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Raising the Bar in Rehab

Acute Care Direct Access

Published October 20, 2011 1:46 PM by Lisa Mueller

There have been a few posts this week from some of the other ADVANCE writers about the progress being made toward direct access for physical therapists. Dean wrote about a London-based hospital staffed by nurses and PTs with very high initial satisfaction results from patients. Brian wrote about new research supporting fewer costs and fewer visits for patients who saw a physical therapist first instead of a referring physician. Obviously, the transition to a DPT degree was in part to promote a physical therapist's ability to practice without the direction of a physician.

The physical therapy profession is moving in the direction of direct access, slowly but surely. Most therapists welcome this change and want the autonomy and responsibility of being first-line providers. The APTA has made a lot of progress for both private practice facilities and other outpatient clinics, but acute-care practitioners still rely on referrals from physicians or nurse practitioners.

Hospitals are big facilities. There are hospitals in Wisconsin with over 700 beds. The New York Presbyterian Hospital has 2,200 beds. It's not possible with numbers that big for a physical therapist to walk from room to room determining if her services are needed. The same reasoning applies for other consulted physicians. For nephrologists, palliative care, neurologists or any other specialized physician who needs to be involved with a patient's care, they receive a consulting order from the primary physician; the same process used for consulting physical therapists. For patients to ensure they are getting the care they need, a primary caregiver needs to direct and organize each involved professional. I mean this in terms of logistics, not in terms of hierarchy or control.

As direct access continues to develop and become the standard of practice for outpatient physical therapists, it will be interesting to see how that missed opportunity for acute-care therapists will impact their professional growth. I don't think acute-care therapists will fall behind outpatient therapists, but the culture of practice will be different between those two types of practitioners.

So, what does direct access mean for physical therapists practicing in acute care? How will the changes in direct access affect them, or won't they? What about other types of facilities, such as a subacute nursing home or long-term acute care? Can physical therapists in those settings expect direct access, and if so, how would it work?


There is a big difference between direct access for outpatients such as Dean describes and those in acute care settings. Dean is correct. There are times when the most appropriate practioner is a physical therapist. Other times, such as in a acute hospital setting, it might not be. I work in a large hospital. Most of those patients are very sick. Even in my area, where I practice with autonomy, some patients are too acute for PT intervention. It's usually pretty obvious who those patients are. I round daily with my docs. I know how they're doing. Once the docs reveiw the medical I status I know when someone is ready for therapy. I wouldn't want to try to make that decision without that input. That is the problem with the acute setting. I can see direct access working on an orthopedic floor, maybe a general medicine or geriatric floor when patients are medically stable. The question for me is who decides when the patient is stable? PTs can easily decide who needs therapy. Someone who is very familar with the area, such as I, could probably make that decision. I don't want the responsiblity. What if I'm wrong? Tell me the patient is stable. Then I'll decide if PT is needed. Reaching that happy medium is going to be very difficult.

Toni Patt October 23, 2011 3:35 PM

Great discussion point! Here in the UK, there are numerous entry points into the health care system. One doesn't necessarily go to an A & E (ER) or to one's GP (PCP) as there is an alternative in the "walk in centre". There is a big cultural difference. People here are not as concerned with who provides the care, they simply want the necessary care to be provided. GP offices are for routine  matters that are not urgent, A&E is for life threatening emergencies, and the walk in centers are for urgent care which is not life threatening. In my experience in the US, that option doesn't exist other than on University Campuses.

There needs to be a cultural change in the US. People still insist on being seen by someone with "MD" after their name. They need to be shown that "NP" or "PT" is not only OK, but in some cases more preferable. I believe this is the work the APTA has ahead of it now. Cultural change typically comes slowly and I think we've all been thinking years (if not decades) ahead. The time to be aggressive is NOW! We need a health care facility willing to take a chance on us. We need to use the information from this study in London to support our stance.

With healthcare reform and other financial concerns at the forefront of people's minds, we should not seek to find the "safe" way, but rather be daring and put ourselves on the line. It is a time of worry, concern, and more importantly of great opportunity! Lets not waste it.

BTW, the physios here are all Bachelor's level, no DPT needed for direct access, care management or prescribing of medications. Just sayin'.....

Cheers, Dean

Dean Metz October 20, 2011 4:07 PM

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