Implementing Treatment Frequency and Duration Guidelines in a Hospital-Based Pediatric Outpatient Setting: Administrative Case Report Heather Hanson, Ann Tokay Harrington and Kim Nixon-Cave PHYS THER. 2015; 95:678-684. Originally published online January 8, 2015 doi: 10.2522/ptj.20130360
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Implementing Treatment Frequency and Duration Guidelines in a HospitalBased Pediatric Outpatient Setting: Administrative Case Report Heather Hanson, Ann Tokay Harrington, Kim Nixon-Cave H. Hanson, PT, DPT, PCS, Step by Step Developmental Services, Rochester, New York. At the time this case report was written, Dr Hanson was affiliated with the Department of Physical Therapy, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania. A.T. Harrington, PT, DPT, PhD, PCS, Department of Physical Therapy, The Children’s Hospital of Philadelphia. K. Nixon-Cave, PT, PhD, PCS, Doctor of Physical Therapy Program and Post Professional Experiential Learning, Department of Physical Therapy, Jefferson School of Health Professions, Thomas Jefferson University, 901 Walnut St, Room 522, Philadelphia, PA 19107 (USA). At the time this case report was written, Dr Nixon-Cave was affiliated with the Department of Physical Therapy, The Children’s Hospital of Philadelphia. Address all correspondence to Dr Nixon-Cave at: [email protected]. [Hanson H, Harrington AT, NixonCave K. Implementing treatment frequency and duration guidelines in a hospital-based pediatric outpatient setting: administrative case report. Phys Ther. 2015;95:678 – 684.]
Background and Purpose. Determining treatment frequency and duration of physical therapist services is an important component of outpatient pediatric physical therapist practice, yet there is little research available to inform these decisions. Treatment frequency guidelines (TFG) can assist decision making in guiding pediatric physical therapy. The purpose of this project was to examine the feasibility and application of implementing TFG in hospital-based pediatric outpatient physical therapy. Project Description. Previously developed TFG were modified for use in our pediatric outpatient physical therapy department to include duration and were referred to as treatment frequency and duration guidelines (TFDG). In order to successfully implement the TFDG, there were 2 phases to the project. In phase 1, the staff were provided the guidelines and procedures in a staff meeting and via email using a PowerPoint presentation. Phase 2 was initiated due to the poor response of the staff in implementing the guidelines in their practice after phase 1. The format was changed to include formal re-education via small-group and one-on-one education sessions (phase 2). Chart reviews were completed to assess therapists’ adherence to using TFDG.
Outcomes. Therapists’ adherence to use of TFDG increased following re-education: phase 1 (n⫽225 charts, 31% adherence) and phase 2 (n⫽197 charts, 90% adherence).
Discussion. Treatment frequency and duration guidelines may assist in guiding frequency and duration decisions in pediatric physical therapy. Education via in-person meetings may improve adherence among staff.
© 2015 American Physical Therapy Association Published Ahead of Print: January 8, 2015 Accepted: December 21, 2014 Submitted: October 16, 2013 Post a Rapid Response to this article at: ptjournal.apta.org 678
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etermining appropriate treatment frequency and duration of physical therapist services is an important component of pediatric physical therapist practice, yet there is little research available on inform the best way to make these decisions.1 The treatment frequency and duration of care determined for various pediatric conditions can lead to opposing views between care providers and families, particularly in the absence of evidence to inform these decisions.2 The determination of treatment frequency and duration of care has become increasingly important due to the Affordable Care Act,3,4 which has led to changes in health care and insurance benefits. In addition to planning care and intervention for the patient, pediatric physical therapists have the responsibility of showing the value for their services to the patient and family, the facility where services are delivered, other health care providers, and insurance and third-party payers. Determining the frequency and duration of care is essential in all settings for patient care but is extremely important in an outpatient pediatric setting, given a history of service provision without clear evidence for frequency and duration of care.2 In an effort to provide the appropriate, patient-specific level of services, episodic care is important to consider when discussing frequency and duration of services. Episodic care refers to the delivery of specific health care services for a specific medical problem or illness for a specific period of time. In patients with long-term health problems, episodic care can be utilized to address a specific need related to that health problem.5 The Guide to Physical Therapist Practice (Guide 3.0) defines an episode of physical therapy care as “The managed care provided for a specific problem or condition during a set time period. The episode can be April 2015
