THE PHYSICAL THERAPIST AS

PATIENT/CLIENT MANAGER

Dr. FATIMA IHSAN PT

DPT, MSPT*
 Although the term patient/client management is relatively new,
this is probably the best established and most recognizable role
of the physical therapist (PT).

Patient/client management for the PT has changed over the

years in five areas:
 Knowledge and skill used in the processes of evaluation and
diagnosis, prognosis, and discharge planning.
 Referral relationships with physicians.

 Technological advances in the tools available for examination

and intervention.
 Interpersonal relationships with patients.

 Outcomes of care.
The physical therapist integrates the five elements of
patient/client management :
 examination,

 evaluation,

 diagnosis,

 prognosis,

 Intervention

in a manner designed to optimize outcomes.

(The Interactive Guide to Physical Therapist Practice with
Catalog of Tests and Measures (2002)
 examination

Intervention evaluation

prognosis diagnosis
EVALUATION AND DIAGNOSIS:

Evaluation:
is the process of making clinical judgments, based on
examination data, to create a problem list for each patient.

This list may include problems

 Require referral of the patient to other professionals.

 Fall within the scope of practice of physical therapy

 This decision making process may also be considered clinical
problem solving, diagnosing, or clinical reasoning.
 The end product of evaluation is a diagnosis, which is the
term for problems that have been categorized into defined
clusters, syndromes.
PHYSICAL THERAPY DIAGNOSIS:
 Rose suggested that using the term is important to distinguish
the PT’s findings from diagnoses made by other health care
practitioners.
 Sahrmann defined the term diagnosis as simply the primary
dysfunction toward which the PT directs treatment. and this
has helped
 Decreases the fears of the medical community that PTs intend to
diagnose disease,
 infringe on the practice of others
 perform clinical services outside their scope of expertise.
 Rose further explained that, by naming and classifying
clusters of symptoms, signs, and demographic data, the
clinician increases the probability that the best results
previously obtained will be replicated or surpassed.
 Physical therapy diagnoses help identify the role of physical
therapy and its scope of practice.
 Nevertheless, some have opposed the idea of PTs using the
term diagnosis, expressing concerns about PTs’ prerogative to
diagnose in the first place and the extent of their involvement
in the process.
PROGNOSIS:
Prognosis is the determination of :
 The predicted optimal level of improvement in function,

 The time needed to reach that level,

 The levels of improvement that may be reached at various

intervals during the course of physical therapy.
 The prognosis is documented in the physical therapy plan of
care, which includes the following :
 Specific short- and long-term goals for identified
problems.
 The duration and frequency of specific interventions selected
to meet goals.
 The expected outcome.

 The optimal level of improvement expected.

 The HOAC II model specifies the types of goals as long term or
short term.
 Long- and short-term goals represent the same kind of
phenomenon (meaningful change for the patient), the only
difference is the time required to achieve them.
 Defining goals in this way is an attempt to reduce confusion
created by PTs who use short-term goals to reflect the
impairments to be addressed so that long-term functional goals
can be met.
 Patient function must therefore be addressed throughout a plan
of care in short and long-term goals that represent meaningful
accomplishments. PTs can check whether a goal is meaningful
or not.
 For the patient’s current problems, PTs decide which
interventions will achieve the short- and long-term goals.
 Jette determined that this decision-making process is
influenced by a variety of factors in addition to the patient’s
current health status.
 Factors that contribute to treatment decisions :
 The PT’s educational level,
 The payment source,
 The self-interests of the PT,
 The size of the PT’s caseload
DISCHARGE AND DISCONTINUATION
PROCESSES:
Discharge:
 Ending physical therapy services provided during a single
episode of care because the expected goals and outcomes of
treatment have been achieved.
 Documentation requirements may need to be met regarding
the conclusion of physical therapy services.

