final 10 17 apta webinar 10 23 14 final an annual physical therapist checkup? • the need –...
TRANSCRIPT
© 2012 American Physical Therapy Association 1
Why an Annual Checkup Should and Could be a Service Your Clinic Offers
David Taylor, PT, DPT, GCS
Jon Delk, PT, MSPT
Introduction
David Taylor, PT, DPT, GCS is a Clinical Assistant Professor in the Department of Physical Therapy at Mercer University, in Atlanta Georgia. Dr. Taylor received his B.S. in Psychology in 1988, Master of Physical Therapy in 1992, and Doctor of Physical Therapy in 2004 from Emory University. He has been a Board Certified Clinical Specialist in Geriatric Physical Therapy since 2001. Dr. Taylor’s teaching responsibilities include health promotion, geriatric physical therapy, service‐learning, and clinical education. Dr. Taylor was the recipient of the 2014 Lynn Phillippi Advocacy for Older Adults Award from the Academy of Geriatric Physical Therapy.
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Introduction
• Jon Delk, PT, MSPT Delk graduated from East Carolina University with a Bachelor of Science degree in Chemistry. He was a four‐year member of the ECU Football staff as a coach’s assistant from 1993‐1997. From there Jon went to the University of Alabama‐Birmingham where he received a Master of Science degree in Physical Therapy in 1999. He has been with Eskridge and White Motion Therapy (EW) since 2001 and is the Clinic Director. Jon co‐founded EW Fit, a fitness, training, and wellness company within EW, in 2005. His clinical specialties include manual therapy, functional exercise application and post‐operative rehabilitation in athletes. Jon has had the opportunity to work with several collegiate and semiprofessional athletes throughout his career.
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© 2012 American Physical Therapy Association 2
DISCLOSURE:
David Taylor, PT, DPT, GCS
No disclosure
Jon Delk, PT, MSPT
Principal Eskridge and White Motion Therapy
4©2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.
Learning Objectives
• At the conclusion of this webinar participants will be able to:
1. Describe the importance of all standardized elements of the Annual PT Checkup.
2. Apply the aspects of EBP to the Checkup process.
3. Describe a model used in clinical practice for implementing the Annual PT Checkup.
4. List business considerations for offering this service.
5. Utilize APTA resources to provide Annual PT Checkups in their clinics.
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Agenda
• The Annual Physical Therapist Checkup
– David Taylor, PT, DPT, GCS
• The Annual Physical Therapist Checkup –A Model for Clinical Practice
– Jon Delk, PT, MS
• APTA Resources
– Lisa Culver, PT, DPT, MBA
• Question and Answer Session with presenters
© 2012 American Physical Therapy Association 3
POLL 1:WHAT IS YOUR CURRENT PRACTICE SETTING?
OUTPATIENT PRIVATE PRACTICE
OUTPATIENT HOSPITAL‐BASEDSKILLED NURSINGHOME HEALTHACUTE CAREOTHER
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POLL 2:ARE YOU CURRENTLY PERFORMING AN ANNUAL PT CHECKUP VISIT OR FITNESS TESTING IN YOUR PRACTICE?YESNO
8©2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.
The Annual Physical Therapist Checkup
© 2012 American Physical Therapy Association 4
Part 1 Overview
• Why and Annual Physical Therapist Checkup?
• Annual Physical Therapist Checkup Elements– Personal Health Profile
– Disease Risk Profile
– Standard Physical Exam
– Physical Performance Exam
– Health Risk Evaluation and Summary
– Personal Wellness Plan and Exercise Prescription
– Management and Outcomes
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Why an Annual Physical Therapist Checkup?
• The Need
– Prevalence of chronic medical conditions, lifestyle behaviors, and disability
• Current Health Care Annual Checkup Models
• The Evidence
– U.S. Preventative Task Force Recommendations
The Physical Therapists’ Role
• The Guide to Physical Therapist Practice
• APTA Position
• Practice Categories
• Development of the Annual PT Checkup
• Considerations for the Annual PT Checkup
© 2012 American Physical Therapy Association 5
The Physical Therapists’ Role
• The Guide
– “intervention, prevention, and the promotion of health, wellness, and fitness are a vital part of the practice of physical therapists.”
