortunate to have a couple of outpatient PTs who have been working with vestibular patients more regularly and for several years. They are great about offering some mentorship, even coming to see inpatients who have vestibular issues and helping us inpatient PTs work through some of the more complicated patients.

Overall, I find the vestibular system pretty intriguing. It seems to me it's a very specialized system that has very specific deficits. And with the various repositioning techniques we have at our disposal, we can offer a unique opportunity for a potentially "quick fix" for our patients. I'm looking forward to growing in this area and hopefully becoming a little more proficient in my examination and treatment of patients in this population.

Does anyone else work with vestibular patients? Any thoughts or ideas on how I might improve my examination skills?

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A Blog of Olympic Proportion
by Michael Kelley

Have you all seen what has been going on in Russia the last few weeks? No, not all that business with the Ukraine and Crimea (although honestly when was the last time one country just up and annexed part of another country? Seriously, it's been a while!). But I'm talking about the 2014 Paralympics in Sochi, Russia. After all the pomp and circumstance of the "regular" Olympic Games back in February, the "disabled" athletes of the world descended upon the Olympic Village for two weeks to show the rest of us how awesome people really can be.

I doubt many people know much about the Paralympics, but I feel it's appropriate for this PT blog setting because I'm willing to bet at one point in their lives, each and every one of those Paralympians had dealings with a physical therapist. Regardless of their sport, the stress and strain even the most gifted, able-bodied athletes put on their bodies would likely warrant some PT intervention. Now imagine you are putting those same stresses and strains through one leg or one arm, for example. I was able to watch a little of the 2014 Paralympics on TV. NBC Sports Network was kind enough to air some of the skiing. It just blows my mind that these athletes are able to do what they do. It really is mind-boggling -- in an awesomely good way.

Team USA didn't do so hot in the medal count, amassing 18 total medals (2 gold, 7 silver, 9 bronze). It should be noted, and was actually covered pretty heavily on some of the major news stations, that the US men's sledge hockey team won gold (you'll recall the US men's "able-bodied" hockey team didn't even medal!). The other gold went to (and this is such an appropriate name) Evan Strong, a 27-year-old from California who won gold in the Para-Snowboard Cross. In 2004 he was riding his motorcycle when he was hit by a speeding car and ended up with a below-knee amputation of his left leg. Now he's a gold medalist. Talk about perseverance.

There's no doubt that all the athletes who participated in the Paralympics have their own stories of tragedy, perseverance and personal triumph. But the road to this triumph is filled with other people who help these athletes truly be all they can. So to all the Paralympians out there -- past, present and future -- thank you for inspiring us, and from a PT's perspective, thank you for showing us that with hard work and determination, we really can help make your wildest dreams come true. And to all the PTs out there who work with Paralympians, Team USA, or just your everyday para-athlete, from one PT to another I say, a job well done so far, and keep up the good work!

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The PT Student Summit
by Michael Kelley

Over the past few months we've had a couple PT students come and go. Most of them were somewhere in the middle of their clinical education and had no idea what they wanted to do with their PT degree upon graduation. As I watched the various CIs and students interact with patients, families, other medical staff and each other, I found that from my vantage point, the clinical education program at our hospital perhaps left something to be desired.

I've had a couple of students during my tenure at the hospital and looking back (hindsight is always 20/20, right?) I realized that I may not have created the best clinical learning experience for them, and I feel like that happens more often than not at our hospital. I don't want to be critical of my coworkers, because I'm just as guilty, but it's had me wondering, what can we do better to improve the overall acute-care experience for our students?

So, I met with my supervisor a few weeks ago and proposed a "Student Summit." Essentially my plan is to bring together some OTs and PTs to brainstorm ideas to help make clinical experiences better for not only our students, but our CIs as well. Last year, I took the APTA's CI Credentialing Course (yeah, yeah, I know, perhaps one "perk" the APTA offers... so sue me!). Personally, I found the course kind of eye-opening. One of the major takeaways I had was this simple idea: "Realize we aren't there to train new employees, but rather teach students to be new therapists."