either for a short period or on a continuous basis, or it may consist of a series of intervals marked by 1 or more brief separations from care.”6 Some patients may require multiple episodes of care, at various frequencies, throughout their life span given the nature of their diagnoses (eg, cerebral palsy).7 Episodic care for pediatric patients has been studied in terms of intermittent intensity of treatment, frequency of treatment, and the perception of the parents and therapists. Researchers have found that short-duration, intensive, and episodic physical therapy models followed by rest periods resulted in higher adherence and improvement in motor performance, as well as both parents and therapists perceiving that the child attained their goals more rapidly.8 –10 An episodic care approach also may be more amenable to parents of children with chronic conditions, who may prefer breaks between episodes of therapy to allow for a rest period and to participate in other community activities as opposed to receiving therapy for an indefinite length of time.8 According to the Guide 3.0, “The plan of care consists of statements that specify the goals, predicted level of optimal improvement, specific interventions to be used, and proposed duration and frequency of the interventions that are required to reach the goals and outcomes.6 As stated in the second edition of the Guide, “The plan of care therefore describes the specific patient/client management and the timing for patient/client management for the episode of physical therapy care.”7(p38) The plan of care is a component of the clinical decisions that physical therapists must make in appropriately serving their patients. Specifically, several factors have been identified that should guide a pediatric physical therapy plan of care, including: the child’s and family’s ability and readiness to partici-
pate, the potential benefit of a current episode of care, the current stage of development, the level of therapist skill needed, a method and setting of service delivery, and frequency and duration.1,2,11 Recently, the American Physical Therapy Association (APTA) Section on Pediatrics convened a research summit that identified a need to address ways to determine appropriate dosing for pediatric patients. Dosing was defined as intensity, time, and type of intervention as well as the frequency of services; all of the variables listed were noted as having the potential to increase the treatment efficacy.12–14 Bailes and colleagues11 developed treatment frequency guidelines (TFG), which can assist with treatment frequency decision making in pediatric settings. The TFG were developed at a large pediatric hospital based on task force meetings to meet the needs of the institution. The guidelines are designed to be used across inpatient and outpatient settings and include the factors previously discussed: readiness of children and family, potential to benefit from therapy, and amount of therapist skill required. The TFG focus on frequency, with frequency categories based on the level of need for physical therapist services, and are defined as follows: intensive (3–11 times per week), weekly/bimonthly (1–2 times per week or 2 times per month), periodic (monthly or regularly scheduled intervals), and consultative (as needed). These guidelines provide a good starting point for decision making regarding frequency for pediatric patients but do not include guidelines for duration of care or define end points for therapy. The purpose of this administrative case report is to describe a quality improvement (QI) initiative that examines the implementation of
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Implementing Treatment Frequency and Duration Guidelines Table. Modified Treatment Frequency and Duration Guidelines Intensity
Definition
Criteria
Intensive
3–5 times per week
Frequent visits for limited length of time, typically of short duration: 2–6 wk
Weekly
1–2 times per week
Depends on length of time required to meet goals: at least 4 wk, and no more than 12 wk
Bimonthly
2 times per month
Typically longer in nature, often 1–3 mo
Periodic
Monthly or regularly scheduled intervals
Typically longer in nature, up to 3–6 mo
Consultative
As needed
Patient has been discharged from regularly scheduled therapy and consults with therapist only when certain needs arise
treatment frequency and duration guidelines (TFDG) to guide episodes of care in a hospital-based pediatric outpatient physical therapy department. Specifically, the goal of this project was to implement and monitor the use of the TFDG.
