PATIENT MANAGEMENT & CLINICAL DECISION MAKING

THERA EX / LECTURE DATE: JANUARY 31 2022

THE PATIENT MANAGEMENT MODEL
OUTLINE AND THE EVOLVING NEEDS OF
INDIVIDUALS
I. Why is it important to understand the Patient and Client Management
patient management model? ● is an ongoing, iterative process that
II. The Patient Management model focuses on the evolving needs of each
III. Examination individual.
IV. Evaluation ○ iterative = certain processes that
V. Diagnosis are repetitive and constant;
VI. Prognosis done religiously
VII. Plan of Care ● Applications: to rehabilitate,
VIII. Clinical Decision Making
habilitate, maintain health or
function, prevent functional decline,
WHY IS IT IMPORTANT TO UNDERSTAND and, in healthy individuals, enhance
THE PATIENT MANAGEMENT MODEL? performance
● way of efficiently gathering data
about our patients and from The process of patient management has five
interpreting the data, we come up basic components:
with solutions and interventions ● A comprehensive examination
● important part of physical therapy ○ gathering data about the
patient and the patient’s
condition
○ baselines or reference points
○ try to compare the changes we
observe to the baselines
● Evaluation of data collected
○ process of interpreting data
that could lead us to the next
steps
● Determination of diagnosis based on
impairments, functional limitations,
and disability
○ categorize the conditions and
we get a clear clinical picture of
the condition
○ how we PTs diagnosed based on
the disability
● Establishment of a prognosis and plan
of care based on patient-oriented
goals
○ prognosis - predicistion of the
outcome

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 THERAPEUTIC EXERCISE – PATIENT MANAGEMENT AND CLINICAL DECISION MAKING
■ based on the current
knowledge, what will
happen to the patient
after therapy (can be a
challenge for most PTs)
○ plan of care - goals and
expected outcomes
● Implementation of appropriate
interventions
○ directly address the patient’s
condition
EXAMINATION: THE KEY ELEMENTS OF
PATIENT MANAGEMENT
● Systematic process by which a
therapist obtains information about a
patient’s problems and his or her
reasons for seeking physical therapy
services
○ find out why are they seeking
physical therapy interventions
● means by which baseline
measurements of current
impairments, functional limitations,
and abilities are established as a
reference point for which therapeutic
interventions can be measured and
documented
○ information after intervention
-> compare with baseline
measurements (to know if there
is a difference or if intervention
is effective)
● a physical therapist gathers sufficient
information about existing or
potential problems of the patient
○ these data would be used to
create a diagnosis and answer a
question (Can the condition be
treated by PTs?)
● examination is required before initial
intervention and performed for both
patient and client
*REMEMBER: before performing
intervention: do a quick assessment
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DISTINCT ELEMENTS OF COMPREHENSIVE
EXAMINATION
● The patient’s health history
○ where we get more information
about the patient’s condition
○ we interview our patients
● A relevant systems review
○ limited examination of some
systems that are relevant to the
patient’s case
● Specific tests and measures
○ confirmatory assessments are
done with the use of specific
tests and measures
Ex: patients with swollen knee
● plant foot and twist with popping
sound (Health history)
● MRI (Systems review)
● Lachman’s Test and Anterior drawer
test (Tests and Measures)
Three purposes of examination:
● To answer the question: Will the
patient benefit from PT services?
● Helps develop plan of care
● help progress the plan of care
HISTORY
● Overview of current & past
information about a patient’s present
condition, general health, & why
patient sought physical therapy
services
**Sources of information:
● Self-report health history
questionnaires
● Interviews
● Review of Medical Record
● Reports from referral source
○ usually from patients who have
home care
*Systematic gathering of data from past and
present
*Answer “Why is patient seeking PT
services?”
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 THERAPEUTIC EXERCISE – PATIENT MANAGEMENT AND CLINICAL DECISION MAKING
DATA GATHERED FROM HISTORY FUNCTIONAL STATUS & LEVEL OF
TAKING ACTIVITY
GENERAL DEMOGRAPHICS ● Prior functional status, and self-care
● Age and home management (i.e., activities
● Gender of daily living [ADLs] and
● Race instrumental ADLs)
● Primary language ● Behavioral health risks
● Sleep patterns and positions
SOCIAL HISTORY ● Patient’s, family’s, or caregiver’s
● Cultural beliefs and Behaviors functional goals for the therapeutic
● Family and caregiver resources intervention
● Social interactions, social activities, ● Current medication list (include
and support systems dosage information and reason for
taking)
OCCUPATION
OTHER TESTS AND MEASURES
● Current or prior work (e.g., job, school,
and play) or community activities ● Review of available records
● Ask the duties in work ● Imaging and laboratory test results

