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Toni Talks about PT Today

Prioritizing Patients

Published November 26, 2013 5:53 PM by Toni Patt

In order to compensate for escalating case loads and inadequate staffing, prioritizing who to see each day has become a way of life. Sometimes my day is easier because patients are unavailable. Generally I start every day deciding who needs therapy the most. With the exception of which doctor will complain the most, I think that's the way everyone does it. I used to think everyone defined that need the same way.

I define need as those who have the worst impairments. These are patients who aren't able to do much on their own. They're going to need more therapy when they leave the facility. They can be time consuming. The going is slow. But there are copious amounts of research suggesting the more we do with those patients and the earlier we do it, the better the outcomes. Other research suggests the patients who are doing okay already will recover no matter what we do.

I work with an OT who thinks completely opposite. She prioritizes the patients who are mobile. They aren't severely impaired so they often make big functional gains. Her rationale is she can help these patients go home. For the more severely impaired, she makes splints, does ROM and UE strengthening exercises. Would it be inappropriate to say she drives me insane? I spend numerous sessions improving trunk control while she sees them in bed.

Nonetheless, neither of us is wrong. Both groups of patients benefit. Usually we're able to see all of our patients, just not for as long as we would like. Right now this compromise works. What happens when staffing is further cut to save money? Or, more likely, no additional staff is available despite higher caseloads? Patients will be missed on a regular basis.

Who do we treat? The ones who make quick gains with minimal staff action or the ones who need time and effort? I work in an LTAC. Most of my patients go to another facility for more therapy. What if it was a SNF? Often those patients become permanent residents if they don't make progress.

There's an even bigger question. Who makes the decision? Right now it's the individual therapist. Eventually the facility could take it out of our hands by decreasing staffing and/or increasing productivity demands. I have one tech. If that position is eliminated, I can't do as much with my impaired patients. In SNFs, the decision is made by who needs the minutes. Patients with minimal potential and great potential get the same duration of therapy if the minutes say so.

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Ms. Patt,

As a pre-physical therapy student, I know from firsthand how important the matter you discuss in your blog post is for the physical therapy community. The issue that you describe is the catch 22 paradox of physical therapy. As patient waitlists continuously grow, physical therapists are pressured to treat as many patients as they can each day. Some therapists that I work with treat an unheard of fifteen patients a day. To treat more patients, one quick solution is to shorten the length of patient appointments, but research shows that the less time therapists spend with their patients the more dissatisfied they are with their care. According to an Australian study, “Patients need to feel that they have had adequate time with the therapist and not feel rushed through an appointment. Reducing patient-therapist time can be interpreted by patients as a lack of interest in them and lead to lower satisfaction.”  Therapists are unfortunately stuck with the opposing dilemmas of catering to the general patient population as well as to each individual patient. I agree with you that it is necessary and almost inevitable for PT’s to prioritize some patients for treatments, but I have a few suggestions to assuage this issue and hopefully help PT’s see all of the patients on a single day’s list.  

For fast-paced outpatient clinics like the clinic where I work, I believe that therapists should see their regular patients for appointments at least half an hour long. Half an hour goes by quick and usually patients do not finish their entire exercise program. Therapists at my clinic hand off their patients to us, physical therapy aides, to guide their patients through the rest of the exercise program and help set them up on post-exercise treatments, such as ice or ultrasound, after the main treatments have been done by the physical therapist. Since hiring a full time therapist is costly to the facility, clinic owners should consider hiring more physical therapy aides or assistants to combat the growing patient population. While some studies have found that utilizing physical therapy assistants resulted in lower recovery effectiveness, I believe that as long as physical therapy aides are trained appropriately by the therapists, therapists should feel assured that their patients are going into good hands as they go on treating their next patient. Other settings, such as hospitals and rehabilitation centers, cannot reap the benefits of physical therapy aides because treatments for these patients are generally require more training and experience. This leaves all the treatments to the therapists alone. At a physical therapy unit in a hospital, the lists of patients to see a day are sometimes two pages long and it is assumed that at least half of the patients will not been seen on that day. At a pediatric hospital I volunteered at, I noticed that there were no specifically set times for inpatient visits. Instead therapists, as you wrote in your post, treated the as many patients as they could on the basis of priority. Scheduling inpatient visits is a difficult task because physical therapy visits compete with other appointments during the day, such as doctor rounds, medication administration, medical examinations, and patient rest time. Despite this fact, I think that it would be more efficient to schedule the appointments so therapists have a set agenda and know how long they should be spending with each patient so they could see as many patients as they can during the day. To avoid timing conflicts, therapists could call the nurses in charge of their patients first thing in the morning to discuss what the best time to see the patient is. This may take out some extra time in the morning but I think that overall it would increase the number of patients seen throughout the day. These proposals that I have brought up have sprouted from my observations as a volunteer and physical therapy aide so I would love to hear your opinion on them.  

Helen Yiu  

University of Southern California  

Dana and David Dornsife College of Letters, Arts, and Sciences  

B.S. Kinesiology, Psychology Minor  

Class of 2015

Helen December 5, 2013 6:35 AM

I completely understand that healthcare needs to run like a business in the USA in order to survive. But what about the product? If we are not actually making people better, then why buy our services? As caseloads increase and patients have to be triaged for care, I'd like to remind owners and shareholders of Detroit in the 70's and 80's when Americans couldn't build a car that would last to the end of the financing contract. Americans bought foreign cars because they were better. Now Americans, who can afford to, are going to places like Brussels for elective surgeries and rehab because it is cheaper and the job actually gets done. It just seems to me these short sighted business models are going to collapse at some point. Unfortunately the patients once again pay the real price.

Dean Metz November 28, 2013 6:21 AM

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