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PT and the Greater Good

‘Can You Back That Up?'
by Dean Metz

I was asked that question last week by a board member of the NHS Trust in which I work. Rather a few members are making the rounds of different services to see how things are working (or not) and to assess if they are getting monetary value for those services. We were well prepared. We had the results of a yearlong audit showing excellent clinical outcomes and positive financial outcomes.

The board member who asked the question is very involved with budgets and reimbursements. We were able to give answers based on a fair amount of research and costing data. They asked us questions for nearly 2 hours. When they left, one commented that this visit wasn't anything like what they expected, but was so much better than they had hoped for.

As I'm developing a similar service in another town, I now also have to back up claims on potential outcomes, both clinical and financial. I'm glad I've got the experience and data to see me through this process! I didn't get them overnight though. This isn't something one can "cram" for in a weekend.

It has been 5 years of developing a culture of data collection in our service and getting others on board with understanding the importance behind a variety of evidence. It has meant working closely with other disciplines to achieve common goals in running an excellent service. In these times of tight and tightening budgets, one must always have data to support one's service. This means a culture of self-reflection, on both personal and group levels.

Does your clinic/practice regularly audit itself? What does it look at? To survive and even thrive these days, it isn't enough to be ready for a JCAHO, Medicare or state DOH survey. One has to be ready for the owners to show up and ask why your service does what it does and the way it does it. Are you ready?

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The SNF Rehab Model Must Change
by Dean Metz

I've learned immense amounts about what my American PT colleagues are going through just to work these days. It disheartened me at first, inspired me next, and now has propelled me to think more creatively. I think it may be time to throw out the baby with the bathwater... and the tub... and the sink... heck let's just rip down the house! The SNF rehab model doesn't work! If owners can't make a profit without professionals having to work off the books, overtime, and destroying their professional lives... it is a failed business model, plain and simple.

I started thinking about this because there are very few SNF rehab facilities here in the UK. Our town (population 283,000) has one with a capacity of about 20 people. Mostly acute TBI patients, acute trauma patients, and an occasional person with a stroke occupy those beds. Care homes here are staffed mostly by CNAs with some nursing oversight. If rehab is required, it is referred out to community teams (the equivalent of home care).

Where has the American SNF model evolved from? Has it actually been changed to maximize reimbursements? With so many stories of inappropriate patients on program, I seriously doubt it has evolved from patient need or demand! I also seriously doubt the situation will improve as time goes on.

Here is where the APTA can step in and not appear to be working as a trade union! They can ask the important questions, such as: Are the patients still benefiting from this model? Who does this model serve? What possibilities exist for changing sub-acute rehab into a more workable model?

In this way they can support us as professionals, demonstrate our ability to be proactive and leaders in patient care, and have a voice in creating the care landscape of the future. If they want us all to have the respect that comes with the DPT and autonomy, then they can't let us work for free in a sweatshop environment. Who is going to respect us when we work in that fashion?

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Effective Agents for Change
by Dean Metz

Two weeks ago I attended, and presented a poster, at a seminar on change within the National Health Service (NHS). We were asked to present because we had excellent outcomes in our service and we got them by doing things differently than other services had done. It was an enlightening day. The primary speaker, Helen Bevan, gave a fantastic presentation on how to effect change in the NHS. I want to share some of her thoughts with you.

"Be a boat rocker... but stay in the boat!"

Radicals, rebels and mavericks are generally not embraced in business, especially at non-management levels, however most great ideas and changes come from them. Some key points to being "different" in an organization: don't break rules -- change them; don't complain -- create; don't see problems -- see possibilities; don't point fingers -- pinpoint causes. She had many more, but these characteristics will help get a point across better than negativity.

She emphasized that successful boat rockers have the following characteristics: they are value-driven, have a sense of self-efficacy, collaborate, achieve small wins to build cohesion, and are optimistic.

So what does this have to do with productivity? First try and empathize with your director/administrator. This person is under pressure from owners to produce! Offer potential solutions to any obstacle you raise. Is there waste in the way things are run in your facility? Do you have a solution that might be easy to implement? Suggest it! Don't be discouraged if nobody listens at first. Keep coming up with possibilities, your enthusiasm will get you support until you become a force that cannot be ignored.

Learn about management; especially lean management. Managers can interpret data to support changes. The same can't be said for opinions and feelings. When we proposed the changes to our service, management was very doubtful, but by having our statistics and service agreement contracts clear, through a lean management approach we validated our ideas and brought management on board. The result was happier patients, realistic workloads, and exceptional clinical outcomes.