GROWTH AND DEVELOPMENT MEDICAL OR SURGICAL HISTORY

● Hand and foot dominance ● Endocrine/metabolic
● Developmental history ● Gastrointestinal
● Genitourinary
LIVING ENVIRONMENT ● Pregnancy, delivery, and postpartum
● Living environment and community ● Prior hospitalizations, surgeries, and
characteristics preexisting medical and other health-
● Projected discharge destinations related conditions

HISTORY OF PRESENT CONDITION FAMILY HISTORY

● Concerns that led the individual to
seek the services of a physical
therapist
● Concerns or needs of the individual
requiring the services of a physical
therapist
● Onset and pattern of symptoms
● Mechanism(s) of injury or disease,
including date of onset and course of
events
● Patient’s, family’s, or caregiver’s
perceptions of the patient’s emotional
response to the present clinical
situation
● Current and prior therapeutic
interventions
● Familial health risks
○ Only ask if it is relevant to the
case
SOCIAL HABITS
● Level of physical fitness (self-care,
home management, community, and
work [e.g., job, school, and play] and
leisure activities)
● Smoking, alcohol, drug habits
PHYSICAL THERAPY EXAMINATIONS
● Aerobic capacity/endurance
● Anthropometric characteristics
● Assistive technology
● Balance
● Circulation (arterial, venous,
lymphatic)

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 THERAPEUTIC EXERCISE – PATIENT MANAGEMENT AND CLINICAL DECISION MAKING
● Community, social, and civic life DATA GATHERED FROM SYSTEMS
● Cranial and peripheral nerve integrity REVIEW
● Education life The systems review includes the following:
● Environmental factors ● Cardiopulmonary: assessment of
● Gait heart rate, respiratory rate, blood
● Integumentary integrity pressure, and edema
● Joint integrity and mobility ● Musculoskeletal: gross symmetry,
● Mental functions gross ROM, gross strength, BMI
● Mobility (including locomotion) ● Neuromuscular: gross coordinated
● Motor function movement (e.g., balance, locomotion,
● Muscle performance (including transfers, transitions)
strength, power, endurance, and ● Integumentary: skin integrity, skin
length) color, presence of scar formation
● Neuromotor development and ● Communication ability, affect,
sensory processing cognition, language, and learning
● Pain style: includes the assessment of the
● Posture ability to make needs known,
● Range of motion consciousness, orientation × 3
● Reflex Integrity (person, place, and time), expected
● Self-care and domestic life emotional/behavioral responses, and
● Sensory integrity learning preferences (e.g., learning
● Skeletal integrity barriers, educational needs)
● Ventilation and respiration
● Work Life
SPECIFIC TESTS AND MEASURES
● *Provides in-depth information about
SYSTEMS REVIEW impairments, functional limitations, &
● taken during history gathering phase disabilities
● Brief relevant screening of the body ● Enables a therapist to support or
systems refute the working hypotheses
○ want to know if there are areas formulated while taking the patient’s
that need a referral or other health history & performing the
medical examinations systems review
○ allow us to look at what ● Helps establish objective baselines
symptoms need other medical
examination Specific Tests and Measures that Identify
● Systems typically screened are; Musculoskeletal Impairments:
*cardiovascular, pulmonary, ● Assessment of Pain
integumentary, musculoskeletal, and ○ ex: pain scale
neuromuscular ● Goniometry
● General overview of a patient’s ● Joint mobility, stability, integrity tests
cognition, communication, and ● Tests of muscle performance
social/emotional responses ● Posture analysis
● Anatomical & Physiological status or ○ assess the posture of the
function of each system is obtained. patient compared to a standard
● Gait analysis
● Assessment of assistive, adaptive, or
orthotic device