– Screenings determine the need for:
• Primary, secondary, tertiary prevention services
• Further examination, consultation by a PT
• Referral to another practitioner
Health
Health Promotion
Wellness
FitnessPrevention
Disease Management
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Poll Question
• Which of these do you want to improve in your practice?
– Disease Management
– Fitness
– Health Promotion
– Prevention
– Wellness
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© 2012 American Physical Therapy Association 6
Evolution of the Annual PT Checkup
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Patient/Client Management Model
Age Ranges (21‐65)
Time (30‐60 min)
Expectations (Documentation & Additional Testing)
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Clinical Judgment
• “ The physical therapist may decide to use one, more than one, or portions of several specific tests and measures as part of the examination, based on the purpose of the visit, the complexity of the condition, and the directions taken in the clinical decision‐making process.” (Guide 3.0)
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© 2012 American Physical Therapy Association 7
Elements of the Annual PT Checkup
Evaluation
Summary of FindingsIndividualized Exercise
PrescriptionOutcomes Management
Physical Performance Exam
Aerobic CapacityBalance
(Static/Dynamic)Locomotion Speed
Mobility ,Flexibility Functional Strength
PostureQuality of Movement
Standard Physical Exam
Body Mass Mental Status Sensation Resting Vital Signs
Disease Risk Profile
Current Health Profile & Behaviors Disease Risk Stratification Emotional Status, Hearing, Integ, Vision, Pain
Personal Health Profile
Individual Goals & Aspirations, QOL
DemographicsMedical & Surgical History
MedicationsPersonal Factors
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Personal Health ProfileGoals
Aspirations QOL
PROMIS Global Health Scale
SF12 or SF 36
Alternatives
Stroke Impact Scale
Parkinson’s Disease Questionnaire‐39
Demographics
Age Sex
Race/Ethnicity
Education level
Occupation &
Employment Status
Adequate Food/Housing
Healthcare Access
Medical History
Medical / Surgical / Family
Specific to Men Women
Medications OTC Supplements
Personal Factors
Communication / Learning style
Language Self‐efficacy
Environmental Factors Abuse / Neglect Screening
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© 2012 American Physical Therapy Association 8
• Activity Classification
• Meeting National Physical Activity Guidelines
• Sedentary Behaviors / Time Sitting
• Nutrition
• Alcohol/ Drug Use
• Smoking History
Current Health Status & Behaviors
• ACSM: Low, Moderate, High OR
• BMI / Waist CircumferenceDisease Risk
• 3 question screen OR
• PROMIS ScalesEmotional Screen
• Do you feel you have hearing loss?
• CALFRASTHearing
• Risk screenIntegument
• Snellen ChartVision
• PROMIS Scale for Pain Interference
• NPR/VASPain
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Standard Physical Exam
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© 2012 American Physical Therapy Association 9
Six Minute Walk Test
OR
Walk, run, cycle,
Step or Treadmill
Alternatives
A6MCT
USCD‐SOBQ
Aerobic Capacity: Field Test
Static Single Leg Stance
Dynamic
Hexagon Agility Test
Four‐Square Step Test
Alternatives
ABC Scale for MS
BBS for Stroke
Static & Dynamic Balance
10‐meter
walk test
Alternatives
10‐MWT for CP
10‐MWT for PD
Locomotion Speed
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Core Strength
McGill Test
Trunk Extension &
Side bridging L / R &
Anterior Trunk
Functional Strength
Sit‐to‐Stand (30 second) &
Push up &
Hand‐held Dynamometer Grip
Strength
Flexibility
Apley’s
Scratch Test
&
Sit and Reach
Alternatives
TUG for PD
LEFS for TKR
Neck Disability Index
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Classification
(Kendall, 2005)
Rib to Pelvis Distance
>40 years of age
Posture
Sit‐to‐Stand
Overhead Reach
Floor Reach
Forward Reach
Quality of Movement
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© 2012 American Physical Therapy Association 10
Interpretation
Consultation
Referral
Wellness Plan
Lifestyle Conditions
Lifestyle Behaviors
Individualized Exercise Prescription
Services
Reexamination
Outcome Tracking & Reporting
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Why an Annual Check Up Should and Could Be a Service Your Clinic
Offers
The Annual Physical Fitness Evaluation Model
The Annual Physical Fitness Evaluation Model
