Continuity Counts

Several years ago, I had the unfortunate opportunity to experience the healthcare system at the side of critically ill family member.  This family member was hospitalized where I had been working as a physical therapist.  It was a large hospital with a Level 1 Trauma Center designation and all the bells and whistles necessary to manage most medical conditions.  I was confident that with my experience at this facility as an employee and over 15 years in healthcare as a Physical Therapist, I would be able to easily assist in navigating the hospital stay and make the necessary decisions to aid in my loved one’s recovery.  Was I ever mistaken!

continuityWe were assigned a Hospitalist who had an Internal Medicine Specialty.  They, in turn, consulted an infectious disease specialist and a surgeon based on the admitting diagnosis, diagnostics and lab results.  Each was highly educated, competent and qualified to meet our ongoing and changing medical conditions.  We met with each one to discuss the diagnosis and their recommended plan of care.  Following these conversations, we felt comfortable knowing there was a plan in place and what to expect during our stay.  That is where everything seemed to go wrong.

Two days into our ten-day hospital stay we began a revolving door of physicians, from all three specialties, who had their own ideas and recommendations about our care.  It seemed the original plan that was set during our initial consults was discarded and replaced by varying and sometimes contradicting opinions of these new physicians, some of who we only saw once.  The other problem was that it was unclear as to which Specialty was in-charge of our case.

We had an Internal Medicine Specialist recommending surgery that the Surgeon recommended we not do.  It seemed as though the Medical Professionals were treating the issues of the day but not looking at the entire case.  Not looking at what got us here, what is going on today, and where we are going.  Very confusing.  We spent a large portion of the remainder of our stay trying to research and decide whose opinion to follow to expedite the recovery and get us home. This lack of continuity resulted in minor, but also avoidable, complications which required further treatments which extended our stay.  We were eventually able to leave the hospital and return home to continue the recovery process.  We knew two things when we left. 1) The admitting diagnosis was going to require surgical treatment in the future and 2) We didn’t want to have the same type of experience we had during this stay.

Elderly patient looking at a nurseOver the next several months, we took the time to find a Surgeon and a Hospital to complete the needed surgery and prevent further medical problems.  We only hoped that we would not have the same experience.  We were pleasantly surprised.  The surgeon set clear expectations for the surgery and hospital stay.  She was clearly in-charge and making all the decisions.  Any modifications to the plan were cleared by her and communicated to us.  We saw other medical specialties during this stay who worked in cooperation with the surgeon and not opposition.  Our stay went exactly as planned.  We discharged on time without complication and made a full recovery.

I have reflected on these two hospital stays over the last several years in hopes to identify what was different about the experiences.  The primary factor that improved the second was “Continuity of Care” from start to finish.  A plan was set forth at admission and all the staff worked together to see it through.  Those who established the plan were present and accountable to ensure the plan was executed.  Those providers who filled-in were aware of the plans and stayed the course.  They all provided information and care consistent with the plan.  It made all the difference!

This experience changed my view about how we deliver care in therapy.  I work in a large therapy department at Salem Transitional Care.  As one of the supervising physical therapists, I evaluate a lot of patients who then get assigned to other therapists and therapy assistants.  These therapists are smart, caring and thorough.  In an ideal world, the therapist that is assigned the case would treat the patient for the remainder of their stay and skillfully execute the plan of care with optimal outcomes, minimal complications in a reasonable timeframe.  But in reality, this is not always the case.

Due to both avoidable and unavoidable circumstances, the patient falls into the revolving door of therapists who do their best to meet the immediate needs of the patient but don’t have a clear picture of what has gone on and where the patient is headed.  What you end up seeing as the primary objective is to complete the treatment for the day to the best of their ability and ensure the appropriate minutes are delivered to capture the RUG.  Less emphasis is placed on providing the best treatment at the right intensity for that patient at that time. Treatments begin to suffer.  They lack specificity, intensity, and progression to move the patient forward to the best outcome in the shortest time frame.  Treatment protocols, such as, gait speed, CJR, and high intensity stepping are not provided consistently to ensure maximum benefit.  Documentation begins to suffer.  The treatment and progress notes are not specific enough to justify medical necessity and continuation of care.

therapy7Suddenly, and as if unexpectedly, the patient is scheduled for discharge.  The scramble begins to complete home safety assessments, recommend equipment, fit wheelchairs, train caregivers, and prepare the patient for the discharge to the next level of care.  The outcomes and overall experience for these patients is not optimal.  This scenario is not true with all patients, but it happens enough for me to ask the question “What could we do differently to prevent this from happening and improve the outcomes and rehab experience for all our patients?”  I think the answer is improving the “Continuity of Care” and assigning a therapist or an interdisciplinary team of therapists who are accountable for each patient.

This is the question I hope to begin to answer during my participation in the Leadership Academy.  At Salem Transitional Care, we are actively looking at our “Continuity of Care” to identify how many therapists, on average, are involved in a case and how that effects adherence to the POC and protocols, outcomes, and length of stay.  Over the course of the next 6 months, our team is looking to modify our therapy delivery approach to minimize the number of therapists involved in the care of a patient and identify who is in charge of making the necessary therapy related decisions for each individual patient.

Our goals are to maximize outcomes, streamline delivery of care, improve discharge readiness, minimize complications, and ultimately improve the overall rehab experience for patients and families.  I know these may be lofty goals with many barriers but with an entire rehab team and Infinity Rehab on board, I think we can move the system in the right direction.

Infinity Rehab has spent years standardizing our CORE measures, identifying best practices, and gathering data to determine outcomes.  This is great and necessary but if they are not delivered consistently and at the intensity prescribed, much of the benefit is lost.  I think we all need to look not only at the treatment approaches but how they are delivered to ensure maximum benefit and outcomes for our patients.

Thank you,

Trent Dunlop, MPT/ATP