Note: Discharge does not occur with a transfer: that is, when
the patient is moved from one site to another site in the same
setting or across settings during a single episode of care.
 Discharge is based on the physical therapist’s analysis of the
achievement of expected goals and outcomes.
The physical therapist plans for :
 Discharge

 Follow-up

 Referral
 Discontinuation:
Ending physical therapy services provided during a single
episode of care because of the following circumstances:
1. The patient, caregiver, or legal guardian declines to continue
intervention.
2. The patient is unable to continue to progress toward expected
goals and outcomes because of :
 Medical complications
 Psychosocial complications

 Financial orinsurance resources have been expended.

3. The physical therapist determines that the patient will no longer

benefit from physical therapy.
 Discharge Planning:
 Hospitals must have in effect a discharge planning process that
applies to all patients, and the discharge planning evaluation
must include an evaluation of the likelihood of a patient
needing post hospital services and of the availability of the
services.
 In addition the patient and family members must be counseled
to prepare them for post-hospital care.
 Physical therapy practice acts may also address the PT’s legal
responsibility for discharge planning.
 The way in which PTs make discharge decisions is important.
 Jette, Grover, and Keck studied occupational therapists and
PTs in acute care settings to explore this decision-making
process.
 Transfer or Referral:
 The hospital must transfer or refer patients, along with
necessary medical information, to appropriate facilities,
agencies, or outpatient services as needed for follow-up or
ancillary care..
OUTCOMES:
According to the Guide, PTs ask themselves early in the
patient management process.
“What outcome is likely, given the diagnosis?”

After listing the likely outcomes for each diagnosis, they

may reexamine the actual outcomes to determine whether
the predicted outcomes are reasonable and then modify them
as necessary.
 At the end of an episode of care, the PT analyzes through
organizational review processes, the overall impact of the
interventions on :
 the patient’s disorders,

 impairments,

 functional limitations,

 disabilities,

 health status,

 satisfaction with care,

 risk prevention

 The more PTs assume responsibility for practicing without

referrals, the more accountable they will become for the
outcomes of the care they provide.
CLINICAL DECISION MAKING
 Regardless of which component of patient/client
management PTs address at any point in time and which
model they use in the process, they are making
decisions at many levels.

 May’s model is useful for considering decisions in every

component of patient/client management

 For instance, a pediatric PT may make the following

kinds of decisions:
 Standard familiar decisions: The PT’s knowledge and
experience make these decisions almost automatic. For
example, 85% of a PT’s caseload may be made up of children
with developmental delays. Patient/client management
 Standard unfamiliar decisions: The diagnosis and treatments
for a condition are well known or at least supported by
research but are not commonly encountered. For example, the
same PT as above may be assigned toriticoliss
 Open familiar decisions: These are familiar decisions that
involve some idiosyncratic element, such that further
investigation or new strategies are required. For example, the
pediatric PT may be assigned a new patient with developmental
delays who also has visual and hearing impairments;

 Open unfamiliar decisions: These decisions involve confusing

or conflicting information that requires longer and more careful
consideration. For example, the parents of a child with
developmental delays may request that the PT incorporate US
into the treatment sessions; otherwise they will take the child to
another PT.
REFERRAL RELATIONSHIPS
 PTs in the military, sports and public health services routinely
have practiced without referrals.

 Before 1960s, the general public typically had access to

physical therapy services only through prescriptions written by
physicians

 now More than 30 states have passed legislation allowing the

public direct access to PTs and in 48 states PTs can perform
initial examinations without a physician’s referral
 However, the form of the required referral has changed. Most
physicians now refer a patient for physical therapy without
prescribing a detailed program; the referral simply reads,
“Evaluate and treat,,

 this change altered patient/client management by PT s, who

have moved from the more technical role of implementing plans
of care as instructed by prescription to total responsibility for the
patient/client management process, from examination to
outcomes

 This increased the responsibility to refer a patient to a physician

when the PT identifies problems beyond the scope of physical
therapy.
 A shift may be seen in the physical therapy profession
toward marketing directly to patients and also to
physicians, who will continue to make referrals. Both
physicians and patients will have more choices in
directly selecting a PT.

 Establishing professional trust with the public may

become more important than referrals in attracting
potential patients directly and in seeking contracts with
third-party payer.