Case Description: Target Setting The Children’s Hospital of Philadelphia (CHOP) is a large academic pediatric health care system in an urban setting. The physical therapy department provides services in the acute care, inpatient rehabilitation, sports medicine, and hospital-based outpatient settings. We initially targeted only the outpatient sites to roll out the TFDG in our department. The hospital-based outpatient services primarily meet the physical therapy needs associated with a medical diagnosis, procedure, or intervention, in contrast to community pediatric services, which are often more developmental in nature. All CHOP outpatient physical therapy settings: main hospital (Philadelphia) and satellite locations in Pennsylvania and New Jersey, with the exception of sports medicine, were targeted for this QI project. Approximately 2,000 to 2,500 patients are seen in the outpatient physical therapy department each year. In today’s era of accountable health care, our physical therapy department began to discuss ways to demonstrate the value of physical therapist services in terms of providing 680
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appropriate levels of services as opposed to providing services based on standard practice of weekly therapy over the course of several years. Improving frequency and duration decision making for the pediatric population may allow families and health care professionals to see the value of the physical therapist services and support families in understanding how to utilize the services for their child with chronic disabilities. The original frequency guidelines developed by Bailes et al11 were generally applicable to our setting and could assist in plan of care decision making; however, the absence of duration guidelines made it difficult to apply them to episodic care, which is a focus of outpatient service delivery at our institution. Thus, in discussion with physical therapist departmental leadership, we modified the original guidelines to include duration recommendations (ie, TFDG). Together with the outpatient supervisor, we identified TFDG as a way to provide a tool for outpatient therapists to make decisions about treatment frequency and duration. Prior to this project, some therapists were using the TFG created by Bailes et al11 but without a formal departmental standard in place. A group consisting of outpatient physical therapy leadership and several outpatient staff members developed the TFDG by adding duration recommendations and discussing how the recommendations would be used. The
physical therapy department leadership team agreed that the departmental standard would be to use TFDG to inform plan of care decision making in the outpatient practice areas, and that a QI initiative monitoring implementation was indicated. Development of the Process We developed a standardized method for using the guidelines in our facility to allow for implementation and monitoring of the use of TFDG. First, together with the physical therapy leadership team, we set a departmental policy, defining the use of TFDG as the standard of practice for all outpatient therapists, including the main hospital and all satellite locations. Sports medicine patients and outpatient research participants were excluded, as the frequency of care provided in these programs is guided by specific multidisciplinary clinical guidelines, algorithms, treatment protocols, and research intervention protocols. Second, we modified the TFG by adding duration guidelines for each treatment frequency category (Table). Duration guidelines were based on current practice by clinical specialists at our facility and informed by the limited literature regarding pediatric duration recommendations.9,10,15,16 Third, we developed a brochure describing TFDG to distribute to patients and families at the time of initial physical therapist evaluation (typically, the patient’s first interaction with the outpatient phys-
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Implementing Treatment Frequency and Duration Guidelines Implemented Treatment Frequency Guidelines (Phase 1)
Phase 1 Chart Reviews: n=225
Comprehensive Re-education Sessions – 1:1 or Small Group (Phase 2)
Phase 2 Chart Reviews: n=197
Preliminary Analysis
Figure 1. Evaluation process.
ical therapy staff). The outpatient physical therapy supervisor and physical therapy department manager set the standard that each family would receive the brochure and education regarding TFDG at the initial evaluation, and therapists would document distribution and discussion of TFDG in the electronic medical record system (EMRS). Finally, to decrease the burden on therapists, we and the outpatient physical therapy supervisor developed a folder with all pertinent documents for families to receive, and therapists to review, at the initial evaluation. The folder contained the TFDG brochure, a welcome letter, the attendance policy, and a Health Insurance Portability and Accountability Act (HIPAA) form. This folder was distributed to families by support staff at check-in for the initial appointment. The policy and procedure, folder distribution, and information regarding TFDG were introduced to therapists in phase 1 of the QI project. Application of the Process Figure 1 illustrates the process used to evaluate the implementation of TFDG.
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Phase 1: initial implementation. For the initial implementation of the TFDG, we chose a straightforward approach to inform the staff of the new policy and procedures. The outpatient supervisor provided the outpatient physical therapy staff with information and philosophy for the TFDG, describing the role and use of TFDG, the frequency and duration categories, the policy and procedure standard for implementation of the brochure and folders, and the method for documentation. Approximately half of the outpatient therapists were presented the information at an on-site staff meeting, whereas the remaining staff, who were primarily located at satellite offices, received an e-mail with the information attached in a PowerPoint presentation. The approach selected to inform the staff is a traditional model of continuing education using learning principles for practicing clinicians.17,18 This traditional method, using a Power Point presentation, appeared to be appropriate to meet our objectives of implementing the new TFDG and to promote change in practice behavior of the physical therapists while meeting the time constraints of daily operations.17 We used these strategies based on adult learning theories that have been
used for many years in continuing education instruction. To evaluate therapist adherence and implementation of the TFDG, EMRS chart reviews of 10 consecutive initial evaluations per outpatient therapist were completed. The chart reviews assessed for therapist adherence to the guidelines, which was defined as clear documentation that the TFDG were reviewed with the patient and family. The chart reviews began 2 weeks after an informational session was provided to outpatient staff members. Reviews of charts from every treating outpatient therapist at all outpatient locations were included. For therapists who treated patients at multiple locations, the first 10 consecutive evaluations completed by each therapist, regardless of site, were used. This method was chosen to capture the “typical” patient population at any given time by each therapist and within our outpatient setting as a whole. Each therapist’s schedule was examined to identify the initial evaluations. Then, using the EMRS, we reviewed charts to determine inclusion and documentation of TFDG use. Only charts that resulted in an episode of care were included; one-time evaluations, specialty multidisciplinary clinic
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Figure 2. Adherence to departmental policy for the use of treatment frequency guidelines.
