Physical Therapy Treatment Optimization (PT2O) Initiative:
Building upon the growing volume of evidence for physical therapy and capitalizing on the success of the Behavioral Health Optimization Program (BHOP) model, the PT2O concept breaks the mold on the traditional delivery mechanism for physical therapy and places them within the family health clinic to expedite the management of musculoskeletal injuries. As Dr. Anthony Beutler highlighted during the 2012 MHS conference, musculoskeletal injury is the leading cause of lost duty time in the military. As the military continues to right-size and navigate the fiscal constraints, innovations that can increase access for MHS beneficiaries and minimize lost duty time will directly impact our readiness and experience of care. The headlines are filled with budgetary analyses which highlight soaring healthcare costs as a threat to our national security. The associated direct and indirect health care cost of musculoskeletal injuries sustained by our MHS beneficiaries is estimated to be in the billions. The Department of Labor and Health projects a 30% increase in physical therapy utilization over the next five years. As the median age of our population continues to rise and the expectation to participate fully in high level physical activities well into retirement years, the volume of orthopedic cases such as total joint replacements will climb considerably. Additionally, as our younger population returns to physical fitness and sporting activities, the incidence of sports-related injuries and associated post-operative rehabilitation for both of these populations will increase.
Due to the demand for services, current musculoskeletal management practices and referral processes, it can take patients up to 28 days to access to care. Recent evidence published by Dr. Julie Fritz and colleagues, in Spine, highlight the impact of delayed access to physical therapy for low back pain, as an example. They concluded that “early referral (within 14 days of the primary care consultation) was associated with reduced risk of subsequent health care utilization, including advanced imaging, additional physician visits, major surgery, lumbar spine injections, and opioid medications, and lower overall health care costs…[specifically], total medical costs for low back pain were $2736.23 lower.” Despite improved efficiencies and productivity within the AF Physical Therapy community, the demand continues to rise as predicted. The second and third order effects of this increased demand and delayed access to care are a negative impact on our readiness, quality of care, and overall healthcare delivery cost.
The PT2O model places one Active Duty (AD) physical therapist into the family health clinic (potentially 2 at our large MTFs). The therapist would require minimal support staff such that the only projected impact on the family health clinic would be administrative assistance with scheduling and the space requirement for a small standard clinical exam room.
The benefit of this model is that it directly impacts all areas of the Quadruple Aim. First, from the readiness perspective, both the AD therapist and AD beneficiaries will enhance readiness. The beneficiaries will receive expedited access to care thus reducing the lost duty time. Since the therapist would be in a position of screening all musculoskeletal injuries, the therapist would be able to mitigate unnecessary referrals to the physical therapy clinic, which would substantially decrease the need for purchased care. The AD therapist would also gain much needed “front line” currency in managing acute injuries identical to how therapists function in a deployed setting. As deployment opportunities decrease this model establishes an enduring currency platform for our physical therapists across the enterprise to ensure they are ready to deploy. Second, from the better health perspective, early access has been demonstrated to reduce pain for sub acute low back pain patients at the six month period compared to a control group. (Nordeman et al) By reducing the chronicity of the condition, beneficiaries can return to duty and prior fitness activities sooner with less pain. Third, from the better care perspective, clinical research supports early access to physical therapy as resulting in “fewer physician visits, fewer restricted workdays, fewer days away from work and shorter case duration.” (Zigenfuss et al) Lastly, this model directly addresses the challenges of healthcare cost containment. Utilization of the physical therapist within the PCMH model can liberate the family practice providers from a portion of the routine musculoskeletal cases and open access for truly sick patients who need their services. Additionally, by triaging the patients prior to seeing the orthopedic surgeon, PTs have reduced the number of patients a surgeon needs to evaluate to generate a surgical case, thus improving the overall efficiency of the musculoskeletal product line. Finally, the PT community is well-versed in non-narcotic management of musculoskeletal pain and employs practices that encourage independence, self-care, prevention and overall healthy lifestyles. Collectively, these advantages directly support the current recommendations and evidence to reduce the escalating healthcare cost/crisis facing our nation by reducing medication costs, engaging patients in self-management, and focusing on both intervention and prevention to maximize long-term patient outcomes.
The proposed pilot program requires a total of $165,000 at each pilot location. The cost breakdown includes $150,000 to purchase a contract physical therapist to allow the AD physical therapist to operate in the Family Health clinic and $15,000 to purchase the initial set-up costs for a 1-person clinic (treatment/evaluation table, computer, and furniture) and operating supplies. The sustainment cost after the initial investment would be the contract PT ($150,000) and approximately $3-5,000 in supplies for braces, supports, resistance bands, athletic tape, and etc. In order to improve the validity and generalizability of the pilot program, five locations would be selected. The anticipated timeline for implementation would be approximately 6-8 months primarily limited by the time required to coordinate the contracting portions of the initiative and hiring the physical therapists. The total cost for the pilot program implemented at five locations would be $825,000. Again using the results from the Fritz et al study, the entire pilot program would require the management of only 301 low back pain patients until they would start generating a return on investment. Since AD therapists across the services are trained and credentialed to practice using this model, this proposal will not require any policy or law exceptions. The greatest anticipated challenge to implementation is the cultural shift in musculoskeletal management and physician buy-in. Since AD physical therapists across the services have the training to operate in this model and are required to maintain their currency in providing early/direct access care, the PT2O model is both scalable and viable across the services.
Ultimately, the PT2O model is perfectly aligned with MHS Quadruple Aim and PCMH model. This innovative solution improves provider currency, maximizes patient outcomes, reduces chronic disabilities, and helps bend the cost curve through the application of evidence based practices and an innovative delivery mechanism.
Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary Care Referral of Patients With Low Back Pain to Physical Therapy. Spine 2012; 37(25):2114-2121. Nordeman L, Nilsson B, Moller M, Gunnarsson R. Early Access to Physical Therapy Treatment for Subacute Low Back Pain in Primary Health Care: A Prospective Randomized Clinical Trial. Clin J Pain 2006;22:505–511
Zigenfuss GC, Yin J Giang GM, Fogarty WT. Effectiveness of Early Physical Therapy in the Treatment of Acute Low Back Musculoskeletal Disorders. J Occup Environ Med. 2000; 42(1):35-40.