It can be done and more than a few people who have responded to my blogs in recent weeks have told me ways they have succeeded. Sometimes we may find ourselves working for "the evil empire," as one of my ADVANCE blogger colleagues called her old employer. A company that so lost its soul she had no choice but to leave. You might face the same dilemma too, but at least give it your best shot to turn things around!

As a non-therapist friend once said, "If you don't want to be a doormat, get up off the floor."

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Productivity: Why Bother Speaking Out?
by Dean Metz

I was asked in a private message, "What are your goals in speaking out about the productivity issues facing therapists in nursing homes (and private practices) today?" A good question! We can whine and complain all we want; very little will come of that activity. If we complain to excess, people will stop listening. So what do we do?

Here is why we need therapists to get research active! It would be interesting to see how outcomes compare between facilities that are productivity-focused versus those that are more patient-centered. Facility-provided outcome data would probably not be helpful. If a facility is willing to fudge data just to get patients on program, how likely would it be to manipulate other data as well?

Instead, what would the re-hospitalization rate look like? How would patients rate their own improvement? What would rates of return to work or sports look like? There is a whole PhD project waiting to be designed and written about this.

I still haven't really answered why I'm speaking out. As bothered as I am that my fellow therapists are being mistreated, I'm even angrier that patients will be the ones really suffering from being on this rehab conveyor belt. If you're working at 90% productivity regularly, tell me, how well do the majority of your patients meet their goals? Could they have done better if you had time to case conference with family or other professionals?

How many patients had limited improvement because they weren't really appropriate in the first place? How much money is being spent from scant resources on unnecessary treatment? What is happening to our professions' reputation? Struggling to meet insane productivity levels hurts more than just the therapy staff.

Maybe, like me, you're not in a place to pursue this as a PhD project. I'll talk about an interesting approach to effecting change on a local level in the next blog post.

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Consent for Professional Abuse
by Dean Metz

If you're thinking this is a post about patient consent, it's not. Last week I wrote about the nearly unachievable productivity levels in skilled nursing facilities. I got a lot of responses from it. A former classmate wrote to tell me he was just separated from his employer due to saying "no" to unreasonable productivity levels.

Professionals are working off the books, unpaid overtime, or making themselves exhausted trying to cram everything into 7.5 hours a day. As professionals we're expected to practice based on the evidence base. Why should our employers behave differently? Productivity should be based on evidence, not randomly picked numbers.

There are many options for our employers to effectively determine what reasonable expectations for productivity are. My ADVANCE colleague, Lisa Mueller, has written about lean management. It's an objective way of maximizing productivity. It focuses on process, flow and the elimination of waste. There's nothing wrong with asking employers how they came up with productivity expectations. If they balk at the question, the odds are good there was no real process to figuring out the numbers. Do you really want to work for a company like that?

We have spent good money and/or gone into debt to learn the skills of care management, care planning, patient and caregiver education, interdisciplinary meetings, and documentation. Why shouldn't we expect to be reimbursed for those skills? They most often are part of the job description when working in an SNF.

Unless one is a business owner in private practice or receives some sort of profit-sharing bonus, one should expect to be paid for all the work one does. When one starts working without reimbursement, then consent has been given for professional abuse. On occasion, we all have worked a few hours over here and there. Generally in those instances, my employers have allowed me to take that time back at a later date. That is not what I'm reading in the posts of many of my fellow ADVANCE bloggers.

The APTA is striving for us to have nearly complete autonomy as professionals. If we keep allowing ourselves to be abused by employers in this fashion, that goal will most likely stay out of reach. If we can't stand up for ourselves, how can we be expected to stand up for our patients? That's why I believe the APTA needs to be part of this discussion.

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Productivity Woes
by Dean Metz

Many of my fellow ADVANCE bloggers have been voicing concerns over productivity standards where they work. There is concern over not being able to reach targets and still do required work that's not billable; concern over working on one's own time; concern over patient outcomes; and concern of personal burnout and exhaustion.

They are not alone. I've recently come across an excellent piece by a speech-language pathologist on the same issue. What value is there in measuring productivity? General Motors sold 9.7 million cars last year... very productive. But they've already recalled 16.5 million cars this year. So although they got the product out the door, what good did it do them or their stockholders? Isn't that exactly what's going on in SNFs in the US now?