The instructors of the course (who happened to be old professors of mine from Marquette) really harped on this idea that we as the CIs were there to ensure that our students were actually learning. Not just going through the motions, not shooting for some predetermined productivity level, but really learning how to better interact with, evaluate and treat patients. That's my driving force for starting up this Student Summit.

Our staff will hopefully be meeting in the next month or so to sit down and discuss how we can really improve our program so that students feel by the end of their time with us, they have actually learned something and maybe have a better appreciation for physical therapy in the acute-care setting. And likewise, maybe we will stumble upon benefits for us as CIs as well.

How do your locations ensure that a student's clinical experiences are beneficial to all parties involved? Any thoughts or ideas I can bring to our Student Summit?

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Do You Have the Right Stuff?
by Michael Kelley

I've written before about the obesity epidemic in this country and the potential impact PTs can have in perhaps helping turn the tide in this seemingly endless battle. But when dealing with obesity, prevention isn't everything. As PTs, we are tasked every day with treating patients who are already overweight or obese, and it falls on us to ensure that we do our best to improve their quality of life while still maintaining the patient's safety as well as our own.

A while back, our supervisor told us that our risk-management and employee health divisions said no employee should be lifting more than 30 pounds. When we heard this, most of our staff chuckled. We laughed because every single one of us knew this was a completely unrealistic aspiration. I personally have treated patients with BMIs well into the 60s, but even more mildly obese patients may require more than 30 pounds of lift assistance.

Our hospital system did some analysis last year and identified units where employees were being injured the most. Obviously any on-the-job injury costs the corporation money, so they made a significant investment in mechanical lift equipment that we're now supposed to use when mobilizing heavier patients. For the nursing staff, this is great. They can safely maneuver patients while maintaining their own well-being. For therapists, however, we are charged with a much more complicated task. We need to actually help patients move. Using machines to move the patient doesn't do the patient any good.

We do have one particular machine at work that's essentially a mechanical stander. The problem: It has a weight limit of 300 pounds. From a safety and liability standpoint, I wouldn't break that weight limit for anything, but I wonder if not only my hospital, but hospitals around the country should invest in at least some mobility equipment that's actually designed for morbidly obese patients.

What do you think? Patients who are overweight or obese still deserve our attention, no doubt, but at what cost? Do employers have some responsibility to ensure their employees have the right equipment to effectively treat every patient who comes through the door, regardless of size?

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When the Teacher Becomes the Patient
by Michael Kelley

I had an interesting experience at work this week. I had a patient who started asking me all sorts of questions about where I went to school and whether I was paid well and things like that. I asked this patient if they were familiar with the PT profession. Their response was a cryptic and simple "yes." Then I asked (rather cryptically, I might say), "How familiar?" The patient then informed me they were a professor at one of the local universities in the PT department. Then they looked me in the eye and said, "And I'm a PT too." Almost immediately I felt like everything I did was being examined under a microscope. The patient was very polite and professional, but I just couldn't help feeling like I was being judged.

Has anyone else had this type of experience... where the "student becomes the teacher," so to speak? I think I handled myself well. I provided appropriate interventions and treatments and tried to offer the patient reassurance that their various ailments were being taken into consideration by the medical team. But still, there was that nagging feeling like if I screwed up even in the slightest way, the patient was going to call up Marquette University and file a complaint about the quality of education I received. Could I have done anything different? I wonder how other healthcare professionals feel when they have to treat the "elders" of their profession.

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Hum-PT-y Dum-PT-y Sat on a Wall
by Michael Kelley

Editor's Note: Throughout the month of February, ADVANCE bloggers Michael Kelley and Lisa Mueller will post "Dueling Blogs," in which they argue opposing sides of the same issue. Topic #4 -- "What Is the Biggest Challenge to the PT Profession?")