 Reimbursement without a physician’s referral has the

potential to reduce health care costs because it requires
fewer visits to the physician and less paperwork.
 However, opponents of direct access suggest that it may increase
costs unless PTs are very good at determining the physical
therapy diagnosis and, perhaps more important, the differential
diagnoses

 Self-referral also has the potential to limit opportunities for

patients to seek the provider of their choice if they believe their
only choice is the provider to whom the physician refers them.

 Physician employment of PTs has been on the decline over the

years and the number of PTs who are better and more interested
in private practice has increased
INTERPERSONAL RELATIONSHIPS
 In the 1977 Mary McMillan , Mary Clyde reminded the
physical therapy profession of the importance of its human
side, seen in PTs’ devotion to human welfare and in the need
for PTs to be compassionate, loving, understanding, and
conversant with the humanistic attribute of self and the
relationship with others

 but the challenges to the therapeutic relationship in which it

must be achieved have Some of these challenges……..
 The need to address a broader range of cultural issues

 Compliance with an ever-increasing number of laws, regulations,

and ethical

 principles that guide physical therapy practice

 Third-party interpretation of regulations governing payment for

services

 Increased access to information for both the PT and the patient

 Increased accountability and responsibility for care
provided

 Employer productivity and caseload expectations

 Professional development of the PT

 Quality of evidence supporting PTs’ decision

 ETHICAL AND LEGAL ISSUES
 Legal issues in patient/client management are addressed in
1.state statutes,
2. practice acts

 which regulate the physical therapy profession. PTs must be

knowledgeable about the practice act in each state in which they
intend to work,

 Professional ethics, however, are guided by professional

documents common to all PTS

 A physical therapist shall place the patient’s/client’s interests

above those of the physical therapist
CODE OF ETHICS AND GUIDE FOR
PROFESSIONAL CONDUCT
 The APTA’s Guide for Professional Conduct20 (GPC) includes

 confidentiality

 trustworthiness or fidelity,

 respect for the individual’s rights and dignity

 autonomy of the patient

FACTORS IMPORTANT TO SUCCESSFUL
PHYSICAL THERAPY TREATMENT
1. The physical therapist’s treatment method is the most decisive
factor in the patient’s recovery.
2. A physical therapist should not become too involved with the
patient’s personal or social problems;
3. Patient motivation is a vital component of successful therapy.
5. Physical therapy should promote the patient’s health rather
than emphasizing the diagnosis.
6. The physical therapist’s knowledge and technique are what
make physical therapy work.
7. The physical therapist should not simply treat a part of the
body part, but rather should be interested in the whole person.
8. Physical therapy should be oriented toward the patient’s resources
rather than the person’s problems.
9. The patient’s own capacity for recovery is a major factor in the
success of physical therapy.
10. Physical therapy is above all an aid to self-help; it works by
eliciting the patient’s own ability to change and improve.
11. The interaction between the physical therapist and patient that
makes physical therapy successful begins during the first therapy
session.
12. The physical therapist should place less emphasis on the patient’s
diagnosis and more emphasis on enhancing the individual’s coping
skills.
13. The interaction that occurs between the client and physical
therapist has no bearing on asuccessful treatment outcome.
14. The patient’s diagnosis should be the central focus of attention in
physical therapy.
INFORMED CONSENT
 informed consent as having five elements
 competence

 Disclosure

 understanding

 voluntariness

 consent.
 Although most PTs would agree that the PT has an obligation
to obtain informed consent from the patient, some debate
exists as to how this should occur and how the process should
be described.

 this debate stems from the differences between the PT’s role
and that of the physician

 Which consent form should be applied if it is necessary

medical or surgical procedure.

 Ethical or legal because Some view informed consent as

primarily a legal rather than an ethical concept
 what are the condition in which the consent form must be used
(Scott suggested that informed consent should always be
obtained before spinal manipulation)

 A review of APTA documents points up the uncertainty of the

profession regarding appropriate procedures for obtaining
informed consent

 the physical therapy profession is still in the process of reaching

agreement on procedures for doing so.
Thanks
Q?