Somehow we need to know that employees are working optimally. Gross numbers are a bad way to measure that. If the product is without quality, then who cares about how many things get made or the number of people who get seen? Also people lie about numbers -- just look at the current VA scandal about misreported waiting times!

When we balk at doing work on our own time, managers can manipulate the situation by reminding us about our professional responsibility or how we should keep the patient in mind. Where will they be should an audit turn up questionable billing or when an unhappy family files a lawsuit? Will they be there to defend you or will they point the finger and simply hire another PT? Although the APTA is not a trade union, they must not remain silent on poor treatment of PT professionals in the SNF settings.

What does this mean beyond those therapists toiling away in sweatshop-like conditions, wondering if they could get fired for missing targets or speaking out? (Which, by the way, is perfectly legal in states with "at-will" employment).

It means that the public is not getting the services it needs in the right amount at the right time. Errors in process or documentation are more likely to impact this vulnerable population. Unscrupulous companies looking to maximize their short-term earnings are pillaging the resources set aside for the needs of this population. SNFs are raping the Medicare system now the way home health did in the early 1990s. If there are no funds left by the time we need them, we'll have only ourselves to blame for not speaking out now.

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My Mentor, My Inspiration
by Dean Metz

For my birthday, I've treated myself to phone calls to friends and family back in the States. I just got off the line with the person who I can say is the reason I became a PT/physiotherapist. I had been in my mid-20s and the whole starving actor gig was more starving than acting and it really wasn't much fun.

I figured that if I wasn't having any fun, I could at least make some better money, so I started my quest for what I wanted to be should I some day grow up. A friend was running a small private PT practice in Brooklyn at the time and I met her for lunch one day at her office. I was early, and with the permission of her patients, I got to watch what she did. I was hooked! She has provided gentle guidance along with the occasional kick in the pants ever since.

We did the usual catching up on the phone today, asking about each other's spouses, trips and such. We also talked about how the practice of PT is changing and what that means for future PTs and ourselves. I was able to tell her about our award nominations, presenting at Physiotherapy UK 2014 in October, and about the grant I applied for this week. I was very touched by her response. "You've successfully reinvented yourself, more than a few times! But you did it in a way that also benefits humanity. The work you're doing is remarkable."

I became a PT because I wanted to help people (and make a living). I didn't expect to have found my calling nor to be in a position now where I can impact a population on a large scale. I suppose the best birthday gift I got this year was the admiration and approval of my mentor.

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Yes, There's a Need for What I'm Doing
by Dean Metz

This morning I learned that a piece of my childhood had passed on. Ann B. Davis, one of the actors in "The Brady Bunch" (new grads, ask your parents, they'll remember) slipped while getting out of the shower, hit her head and died.

This is really unfortunate. I've read that she needed a walker to get around. I wonder if she had assistance in the shower or was she attempting it on her own? Could she really manage to bathe on her own? Were there rubber mats and/or grab bars in place? Was there anything that could have prevented this outcome?

Working with older adults, I know too well that many of them do not wish to "go gentle into that good night." Nope, they will kick and scream all the while you are showing them how much their gait has improved with the use of a cane. I imagine I will probably be much the same if and when the time comes.

Prevention is so much better than cure, but nobody seems to want it. This is the dilemma I'm confronting with my projects here in the UK. How am I going about dealing with it? I'm targeting the children and caregivers of older adults! My thought is that if I can educate them on how to look after their parents successfully, they'll apply those same ideas to themselves 10-15 years down the road when they become the "at-risk" population.

Will it work? I'm not sure. I suppose I'll be the one creating the evidence if it does. One thing I do know for sure -- no country will be able to afford the medical care necessary when this group reaches that age unless we take action now.

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Changing a Culture
by Dean Metz

I've just gotten back from a day trip to London. My colleague, a nurse, and I presented for a panel of judges on why our service should be awarded the National Patient Safety Award for 2014. It went well, I think. It's based on the fact that our service succeeded at reducing falls by 81% in a cohort of 142 people for six months after discharge. The literature states a well-run service should be able to achieve 33%. I'd call that a real success.

The panel wanted to know what innovation we'd implemented to get those results. It is a simple thing actually; our assessments are joint evaluations with both physios and nurses working together in the same 90-minute assessment. It has improved our efficiency and patient outcomes. It also took a lot of convincing for management to accept this before we had the clinical outcomes stated above.