When you have a fever, you go see the doctor. When you have a toothache, you go see the dentist. When you break a bone, you go see the orthopedic surgeon. And when you strain a muscle, you go see... who again? This week, Lisa and I are talking what walls stand before our profession that are limiting our growth and effectiveness. For me, I don't know that there is just one primary entity to blame here, but rather a combination of things. I'm going to discuss them by saying one major barrier to our profession is access.

For me, access to PT is not just about being able to see a PT, it starts with the public understanding what physical therapy is along with what physical therapists are licensed to do and capable of doing. Here in Chicago, a number of large companies have multiple PT clinics scattered around the city and suburbs, but rarely do I see or hear any mass media advertising for them. I do see a number of these companies represented at various community or charity races (5Ks and the like) but I feel most of the people participating in these events already know to some extent what PT is and what we can do for patients.

I think PTs need to come out of their shell a little and really learn to market themselves to their communities through all forms of media. I think most business-minded individuals (which I most definitely am not) would say "word of mouth" is one of the best forms of communication. I agree, but in such a competitive healthcare marketplace, is that really enough?

Along with educating the public on what we as PTs are capable of doing for them, I think access to actually obtaining PT services has some major roadblocks as well. As discussed in previous blogs of mine, the insurance industry holds some serious power when it comes to who can receive PT services and what PT interventions they can receive. This power obviously comes in the form of reimbursement. I don't think the insurance industry is entirely sadistic or anything, as they clearly have a vested interest in what we do, but the role PTs play in the reimbursement and insurance coverage processes should be more substantial.

Now bringing this notion to fruition is going to take some serious work on our parts and is likely going to take a considerable amount of time. In my mind, we need a group that can effectively lobby not only governmental leaders, but also leaders within the insurance industry. If the insurance companies want to pay us more money, they don't need an act of law to say they can. They just need solid evidence that the treatments we're providing are worthwhile and effective and may prevent further injuries or ailments that would result in more claims needing to be paid out by them.

Access to the knowledge of what PTs do and access to quality, effective PT services are clearly barriers to our profession as a whole. I think they are barriers that can be overcome with hard work and patience. What about you? What do you think are the important walls standing in front of us that need to be torn down in order for our profession to grow?

I'd like to thank everyone for their feedback and comments over the past few weeks. It's been a great exchange of ideas between Lisa and I, and I want to thank Lisa for participating in these "Dueling Blogs." Next week, we part ways, but I'm sure many great topics will continue to be discussed on both our blogs for a long time to come.

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The Gold Medal of PT Settings
by Michael Kelley

(Editor's Note: Throughout the month of February, ADVANCE bloggers Michael Kelley and Lisa Mueller will post "Dueling Blogs," in which they argue opposing sides of the same issue. Topic #3 -- "Does the Inpatient or Outpatient Setting Allow Greater PT Practice?")

Over the past couple of years, I've started to see a clear dichotomy of physical therapists. In the most simple of terms, there are those therapists (often in an outpatient setting) who work on strengthening, flexibility and overall conditioning. Then there are those (often in an acute or rehab setting) who work on functional training and task-oriented objectives.

Now, is real life this black and white? Of course not. I'm well aware of the fact that strengthening and flexibility are important for being able to perform functional tasks, and that repetition in functional training can be a great way to help improve strength and conditioning. But for me, the bread and butter of PT practice actually happens in a setting that I've never worked in: acute rehab.

To me, acute rehab is where physical therapists are really the center of attention. Everything PTs do in acute rehab is focused on returning patients to as close to their prior level of function and independence as possible. While strengthening and flexibility are important aspects of this, the acute rehab PT has a unique ability to help train patients to return to "real life."

For many patients who are in acute rehab, so many aspects of their lives have been turned upside down from either a trauma, CVA, or other acute ailment. Because of the time requirements of acute rehab, therapists have the ability to develop not just a rapport, but an actual relationship with their patients that may not be possible in other settings.

