Pursuit and Implementation of Hospital-Based Outpatient Direct Access to Physical Therapy Services: An Administrative Case Report

Abstract

Background and Purpose Despite legislative approval of direct access to physical therapy, other regulatory barriers and internal institutional policies often must be overcome before this practice model can be fully adopted. Few institutional initiatives have been published describing strategies designed to change policies restricting direct patient access. This case report describes steps and strategies associated with successful implementation of a direct access physical therapy model at a large academic medical center. Case Description The process of obtaining institutional medical board and hospital authority board approval and implementing a pilot program is described. Program details, including therapist qualifications and scope of practice, the required internal training program, and program outcome assessment, are provided. The therapist scope of practice includes the ability to refer patients directly to a radiologist for plain film radiography. Early pilot program findings, including challenges faced and subsequent actions, are described. Outcomes Reviewed patient care decisions by therapists participating in the pilot program were deemed appropriate 100% of the time by physician chart reviewers. Approximately 10% of the patients seen were referred to a radiologist for plain film imaging, and 4% and 16% of the patients were referred to physicians for pain medications or medical consultation, respectively. The pilot program's success led to institutional adoption of the direct access model in all physical therapy outpatient clinics. Discussion Autonomy is described, in part, as self-determined professional judgment and action. This case report describes such an effort at a large academic medical center. The interdependent, collaborative relationship among physical therapists, physicians, and hospital administrators has resulted in the implementation of a patient-centered practice model based on the premise of patient choice.

Physical Therapist Practice and the Role of Diagnostic Imaging

“…Additionally, none of the physical therapists had their credentials or state licenses modified or revoked for disciplinary action, nor were there any litigation cases filed against the United States government involving physical therapists. 44 Boissonnault et al 12 assert that the military's long track record of physical therapists in the physician-extender role dispels concerns among decision makers who may believe that physical therapists seek to operate in an untested practice model. Other agencies within the government sector have come to the same conclusion.…”

“…The nonprofit managed-care organization, Kaiser Permanente Northern California, has provided imaging privileges for their physical therapists. 70 In addition, the University of Wisconsin Hospital and Clinics 12 have extended this privilege to physical therapists by allowing the ordering of plain film radiography. Despite the numerous credentialed physical therapists ordering imaging, we were unable to identify any documented case of litigation or a suspended or revoked license resulting from physical therapists ordering imaging for their patients.…”

“…Kaiser Permanente Northern California included educational courses focusing on differential diagnosis of musculoskeletal versus nonmusculoskeletal conditions, acute mus-culoskeletal injuries of peripheral joints, and radiological review of plain films and magnetic resonance imaging (MRI) for physical therapists. 46 Boissonnault et al 12 described a direct-access physical therapy model at the University of Wisconsin Hospital and Clinics that included the ability to refer for imaging. Physical therapist qualification included successful completion of direct-access/diagnostic imaging training that emphasized "red flag" recognition and any 1 or more of the following 5 requirements: (1) APTA American Board of Physical Therapy Specialties current certification in a relevant practice area (Orthopaedic Certified Specialist for therapists practicing in an orthopaedic setting); (2) completion of an APTA-credentialed residency or fellowship program in a relevant practice area; (3) an advanced academic degree with a clinical emphasis; (4) advanced clinical practice training (based on quality, emphasis, and extent of practice experience or a certain number of continuing education units); and (5) advanced/expert clinical practice level per the institution's professional advancement and recognition program.…”

Diagnostic and Procedural Imaging Curricula in Physical Therapist Professional Degree Programs

“…As with the military model, the civilian institutions allowing physical therapists to refer patients directly to radiologists required the completion of imaging training programs. 6 The required training raises the question (also raised by Boyles et al 7 and Elliott 13 ) as to whether physical therapists in general are adequately trained in imaging or such required training is simply meant to be a refresher course.Although the advent of Doctor of Physical Therapy (DPT) degree programs (professional and postprofessional/transitional) has resulted in increased emphasis on imaging as a content area, no accepted standard for expected depth and breadth of imaging content in physical therapist professional degree programs exists. 3,9 In addition, authors were unable to find publications that described current imaging curricula in these programs.…”

Magnetic Resonance Imaging: Generating a New Pulse in the Physical Therapy Profession

“…2 It must be emphasized that the physical therapists in these settings have undergone extensive advanced training in evaluating, diagnosing, and treating patients' conditions in a direct-access setting, and in ordering imaging to aid in diagnosis when necessary. These examples provide evidence that an advanced training program can effectively establish the primary care scope of the physical therapist.…”