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 THERAPEUTIC EXERCISE – PATIENT MANAGEMENT AND CLINICAL DECISION MAKING
FUNCTIONAL OUTCOME MEASURES
● Reflect the impact of a patient’s
pathological condition to and
resulting impairments on functional
abilities and health-related quality of
life
● *specifically measure functional
limitation and disability
● subjective information on:
○ changes in patient function
○ patient’s perceived level of
disability
IMPORTANT DATA ACQUIRED THROUGH
Ex: patient with low back pain
● functional outcome measures -> level
of disability that comes with the
impairment or cheap complaint
EVALUATION
● Interpretation of collected data
● Involves analysis and integration of
information to form opinions by
means of a series of sound clinical
decisions
● Fundamental to the determination of
a diagnosis of dysfunction and
prognosis of functional outcomes
*Examine (Gather data) -> Evaluate
(Interpret) -> Diagnosis
***One of the most critical stages in clinical
decision making
Four purposes of evaluation:
1. determine the progression and stage
of the signs and symptoms
2. determine the stability of the
condition
3. determine the pre-existing conditions
4. determine the relationships among
involved systems and sites
Evaluation is a process that includes the
following:
● Making judgments based on data
gathered during the examination
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● Interpreting the individual’s response
to tests and measures
● Integrating the test and measure data
with other information collected
during the history
● Determining a diagnosis amenable to
physical therapist management
● Determining a prognosis, including
goals for physical therapist
management
● Developing a plan of care
EVALUATION
1. Patient’s general health status and its
impact on current and potential
function
2. Acuity or chronicity and severity of
the current condition
3. The extent of structural and
functional impairments of body
systems and impact on functional
abilities
4. Impairments related to functional
limitations. patient’s current, overall
level of physical functioning
(limitations and abilities) compared
with the functional abilities needed,
expected, or desired by the patient
- evaluation: to identify causes
and sources of disablement
- sources: pathoanatomic
aspects of patient’s condition
- causes: pathomechanic aspects
5. The impact of physical dysfunction on
social/emotional function
6. The impact of the physical
environment on a patient’s function
7. A patient’s social support systems and
their impact on current, desired, and
potential function
DIAGNOSIS
● process or a category
○ process = we try to cluster
anmd categorize all the signs
and symptoms
○ category = diagnosis itself
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 THERAPEUTIC EXERCISE – PATIENT MANAGEMENT AND CLINICAL DECISION MAKING
○ Diagnosis: impairment, activity
limitation, participation
restriction
● essential element of patient
management because it **directs the
physical therapy prognosis (including
the plan of care) and interventions
THE DIAGNOSTIC PROCESS
● complex sequence of actions and
decisions
○ Brody and Hall: PT’s
perspective: Diagnosis ->
classifying dysfunction
○ Physician -> identify the
disease
● necessary to develop a prognosis
(including a plan of care) and is a
prerequisite for treatment
● ***PT’s Focus: consequences of a
disease or health disorder
THE DIAGNOSTIC PROCESS
1. the collection of data (examination)
2. the analysis and interpretation of all
relevant data collected, leading to the
generation of working hypotheses
(evaluation)
3. organization of data, recognition of
clustering of data (a pattern of
findings), formation of a diagnostic
hypothesis, and subsequent
classification of data into categories
(impairment-based diagnoses)
THE DIAGNOSTIC CATEGORY
● grouping that identifies and describes
patterns or clusters of physical
findings
● describes the impact of a condition on
function at the system level and at the
level of the whole person
● Essential to the selection of a
**Preferred Practice Pattern
○ consistently updated
○ clinical practice guidelines
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Why do we need to have a diagnostic
category?
- so that there is clarity of
communication in the practice and
research
DEFINITION OF TERMS
● Cluster: A set of observations or data
that frequently occur as a group for a
single patient.
○ observations that you see as a
group
○ Ex: strain -> heat, redness,
swelling
● Syndrome: An aggregate of signs and
symptoms that characterize a given
disease or condition.
○ Ex: set of signs and symptoms
-> associated with a specific
disease
○ Ex: 4Ps of Diabetes
● Diagnosis: A label encompassing a
cluster of signs and symptoms
commonly associated with a disorder,
syndrome, or category of impairment,
activity limitation, or disability
TAKE NOTE!
● ****Diagnosis in the physical therapy
patient management model is
synonymous with the term clinical
classification and is not to be
confused with the term medical
diagnosis
● Medical diagnosis is the identification
of a patient’s pathology or disease by
its signs, symptoms, and data
collected from tests ordered by the
physician.
● Diagnosis established by a physical
therapist is related to the primary
dysfunction toward which the
physical therapist directs treatment.
PROGNOSIS
● prediction of a patient’s optimal level
of function expected as the result of a
plan for treatment during an episode
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 THERAPEUTIC EXERCISE – PATIENT MANAGEMENT AND CLINICAL DECISION MAKING
of care and the anticipated length of PLAN OF CARE
time needed to reach specified ● Anticipated goals
functional outcomes ○ short term or long term goals
○ changes that we expect when ○ **very organized and specific
we treat the patient ● Expected functional outcomes that
are meaningful, utilitarian,
Factors: sustainable, and measurable
● **Level of optimal improvement after ○ SMART principle
the intervention ● Extent of improvement predicted and
● **Amount of time needed to reach length of time necessary to reach that
that level level.
● Specific interventions
● Proposed frequency and duration of
interventions
● Specific discharge plans