By developing this relationship, I think therapists can get through to patients in a much more meaningful way than in other settings where we may only see patients once or twice a week. Education, encouragement, reinforcement -- these are all things acute rehab patients would need, and things PTs are exceptionally equipped to provide.

Is there a "right" answer to this question of what the "best" PT setting is? I don't think so, but this is essentially my vote. What's yours?

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Also, if you'll permit me, I thought I'd share a recent Huffington Post article that relates to a previous blog post of mine about sick time.

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Who's In the Driver's Seat?
by Michael Kelley

(Editor's Note: Throughout the month of February, ADVANCE bloggers Michael Kelley and Lisa Mueller will post "Dueling Blogs," in which they argue opposing sides of the same issue. Topic #2 -- "What Drives the PT Profession?")

The PT profession has no doubt changed a lot since our humble beginnings. Even over the past 10-20 years, the education standards and demand for physical therapy have significantly increased. But what's driving these changes and what will continue to drive the evolution of our profession?

There are obviously many entities that guide our profession, but one in particular stands out in my mind: the insurance industry. I'll give you an example. A few weeks ago, my ADVANCE counterpart Lisa and I were talking about direct access. Lisa said, "Michael, every state in the country has direct access." To which I replied, "Lisa, that's just not true!" Naturally I did some research and according to our dear friends at the APTA, every state in the country does enjoy direct access.* (You'll notice the glaring asterisk at the end of that sentence).

You see, in every state practice act, there is some language that establishes some form of direct access. Here's the problem, the state practice act governs our profession as PTs. It does not have any enforceable action on the insurance industry. If an insurance company says you must have a doctor's prescription prior to going to see a PT or it won't pay for PT services, then a patient is obviously going to obtain one. Regardless of what our practice acts say, the insurance company gets to decide what it's going to pay for and what documentation and prior authorization are required to pay for it. So even when our state practice acts and educational institutions preach direct access, we're still at the mercy of the insurance industry.

As healthcare professionals, we're always striving to do what's in the best interest of our patients. But we do so realizing we're not the only players in the game. And unfortunately in this game, the players with the most influence also are the ones who control the most money. The future of the PT profession looks bright, but we need to keep advocating for our patients and profession not only to our congressmen and political leaders, but to the insurance industry as well.

For the time being though, it's my belief that the insurance industry is the biggest driver of our profession. They are the ones dictating who can be seen, how often we can see them, what we get paid for, and how much we get paid. Do I think this is the way things should be? Of course not, but this is the world we live in and until the stronghold the insurance industry has on the healthcare marketplace is broken, it seems we're going to have to continue to play by their rules.

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The APTA -- Why Bother?
by Michael Kelley

(Editor's Note: Throughout the month of February, ADVANCE bloggers Michael Kelley and Lisa Mueller will post "Dueling Blogs," in which they argue opposing sides of the same issue. Topic #1 -- "Is APTA Membership Valuable?")

I was an APTA member for one year when I started working. I'll be honest, the only reason I joined was because my employer paid the APTA dues. As a new grad, however, even the state chapter dues seemed impossible to afford on my own, so I let my membership lapse and have never rejoined. As a young therapist, the cost of APTA and state chapter dues were just too much. Other therapists I've talked to (both young and older) have offered similar reasons for why they aren't members. As with any financial decision, the cost-benefit analysis does not seem to add up when it comes to the APTA.

I spent much of the past week looking around on the APTA website to learn more about what exactly they do and how exactly they do it. I have to be honest, they do seem to do quite a bit. There are various sections on their website for patient advocacy, political pursuits, reimbursement information etc. What complicates things is when I wanted to learn more about what the APTA specifically does within these various areas, I was met with a "Log-in" screen.