• History of Development
• Business Considerations For Implementation
• Case Example
• Demographics/Statistics
© 2012 American Physical Therapy Association 11
History
• PT Access laws in 2007
• We are referring patients to outside sources for wellness/fitness needs post Physical Therapy
• Created Wellness Company in space contiguous with PT clinic
• Initial challenges
• Initial success
History
• Developed the Physical Fitness Evaluation Program
• Initially designed to strengthen relationship with MD group
• MD group was concierge practice and was performing annual check up that included medical evaluation and nutrition services
• Fitness Evaluation performed by a non‐PT employee of wellness company
The Fitness Evaluation
• Initial subjective history and questionnaire. Evaluation assesses height/weight, vital signs, UE/LE functional strength and mobility, balance, agility, core stability, body composition and cardiorespiratory fitness
© 2012 American Physical Therapy Association 12
The Fitness Evaluation
• Results reviewed with client and report sent to MD for baseline
• Based on results/deficits a fitness program or supplement to current program is developed
• Client returns for one follow up “instructional session”
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Tests Used in Fitness Evaluation
• Lower Extremity Strength – Sit to Stand
• Upper Extremity Strength – Push Up, Handgrip
• Lower Extremity ROM – Sit/Reach
• Upper Extremity ROM – Back Scratch
• Agility – 8 Foot Up/Go, Cone Drills
• Core Stability – Plank Progression
• Body Composition – Bioelectrical Impedance
• Cardio – 6 Minute walk, Bruce Submax, AirdyneFitness
Sample Fitness Evaluation Report
© 2012 American Physical Therapy Association 13
Sample Fitness PrescriptionMuscular Strength / ConditioningType: Continue current program with additional core strengthening exercisesIntensity: ModerateDuration: 1‐2 exercises per major muscle group2‐3 sets of 10‐20 repetitions per exerciseFrequency: 2‐3 days per week
Cardiorespiratory Fitness Type: CyclingIntensity: Moderate – highTarget Heart Rate = 134 – 154 beats per minuteDuration: 30‐60 minutesFrequency: 3‐5 days per week
FlexibilityType: Stretches provided in packet
Intensity: To the point of tightness, NOT PAIN
Duration: Hold each 5‐10 seconds, 5 times
Frequency: Everyday!
Special Considerations
Always maintain a neutral spine posture when performing strength exercises. Be sure to stretch after each exercise session while muscles are warm. Discontinue any exercise if it causes pain. Please call or e‐mail me if you have any questions regarding your fitness assessment or exercise prescription. Keep up the good work!
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reproduction or redistribution prohibited.37
Fitness Prescription
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The Fitness Re‐Evaluation
• Performed as close to year anniversary as possible
• Slightly less expensive
• Same tests performed and results compared in a table
• Table indicates progress or decline in each area as compared to previous year
© 2012 American Physical Therapy Association 14
Sample Fitness Re‐Eval Report
July 2013 – Direct Access
• State law changed to allow for direct access
• Explanation of law
• Allowed PTs to become involved in this process
• Patients can now opt to come to our facility for this service without an MD referral
• Fitness evaluation client may become PT patient
Business Considerations for Implementation
• Staffing
• Equipment
• Insurance Coverage
• Space
• Marketing/Promotion
• Your Brand
• Key Competitive Capabilities
• Success Factors
© 2012 American Physical Therapy Association 15
Staffing
• Non‐issue if PT or multiple PT staff intact
• May consider hiring a certified fitness instructor (personal trainer)
Equipment• Evaluation tools will vary based on choice
of tests
• Movement screening tool, hand dynamometer, BP cuff, HR monitor, treadmill, Airdyne, plyo boxes
• Evaluation software and laptop
• Office supplies
Insurance Coverage
• Liability coverage
• Not as expensive for non‐professional (PT) staff
© 2012 American Physical Therapy Association 16
Space
• Extensive use of space
• Consultation area
• Space for follow up services (personal or group fitness training)
Marketing/Promotion
• Discussion of laws regarding marketing a free service
• Targets
• Cross‐consulting with other health care providers (PTs)
Your Brand
Does it fit with the image or culture of your clinic?