At the end of the week, I'm submitting a grant for another Trust, which is focused on changing culture between general practitioners and the public. We're including public health and pharmacists in the plans as well. This is based on a health needs assessment that determined prevention of falls was rarely, if ever, discussed between GPs and their patients. Once again I'm looking to change a longstanding culture. It won't be easy, even if we do get the grant! However it is what's necessary to improve patient outcomes and meet the demands of the future.

Change in the health culture of the USA is necessary now as well. The ACA has tried to do that. It may or may not be the solution, but who has offered up better ideas? Maybe it needs to happen first on small local levels first, like I'm doing, gathering evidence to support our ideas, and taking them forward to state and national levels. How have you helped changed culture that is no longer serving the needs of your patients?

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What if You Could Impact the Milliman Guidelines?
by Dean Metz

When I was working for a managed care company back in New York, the Milliman Guidelines were the book that drove levels of care and reimbursement. Treatments were approved or denied based on what was in that book.

In the UK, the NHS is actually a single payor insurer with each local Clinical Commissioning Group (CCG) deciding which treatments, procedures and services will get funded and provided. They may be provided by the NHS or by private companies depending on the bidding process. The CCG works similarly to the Milliman Guidelines. The big difference though is that tomorrow I may get to influence how they spend the money in our area.

I previously mentioned that our Community Falls Service was up for an award for patient safety. In addition, I believe we've shown that our service saves money in the long term. I will have seven minutes to give a presentation about that tomorrow. In short, our interventions have decreased the rate of falling by 81% in the cohort we followed, with 69% of the patients experiencing no further falls even six months after discharge.

Considering what a visit to Accident and Emergency (A&E) costs the NHS, never mind a hip fracture, by decreasing the number of falls we have decreased the number of hospital visits and associated costs. I have extrapolated figures for that to present to the commission tomorrow. I don't know that I would've had a similar opportunity to affect the Milliman Guidelines back in the US.

By the way, a week from today my colleague and I will travel to London to present on our service, which has put us on the short list of finalists for the National Patient Safety Awards. Wish us luck!

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Restructuring
by Dean Metz

The very word can strike fear into many employees. In my previous experiences, that translated into layoffs, with those lucky enough to remain absorbing many of the jobs that used to be done by those laid off. The NHS has gone through a fair amount of restructuring in the past four years, so it has become nearly commonplace. Since 2009, I have worked for three different NHS trusts while working in the same job.

This time is different though. A colleague of mine has decided to move on to another role and resigned. Our business managers are beginning to think about not replacing like for like (a nurse for a nurse), but rather what does the job really entail and who would be best to perform that task. I think that is a brilliant approach to problem-solving and staffing appropriately.

The role I'm currently in is only a fixed-term temporary post filling in for someone (a nurse actually) while that person is seconded to another post. What this could mean for me is a permanent job and not having to start the job search all over again in August.

How could I be filling in for a nurse? Again, the managers stopped and looked at what the role entailed (acting as a consultant for residents of nursing homes who have fallen over). What matters is the skill set, not the title.

I hope I see more of this trend in thinking, particularly for my former colleagues back home in the US. I remember seeing job postings requiring a nursing degree and I would ask, "Why?" What was it about the job that required a nurse? Often it was simply historical and no other reason. As we become more highly skilled, with DPT degrees back home and the ability to prescribe over here, new doors should be opening for us. It is time for us to go where no PT has gone before!

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Unintended Consequences
by Dean Metz

A while back there was some chatter among us ADVANCE bloggers on the public health issue of obesity. Since having an elevated BMI can cause a host of health problems, and Westernized nations on the whole are getting heavier and heavier, this is an area where many PTs could possibly have some input. The discussion at the time of the blogs had to do with the former mayor of New York, Michael Bloomberg, and his ban on supersized sugary soft drinks.

A new paper has recently shone some light on how with the best of intentions, public health interventions can inadvertently cause harm. One of the most common areas where interventions went wrong was in regard to obesity. The harm ranged from the boomerang effect, where some people wound up developing anorexia after the interventions; to psychological, where others wound up with lowered self-esteem and the stigma of being labeled obese; to financial harm, with resources wasted on interventions that didn't work at all.

The reasons many of these harms happened varied as well, including poor evidence base for some interventions, poor engagement of the target population, poor establishment of the root cause of the problem, and implementing an intervention that worked in one group that was very different from the intended group.

These are all things I have to take into account when planning how to decrease the risk of falls in the people of the towns I work within. I know the key challenge I'm facing is engagement of the target population. Many of the older adults in this area feel falling is just part of getting older and there's nothing to be done about it. One of the first things we have to do is change that mindset.