I've always been the kind of guy who likes to see proven results upfront before I offer an individual or organization my time or money. For instance, it baffles me why the APTA would not want me to know what their "Public Policy Priorities" are for this coming year. Wouldn't that be something you would want potential members to know? By being open about what your goals are, wouldn't that be a way of drawing in a larger membership? Not everything is blocked on their website, of course, but the vast majority of the information compiled is available via a quick Google search.

When I asked my coworkers about the APTA, one big topic that arose was the PT Journal. Now, obviously, there are no other peer-reviewed journals out there that offer only PT-related content (at least to my knowledge). But is this reason enough to join the APTA? An older coworker of mine pointed out that every journal article in the PT Journal is likely available independently online. Even if you have to purchase the article, it's still cheaper to pay for one article you need as opposed to hundreds of dollars for an annual membership.

We'll be getting to this next point in an upcoming "Dueling Blogs" post, but I wanted to mention here as well that when it comes to politics, I just don't see the APTA having the political muscle necessary to effect real change within our profession. The APTA has some political sway, no doubt, but comparing that to the political capital the insurance lobby has makes the APTA look pretty pathetic. I crunched the numbers; the APTA has in its membership approximately 20% of the national PT, PTA and physical therapy students (2012 data from the Bureau of Labor Statistics and CAPTE). I wonder how seriously members of congress on any level of government take the APTA when they represent such a small fraction of their total numbers.

I looked it up and for me to be an APTA member in the state of Illinois, it would cost me $485/year. Is it worth it to join not knowing what their political aspirations are? Is it worth it to join for a peer-reviewed journal that's available elsewhere? Is it worth it to join when the other players in the game so incredibly dwarf the APTA? For me, right now, the answer is no.

Now don't get me wrong... I believe in the power of people speaking up for what they believe in and fighting for those beliefs on whatever battlefield they can. I believe in the importance of evidence-based practice. And I believe in the furthering of our profession through both political and non-legislative avenues. It just doesn't seem like the APTA is doing enough to warrant me spending that much money right now. So for the time being at least, I will remain but a lowly "non-member."

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How Sick Is Too Sick?
by Michael Kelley

When I was a student, I did a clinical rotation at a children's hospital. Now anyone who has worked with kids before or even has kids of their own are well aware of the fact that kids can be, well, germy. Very, very germy. Needless to say, six weeks into that clinical rotation, my immune system finally gave in and I came down with strep. I hadn't had strep since I myself was but a wee lad, so it hit me pretty hard. I went to see the doctor and had to take a couple days off while on antibiotics. I would say I recovered nicely, but on my next clinical rotation, the strep came back and I had to be put on antibiotics again, this time triple the dosage.

Now that I've been working in a hospital, I often ask myself, "How is it that medical staff aren't sick more often?" I mean, of course we use preventative measures such as washing our hands and wearing gloves or other personal protective equipment, but honestly, those things aren't 100% effective. Are the immune systems of medical personnel somehow superior to those of the general population? Wishful thinking.

I bring this up because this morning, I called in sick to work. I think I either have laryngitis (which I had about two months ago and kept me out of work for close to a week) or just a sinus infection. Either way, I know the remedy is just lots of fluids and rest. I wonder though, when should I be expected to return to work? Do I go back when I think I can make it through an 8-hour day without being too miserable? Do I go back when I'm completely healthy again? Do I go back when my voice isn't cracking like a 12-year-old boy every time I try to talk?

Now I've pushed myself through some miserable days before. That second time I had strep throat on my clinical, I worked the entire day going through fevers and sweats one hour to chills and shivering the next. Where do I draw the line between my personal well-being and comfort level and my patients' health? I work in acute care where many patients already have compromised or weakened immune systems. A simple cold could lead to pneumonia, which quite frankly could kill a number of the elderly patients I normally treat. It's a drastic worst-case scenario, I know, but it could happen.