© 2012 American Physical Therapy Association 17
Key Competitive Capabilities
• Very little existing competition
• Already trusted authority in your community
Success Factors
• Qualified personnel
• Valuable evaluation tools, tests and methods
• Fitness program knowledge
• Clean/Spacious environment
• Ability to follow up
Case Example – 74 year old male
• Fitness Evaluation in 2011 – history of falls
• Results – poor body composition, lower/upper extremity strength/ROM
• Began training 1 month later
• Fell at home and injured RTC in 2012
© 2012 American Physical Therapy Association 18
Case Example
• Did 4 weeks of PT in clinic
• Regained full shoulder strength and ROM –returned to training
• Still training at our facility today
• 78 years old. Can perform squats, deadlifts, push ups and overhead press pain free
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Demographics/Statistics• 90% of referrals are 60‐90 year old retirees
• Have received over 300 fitness eval referrals since 2008
• 90% show for fitness evaluation
• 75% elect for follow up instructional session
• 60% return for I year follow up (declines each year)
• 10% become regular training clients
• 35% have become PT patients at some point since their evaluation
• Fitness evaluation referrals make up about 15% of total current fitness clients
APTA Resources
Lisa Culver, PT, DPT, MBA
© 2012 American Physical Therapy Association 19
APTA Resources
• www.apta.org/annualexamination
• Healthy population examinations by age groups
• Links to alternative tests for individuals with disease and disability requiring a different tests
• What if I don’t find what I want?
• Additional sources and EBP
Summary
• The Annual Physical Therapist Checkup
– Health Promotion and Prevention
– Standardized Elements
– Clinical judgment
– Integrates into practice
– Addresses need
– Resources available to support practice
©2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited. 56
Thank You
• Contact information
• David Taylor: [email protected]
• Jon Delk: [email protected]
• Lisa Culver: [email protected]
© 2012 American Physical Therapy Association 20
References• American College of Sports Medicine, eds. ACSM’s Guidelines for Exercise Testing and Prescription. 9th ed.
Baltimore, MD: Lippincott, Williams & Wilkins; 2013.• American College of Sports Medicine, eds. ACSM’s Health‐Related Physical Fitness Assessment Manual. 3rd ed.
Baltimore, MD: Lippincott, Williams & Wilkins; 2010.• Arroll B, Goodyear‐Smith F, Kerse N, Fishman T, Gunn J. Effect of the addition of a “help” question to two screening
questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ. 2005;12(7521):884
• Beekhuizen K.S., Davis M.D., Kolber M.J., Cheng M.S. (2009) Test‐retest reliability and minimal detectable change of the hexagon agility test. J Strength Cond Res 23, 2167‐2171.
• BMI/Waist Circumference Index. Available at: http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/bmi_dis.htm
• Casanova C, Celli BR, Barria P, Casas A, Cote C, de Torres JP, et al. The 6‐min walk distance in healthy subjects: Reference standards from seven countries. Eur Respir J. 2011;37:150–6.
• Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: US Department of Health and Human Services; 2014. Available at: http://www.cdc.gov/diabetes/pubs/statsreport14.htm. Accessed 10/4/2014.
• Centers for Disease Control and Prevention. Age‐Adjusted Percentage of Adults Aged 18 Years or Older with Diagnosed Diabetes Who Were Physically Inactive, United States, 1994–2010. Atlanta, GA: US Department of Health and Human Services; 2014. Available at: http://www.cdc.gov/diabetes/statistics/comp/fig9.htm. Accessed: 10/5/2014.
• Feldhaus KM, Koziol‐McLain J, Amsbury HL, Norton IM, Lowenstein SR, Aboott JT. Accuracy of three brief screening questions for detecting partner violence in the emergency department. JAMA. 1997;277(17):1357–1361.