SETTING GOALS & OUTCOME

● Anticipated goals & Expected
outcomes should be Patient-centered
● Goals & Outcomes should be directed
at the elimination of the physical signs
& symptoms & impairments
● Outcomes directed at eliminating
functional deficits & participation
restrictions to the greatest extent
possible
● Explain how the health condition and
identified impairments are associated
BASIS FOR ESTABLISHING A PATIENT’S with the patient’s activity/functional
PROGNOSIS limitations and participation
restrictions and why specific
● Familiarity with the patient’s current
interventions will be used
health condition(s) and the surgical
intervention(s) and previous history
of diseases or disorders
○ Ex: specialization of PT:
Orthopedic -> PT already
treated many patients with LBP
(can predict easier with LBP)
● Knowledge of the process and time
frames of tissue healing
● Experience managing patients with
similar surgical procedures,
pathological conditions, impairments,
and functional deficits
● Knowledge of the efficacy of tests and
measures performed, accuracy of the
findings, and effectiveness of the
****IMPORTANT
physical therapy interventions

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 THERAPEUTIC EXERCISE – PATIENT MANAGEMENT AND CLINICAL DECISION MAKING
BASES FOR PROGNOSIS & PLAN OF CARE
● The patient’s health status, risk
factors, and response to previous
interventions
● The patient’s safety, needs, and goals
● The natural history and the expected
clinical course of the pathology,
impairment, or diagnosis
● The results of the examination,
evaluation, and diagnostic processes
INTERVENTION
● any purposeful interaction a therapist
has that directly relates to a patient’s
care
○ Coordination, communication,
and documentation
○ Procedural interventions
○ Patient-related instruction
■ ex: communicating with
the doctor, telerehab
● key to successful intervention: DO
THE RIGHT THINGS WELL
TYPES OF INTERVENTION
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● Direct intervention (e.g., therapeutic
exercise, manual therapy techniques,
integumentary repair and protection
techniques, motor function training)
● Patient-related instruction (e.g.,
education provided to the patient and
other caregivers involved regarding
the patient’s condition, treatment
plan, information and training in
maintenance, and prevention
activities)
● Coordination, communication, and
documentation (e.g., electronic
medical record, patient care
conferences)
CLINICAL DECISION MAKING FOR
INTERVENTION
● Treat the “right” impairments
○ TIP: when deciding for what to
intervene, first treat
impairments that contribute to
activity limitation
● determine the impairment that most
closely relates to an activity limitation
or participation restriction
● the treatment of impairments can
only lead to improvement in function
if the impairments contribute directly
to a limitation in activity
QUESTIONS TO ASK
● Will the patient benefit from the
intervention (i.e., can treatment of the
impairment improve functioning or
prevent functional loss)?
● Are there any possible negative effects
of the treatment (contraindications)?
● What is the cost-benefit ratio?
IF NO TREATMENT CAN BE JUSTIFIED
● Discussing the decision to decline
intervention with the patient to
ensure patient agreement and
understanding of the decision
● Referring the patient to an
appropriate practitioner or resource
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 THERAPEUTIC EXERCISE – PATIENT MANAGEMENT AND CLINICAL DECISION MAKING
● Assisting in modifying the
environment in which the individual
lives, goes to school, or works to
ensure maximal performance despite
the impairment, activity limitation, or
participation restriction
● Teaching the individual to
appropriately compensate for the
impairment during activities or
participation in more complex social
roles
○ We can make adjustments
PATIENT - RELATED INSTRUCTION
● Patient-related instruction is critical
to enhance compliance in following
through with interventions and
preventing future limitations in
activity or restrictions in participation
○ imparting the knowledge
○ Explain to the patient: rationale
○ Don't use scientific terms
● Imparting your knowledge of the
patient’s function/disability process
enables the patient to gain confidence
in your skills, which further enhances
compliance
EDUCATION PERTAINING TO THE
● Pathologic process and impairments
contributing to activity limitation and
participation restriction
● Prognosis
● Purposes and potential complications
of the intervention
Instruction and assistance in making
appropriate decisions about management of
the condition during ADLs.
Instruction and assistance in implementing
interventions under the direction of the
physical therapist
BENEFITS OF PATIENT-RELATED
INSTRUCTION
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● Reduced participation restriction,