Then there's the whole human resources thing. At our hospital, we're allowed five sick occurrences in a rolling calendar year. An occurrence is considered an entire episode of sick days. So if I take three consecutive sick days, that's only one occurrence. After five occurrences, you get written up. Six occurrences is another write up. And if I'm not mistaken, seven occurrences is grounds for termination. Sometimes, you just can't help getting sick. I think I lead a pretty healthy lifestyle. I work out five times a week, I eat healthy etc., but I also work in a hospital, which by definition is full of sick people, so my exposure level is pretty high.

What do you think? How sick do you have to be to call in? And on the flipside, how healthy do you have to be to go back to work? Where do you draw your line between being a healthy therapist and putting your patients at risk of catching whatever you have?

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I also want to mention that throughout the month of February, fellow ADVANCE blogger Lisa Mueller and I are going to experiment with "Dueling Blogs!" We have selected a few topics that are "trending" in the PT world right now and Lisa is going to argue one side of the topic while I argue an opposing side. Feel free to comment on either one of our blogs with your own thoughts, questions or ideas. Thanks!

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Bundled Payments
by Michael Kelley

It sounds like a cable/Internet/phone special being offered by a cable company... but wait... this time the "cable company" is actually the Centers for Medicare and Medicaid Services!

Last year, CMS announced a new payment method called "Bundled Payments." Prior to this, for a given episode of care (for example: acute-care hospital stay, followed by a SNF stay, followed by home health care, followed by outpatient), each entity (the hospital, SNF, HHC agency, and outpatient company) were all paid separately for their services. Now CMS wants to try to bundle these payments into one big payment that's shared among the various entities involved in a patient's care.

The idea is that by having one payment, these entities can work more closely together to coordinate care across the spectrum and help reduce costs in the process, since each entity realizes the care they provide may affect how other entities are reimbursed and therefore how they themselves are reimbursed. It's a bit more complex than that, but I guess that's the "nutshell" version.

CMS opened up a "challenge," so to speak, where organizations are asked to develop plans to help reduce costs for various diagnosis codes. To use total joint replacements as an example, CMS will come up with a historical cost for a patient based on the last three years' worth of data and reimbursement rates. Then they will subtract 3%. This is the new "target price" they want the organization to design a plan to meet. If the organization reduces costs below this 3% threshold, the organization keeps 100% of the surplus. If they do not meet the 3% threshold, they owe CMS the difference. Again, perhaps overly simplified, but I'm not a business major, so cut me some slack.

This morning, I attended a meeting with an orthopedic group our hospital system works with. Basically their surgeons bring in patients and perform their total joint surgeries at our hospitals. We cover the acute care, then the patients are sent off to their preferred discharge location and further care is overseen by the original surgeon. This orthopedic group (which is comprised of both physicians and a comprehensive rehab team) has taken on the CMS challenge and created a plan to try to reduce costs for these total joint patients. The plan is ambitious to say the least, but has some serious potential to not only reduce costs, but also streamline care for these patients across the spectrum of rehab entities they may find themselves in.

Without getting into too many specifics, this is how it works: A physical therapist sees the patient pre-op and fills out a pre-op evaluation. It's essentially a questionnaire based on physical status, cognitive status, social factors, co-morbidities etc. This information is plugged into an algorithm that then helps determine the best plan of care for a patient after leaving the hospital (should he go to a SNF or home, when he should start outpatient therapy etc.).

This "care plan" is shared with everyone involved in the patient's care from the minute he leaves the hospital until he has completed his "recovery." By bringing everyone together, they believe they can help focus patients to discharge to the most appropriate location where they'll rehab the best, therefore achieving better outcomes in a more time-efficient and cost-effective manner. The end result being: a lower cost for the overall care beginning to end.

It's a bold idea, no doubt, but from my vantage point serves a good purpose. There are obvious barriers (the presenters today noted the "fee-for -service" model was the biggest among them). But by streamlining care and keeping everyone involved in that care (including the patient who has to sign off on the whole thing), perhaps we can have better outcomes and reduce costs to both the various rehab entities and CMS.