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Presenting, Presenting, Presenting...
by Dean Metz

I got word today that the abstract for our study on the clinical and financial efficacy of our fall prevention clinic has been approved for a poster presentation at the annual Physiotherapy UK conference in Birmingham in October. I'm very pleased. While I was back in New York last year, the team here was collecting data. When I returned, we put it all together and were very pleased with the outcomes. It seems the Chartered Society of Physiotherapy was as well. This will make two presentations in three years. Not bad going, if I do say so myself.

Tomorrow I'm presenting at the strategy meeting on fall prevention for the local authority where I'm working. It's in conjunction with public health, third-sector (charity) stakeholders, and health service providers. Essentially this is about how to integrate all these stakeholders toward a common goal of reducing risk for our older and late-middle-aged adults. These meetings really excite me. How often would all these parties get together to work on common goals back in the US? On top of that, we're meeting monthly to assess progress, plan future initiatives, and ensure no gaps are left in addressing this public health problem.

If I'm very lucky, I'll also be presenting in London in May too. Our unit has been shortlisted for a national award based our work. We'll have to present to a panel on why we deserve the award and what makes our team and approach unique. I'm not able to go much into detail for a few weeks, but when I've been given the go ahead, you'll hear all about it.

Not that there was any real doubt, but I'm thinking coming back here was absolutely the right move for my career.

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Making a 'Very Bold Statement' to Physicians
by Dean Metz

A large part of my current position involves reducing the risk of falling for people in the community as well as those residing in care homes. That's what prevention is all about -- reducing risk. Not long ago, I received a phone call from an irate physician who took offense that a mere physiotherapist would write him a letter detailing which medications were potential culprits in the patient's falling.

"Are you implying I don't know my own patient's medications?"

"No sir, but we find it helpful to remind GPs of how many culprit medications a person may be taking."

"You're saying I don't know that?"

"Not you personally, sir, but I have had some GPs in the past who were not as well versed in a patient's current regimen."

"That is a very bold statement, sir!"

We discussed a little further and then discovered that indeed he had forgotten the patient was still on one particularly troublesome medication. Bold. Indeed.

To give GPs a break, they have precious little time to sit with older adults and figure out exactly what meds they should and should not be taking. Because there is such evidence that blood pressure medications reduce the risk of heart attack, stroke, and kidney disease, nearly every older person is on at least one such medication.

Mary E. Tinetti, MD, just published an article in JAMA about the risks created by these very medicines. We now have excellent evidence that these medications are not merely innocuous, but rather can affect a large number of people in disastrous ways.

So which risk do we try to reduce? Use the medications and run the risk of a debilitating fall and/or fracture? Don't use the medications and run the risk of heart attack or stroke?

Prevention, like every other aspect of healthcare, is not a simple black-and-white situation.

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Now I'm Convinced
by Dean Metz

A few months back, a member of my family was in a business meeting when suddenly his right hand became spastic. He looked at the person he was meeting with and couldn't figure out why he was there or what they had been talking about for half an hour. He was having a stroke.

He was rushed to the local hospital in Florida and immediately received wonderful treatment in the emergency room. His wife joined him there and they were suddenly confronted with a screen that had a live feed from Rhode Island. The doctor who would be tending to him was nearly 1400 miles away. He was getting live feed from the monitors in West Palm and talking with the patient and his wife about options for treatment. They reached an informed decision, treatment was rendered, and now the former patient is back to work, playing golf, and virtually indistinguishable from his pre-stroke self.

I've railed against tele-health many times in previous blogs. Often because it's used as a cost-cutting measure, rather than a way to bring the best parties to the table in situations where it would have been otherwise impossible or where waiting could have resulted in a vastly different outcome. Imagine the potential for treating people in remote rural areas. How about the ability to supervise a PTA in a home care setting without both having to be in the same physical space at the same time? How about my fellow ADVANCE blogger Michael Kelley, who last week posted about some trepidation treating vestibular patients, being able to consult with a trusted expert hundreds of miles away?

We have the technology to make our lives, and the lives of our patients, more secure, more efficient, and better able to achieve positive outcomes. We must ensure it is used for the noblest outcomes in our profession. We need to embrace it and be innovative with how we use it. Skype, FaceTime, and a host of other providers can link us together for the better.

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About this Blog


    Dean Metz
    Occupation: Staff Development Specialist
    Setting: New York, NY – Newcastle Upon Tyne, Great Britain
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