• Gans KM, Ross E, Barner CW, Wylie‐Rosett J, McMurray J, Eaton C. REAP and WAVE: New Tools to Rapidly Assess/Discuss Nutrition
• with Patients. J Nutrit. 2003;133:556S‐562S.• Guide to Physical Therapist Practice. 3rd ed. Alexandria, VA: American Physical Therapy Association; 2001. Rev.
August 2014.• Hexagonal Obstacle Test. Available at: http://www.brianmac.co.uk/hexagonal.htm
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References• Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. Muscles: Testing and Function, with Posture
and Pain. 5th ed. Baltimore, MD: l Lippincott, Williams & Wilkins; 2005.• Magee DJ. Orthopedic Physical Assessment, 5th ed. Philadelphia, PA: Elsevier Health Science; 2007.• McGill SM, Childs A, Leibenson C. Endurance times for low back stabilization exercises: clinical targets for testing
and training from a normal database. Arch Phys Med Rehabil.1999;80:941‐944.• PQRS foot screen. Available at: www.mdinteractive.com/files/uploaded/file/.../Measure163‐2014cms.pdf .
Accessed: April 22, 2014.• Paxton AE, Strycker LA, Toobert DJ, Ammerman AS, Glasgow RE. Starting The Conversation Performance of a Brief
Dietary Assessment and Intervention Tool for Health Professionals. Am J Prev Med 2011;40(1):67–71.
• PROMIS Short Form Instruments. Available at: https://www.assessmentcenter.net/PromisForms.aspx• Siminoski K, Warshawski RS, Jen H, Lee KC. Accuracy of physical examination using the rib‐pelvis distance for
detection of lumbar vertebral fractures. Am J Med 2003;115:233‐6.• Six‐minute Walk Test. Available at: http://www.ptnow.org/. Accessed April 22, 2014.• Stevens S. Test distance vision using an eye chart. Community Eye Health. Sep 2007; 20(63): 52. Available at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2040251/.• Torres‐Russotto D, Landau WM, Harding GW, Bohne BA, Sun K, Sinatra PM. Calibrated finger rub auditory
screening test (CALFRAST); Neurology. 2009 May 5; 72(18):1595‐1600.• U.S. Census Bureau, 2004 Survey of Income and Program Participation, Wave 5, June‐September 2005. as reported
in: Hootman JM, Brault MW, Helmick CG, Theis KA, Armour BS. Prevalence and Most Common Causes of Disability Among Adults —United States, 2005. MMWR 2009;58(16):421‐426.
• US Department of Health and Human Services. Physical activity guidelines advisory committee report, 2008. Nutrition Reviews. 2009;67(2):114‐120.
• U.S. Preventive Services Task Force. Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Final Recommendation Statement. AHRQ Publication No. 13‐05179‐EF‐2. Available at: http://www.uspreventiveservicestaskforce.org/uspstf13/cvdhighrisk/cvdhighriskfinalrs.htm
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Screening Questions• Abuse/Neglect (Feldahus, JAMA, 1997)
– Do you feel safe in your current relationship?– Is there a partner from a previous relationship that is making you feel
unsafe now?– Have you been hit, kicked, punched or otherwise injured within the past
year? If so, by whom?
• Nutrition– “ what can you do to improve your diet?”– REAP and WAVE (Gans, 2003) / Starting the Conversation (Paxton, 2011)
• Alcohol Use– “How many times in the past year have you had 5 drinks (men) or 4
drinks (women and all adults >65 yo) or more in a day?”
• Smoking – “Do you smoke or have you quit smoking within the previous 6
months?”
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© 2012 American Physical Therapy Association 21
Screening Questions
• Emotional Status (Arroll et al, BMJ 2005) – “During the past month have you often been bothered by feeling down, depressed, or hopeless?”
– “During the past month have you often been bothered by little interest or pleasure in doing things?”
– “Is this something with which you would like help?”– Optional: “Is this something you would like to address in the near future?”
• Hearing– “Do you feel you have a hearing loss?”
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