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‘Observation' Patients
by Michael Kelley

This week my topic is a suggestion from a friend who is an outpatient therapist: Medicare's observation status.

For those unfamiliar, patients with Medicare benefits can have one of two "statuses" while in the hospital. Based on their diagnosis and the treatments being provided, patients may qualify as standard "inpatients" where their Medicare A benefits are utilized, or if they do not require significant interventions or meet the necessary criteria for "inpatient" status, they will instead be admitted to the hospital under "observation" status. Essentially, they're admitted for usually a 24-hour stay for monitoring with the expectation of a quick discharge. The trick is that these "observation" patients have their Medicare B benefits utilized as if they were receiving outpatient care.

Now there are a number of reasons why a patient might be in the hospital under either an inpatient status or observation status. At our hospital, many cases go to a third-party review service that looks at the patient's chart and determines his status. We also have a discharge planner in our emergency room who helps determine what a patient's status will be.

The major issue from a rehab viewpoint, as far as I see, has to do with reimbursement. The patients who are on observation status are utilizing their Medicare B benefits, so if for some reason they need to go to a skilled nursing facility, there's no three-midnight rule because Medicare B has no skilled nursing benefits. So essentially, these patients would have to pay out of pocket if they required those services upon discharge.

Another reimbursement issue to keep in mind is that again these observation patients are using Medicare B benefits, under which there is that "Medicare cap" for therapy services. If we see a patient in the hospital while he is admitted under an observation status, any charges we issue eat into that Medicare cap. This can be problematic, especially as we start a new year, since a patient might need those outpatient therapy services down the road. So how do we balance their potential future needs with their current, more acute needs?

At our hospital, we obviously treat the patients who need to be treated. We would never intentionally withhold treatment just because of reimbursement issues. However, when we look at frequency of treatment, we tend to see observation patients about as frequently as they would be seen in an outpatient clinic (e.g. not every day!).

Managing the acute-care needs of these observation patients can obviously be difficult. Having knowledgeable and dedicated discharge planners or social workers helps a lot with patients and families planning for the next steps after discharge. What are your thoughts on treating observation patients? Does your facility have other creative ideas for treating these patients without cutting significantly into their Medicare cap for outpatient therapy services?

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Hospice PT
by Michael Kelley

These last few weeks, there has been a particularly troubling story in the news about 13-year-old Jahi McMath. For those unfamiliar with her story, here is an article from CNN, which provides a synopsis of what has taken place over the past month. Briefly, in early December, McMath went into a California children's hospital for a surgery to treat pediatric obstructive sleep apnea. After surgery she was okay for a short period, but then suffered unexplained profuse bleeding. Despite the doctor's best efforts, McMath went into cardiac arrest and was placed on life support.

Follow-up tests showed that she had suffered massive brain damage and had no cerebral or brainstem activity. Doctors declared she was not only brain-dead, but just before Christmas a coroner actually issued a death certificate. All the while, McMath's family refused to take her off life support. The courts and third-party groups got involved and just this week the courts ruled that the hospital had to release McMath to her family, still on life support. The family states they are transporting her to a facility where doctors will "treat" her, but haven't disclosed her condition or where she is.

It's a sad and tragic story. It brings back memories of the Terri Schiavo case in 2005. These situations are never easy to come to terms with, especially for family members, when something so sudden happens to someone who was so seemingly healthy. Working in an acute setting, it's not uncommon to see patients who are nearing the end of life. We have a hospice unit at our hospital for patients receiving only comfort care, and obviously our ICU sees a fair number of cases where perhaps more sudden events have led to difficult situations for family members making decisions about goals of care for their loved ones. It's never easy.

It doesn't happen too often, but on occasion, we'll receive an order to see a patient who is on hospice care. Sometimes these orders are completely appropriate. The family and patient want to know what equipment they may need if they're going home with hospice care. They may want to know what kind of assistance they'll need at home or how they can maneuver. In these instances, PT is definitely warranted to try to help patients and families problem-solve and plan to make this transition as easy as possible. In other instances though, we'll receive PT orders for patients who are very low level at baseline and have difficulty with even maintaining alertness. The order often derives from family wishes to have patients "try PT" to see if they can do anything or even improve their level of function.