secondary conditions, and recurrence
● Enhanced decision-making about the
use of health care resources by the
patient, significant others, family, or
caregivers
● Decreased service use and improved
cost containment
OUTCOMES
● Results
● Functional Outcomes
● Measuring Outcomes
● Patient Satisfaction
An outcome is considered successful when
the following conditions are met:
● Activity and participation is improved
or maintained whenever possible
● Activity limitation or participation
restriction is minimized or slowed
when the status quo cannot be
maintained.
● The patient is satisfied
MODIFICATION
● If functional status has not improved
when expected to, or declines when
maintenance was the goal, consider
modifying the intervention plan.
○ modification begins on
reexamination
● Modification of intervention is based
on the status relative to the expected
outcome and the rate of progress.
FACTORS TO CONSIDER WHEN
MODIFYING AN INTERVENTION
● Medical safety
● Patient comfort
● Patient’s level of independence with
the intervention (especially related to
therapeutic exercise intervention)
● Effect of the intervention on the
functional activities and participation
restrictions
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 THERAPEUTIC EXERCISE – PATIENT MANAGEMENT AND CLINICAL DECISION MAKING
● New or altered symptoms because of
intervention by other health care
providers
● Patient finances, environment, and
schedule constraints
******The intervention may be modified by
one of the following actions:
● increasing or decreasing the dosage of
the intervention, especially in the case
of therapeutic exercise intervention
● Treating different impairments
● Changing the focus to activity
limitations
● Consulting or referring to a physical
therapist with advanced training or
certification in a content area
● Referring the patient to another
health care provider specializing in a
system that is beyond the PT scope of
practice
● Improving physical therapy
techniques, verbal cues, and teaching
skills
DISCHARGE PLANNING
● A patient is discharged from physical
therapy services when the anticipated
goals and expected outcomes have
been attained.
● Includes the following:
○ home program
○ appropriate follow-up
○ possible referral to community
resources
○ re-initiation of physical therapy
services
When do we discharge patients?
● When we attain the anticipated goals
and outcomes
CLINICAL DECISION MAKING
● Dynamic, complex process of
reasoning and analytical (critical)
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thinking that involves making
judgments and determinations in the
context of patient care
● There are several bodies of knowledge
that describes various strategies and
models of clinical decision making in
the context of patient management by
PTs. An example is the Hypothesis
Oriented Algorithm for Clinicians
(HOAC II)
“Physical therapists who wish to provide
high-quality patient care must make
informed clinical decisions based on sound
clinical reasoning and knowledge of the
practice of Physical Therapy”
Ex: improve mobility (stretching, PJM)
WHAT CHARACTERISTICS OF A PT ARE
NEEDED TO EXCEL IN MAKING CLINICAL
DECISIONS?
● Wide range of knowledge
● Ongoing acquisition of knowledge
○ Open for reviews
● Need for order or a plan of action
● Questioning unproven conventional
solutions
● Self-discipline and persistence in
work
CLINICAL DECISION MAKING TIPS FOR
PATIENT MANAGEMENT
● Examination: Prioritize the problems
to be assessed and the tests and
measures to be implemented
● Evaluation: Consider and analyze all
examination findings for
relationships, including the
progression and stages of the
symptoms, diagnostic findings by
other health care professionals,
comorbidities, medical history, and
treatment or medications received.
○ ***ALL RELEVANT DATA that
you gathered must be taken
into the diagnosis
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 THERAPEUTIC EXERCISE – PATIENT MANAGEMENT AND CLINICAL DECISION MAKING
● Diagnosis: Segregate findings into
clusters of symptoms and signs by
common causes, mechanisms, and
effects
● Prognosis and Plan of Care: Develop
long-term and short-term goals based
on patient safety, needs, and goals and
on information regarding the natural
history and expected clinical courses
of the pathology, impairment, or
diagnosis
● Intervention: Determine whether
impairments correlate with an
activity limitation or disability and are
amenable to physical therapy
treatment. Select and justify a method
of intervention. The most credible
source of justification is based on
relevant research literature
● Outcome: Measure the success of the
intervention plan according to
functional gain and make appropriate
modifications when necessary.

Reference:
- Powerpoint and Lecture
- Kisner

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