Our department has had many discussions about whether we should keep these hospice patients on our schedule. Some say yes. They argue that it's our job to help patients transition to whatever their next level is and make their quality of life as high as possible, within their stated wishes. Others (and I'll admit I fall into this camp too) hold that PT intervention does not necessarily coincide with the goals of hospice care. To me, hospice care exists to make patients comfortable when there is no clear sign their condition will improve. Alternatively, I think PT exists with the expressed purpose of improving people's strength or mobility or function. Again, with the exception of those "planning" type of PT orders, I wonder, should PT really be involved in the care of hospice patients? What role do we play in end-of-life care? Any thoughts?

Also, I should say this: I know it's a very touchy subject and one that has certainly drawn national and international scrutiny over the years. I know there are many opinions out there and certainly don't believe my views are any more right or valid than anyone else's. If you choose to post a response, and I certainly encourage you to do so, I just ask that you please be respectful. Thanks.

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That Was So 2013
by Michael Kelley

It's all over. And people from every far corner of the world, from Tasmania to Tokyo, Swaziland to Switzerland, Poland to Portland, and even in my snow-covered hometown of Chicago, are celebrating the end of 2013, and the beginning of a brand new year.

I'm sure many out there have their New Year's resolutions all planned out. Whether it be finally shedding that "freshman 15" (regardless of how many years ago you were a freshman), or saving more money for retirement, or completely reinventing yourself, the challenges we set for ourselves are endless. For me, I've never been a fan of the New Year's resolution. Last year however, I decided to try something slightly different, so instead of setting a specific goal that was measureable and all that, I decided to try living my life in a slightly different way. I decided to try to make life decisions, both big and small, with a simple mantra in the back of my head: "Live life more simply."

Some things were big changes -- I moved into a smaller apartment, realizing that I didn't need the larger space that I had. I chose not to buy a new car, realizing I could get by on public transportation (although that is starting to wear on me... see my previous blog post). Some decisions were less drastic -- I decided I didn't need all the clothes I had, so I pretty much cut my wardrobe in half and donated most of my clothes to the Salvation Army. I've tried to be more accommodating when dealing with other people, attempting to live a less rigid lifestyle and be more fluid and flexible in my day-to-day dealings with others. All in all, I think I'm in a better place, and at the end of the day I can confidently say 2013 was a good year.

That being said, 2013 is, well, over. So I have to start thinking about 2014. I'm going to continue with the "living simply" mantra because I think it's a great way for me to stay grounded. But I also think I can focus on my work life a little more and try to create a better working environment for myself.

I think when we look at changing the environment around us, there are two ways to do so: The first is to change aspects of your current environment to better suit your needs. The second is to completely change the environment you're in. Apply this to work as a PT and I can try to change the aspects of my current job that I don't like, or I can find a new job. Obviously there are some things I have no control over at my current job; for instance, I would love if my commute were shorter, but I can't move the entire hospital closer to where I live.

So putting those "unchangeable" things aside, I often wonder if I should be a little more forceful in my requests to try to make my current working environment work better for me. I've been at my current job four-and-a-half years and I have a little seniority, so do I start to use that to push for things I want? On the flip side, if I start looking for a new job, I can change some things that I wouldn't be able to with my current job. For instance, I could find a new location closer to my house, thereby shortening my commute (no hospital relocations needed!). But there are risks here too; the PT job market in Chicago has slowed quite a bit over the past year or two and it can be pretty daunting to update a resume and reference lists, apply for jobs and interview.

All in all, there are a lot of unanswered questions for 2014, but I know what I want to work on and I have 365... well, 364 days now... to work on it. Let the fun begin!

Best wishes to you all for 2014!

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