evaluations, and re-evaluations were excluded. Chart reviews from the initial implementation phase revealed that TFDG were distributed and documented in only 31% of the charts reviewed (Fig. 2). As a result, we reviewed the implementation process and determined that a different educational approach was needed to improve adherence to the TFDG and to promote change in clinical practice.16 –18 Phase 2. Phase 2 was initiated due to the poor response from the clinicians in implementing the TFDG during phase 1. The low implementation rate suggested that changing clinicians’ practice for a longstanding cultural practice in pediatric physical therapy (ie, treating pediatric patients with chronic disabilities for an extended period of time) was going to be a challenge.18 In reviewing the literature on learning strategies and changing clinicians’ practice, we recognized that it would require essentially changing the cultural practice of the clinicians as a group. According to Fox and 682
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Bennett,17 traditional approaches to continuing medical education, which is what we used in phase 1, have limited impact on learning and professional development and result only in change in clinicians’ practice when used in conjunction with other strategies, including organizational learning and self-directed learning. We reviewed adult learning theory (andragogy), focusing on behavioral change and the experience of the clinicians,20,21 with the goal of influencing clinicians’ behavior and promoting organizational learning by infusing a change into the clinicians’ practice and the culture of practice.17,19 Cook and Yanow21 defined organizational learning in the following manner: “Organizations are seen as cultures, they are seen to learn through activities involving cultural artifacts, and that learning, in turn, is understood to entail organizations’ acquiring, changing, or preserving their abilities to do what they know how to do.”22(p386) In an attempt to promote the organizational change and effect a
change in a long-standing cultural practice, we used adult learning strategies with transformational learning theories.18,19 We included the 3 key elements of transformational learning identified by Merriam and Caffarella20: experience, critical reflection, and development. In transformational learning, the clinicians needed additional education to understand why the new guidelines were being instituted and to understand the concept and philosophy of episodic care. They needed the opportunity to use the guidelines to work through philosophical or clinical decision-making challenges, as well as support as they reflected and worked through a potential cultural shift in clinical practice. Finally, the clinicians needed to use the guidelines immediately after receiving one-on-one education so that any questions could be addressed or problems solved as they worked through the cultural shift.20,21 In contrast to the large-group staff meeting informational session or email correspondence in phase 1, in phase 2 therapists were re-educated
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Implementing Treatment Frequency and Duration Guidelines via small groups, which provided the opportunity for group learning, and one-on-one sessions based on their practice location and schedules. The educational sessions included a review of the role of TFDG, initial findings from phase 1, the rationale and philosophy for an episodic care model, and a discussion on the application of TFDG in their clinical practice. The sessions took place in the therapists’ practice location; thus, 3 therapists received one-on-one education, and the majority (n⫽14) participated in small groups of 2 to 7 therapists. We reviewed the educational materials (folder, brochure, PowerPoint presentation that was used in phase 1 expanded to include additional background information, and phase 1 adherence data). We provided these sessions to encourage clinicians to openly voice any concerns or questions regarding the use of TFDG with individuals or as a group. Following the sessions, staff signed off that they understood the TFDG was the standard of practice at our facility. The in-person education format allowed for an interactive dialogue with therapists regarding the rationale for use of TFDG, examples of how and when to apply certain TFDG categories, strategies to initiate conversations with families who may be resistant to TFDG, and documentation options. Two weeks after completion of the staff education component of phase 2, chart reviews were completed in the EMRS in the same manner as the chart reviews completed following phase 1 (see “Development of the Process” section for details on chart reviews).
Outcome A total of 225 charts were reviewed in phase 1, and 197 charts were reviewed in phase 2. In phase 1 chart reviews, 31% of the charts showed adherence to the standard (clear documentation that the frequency guidelines were reviewed with the April 2015
patient and family), whereas 90% of the phase 2 charts showed adherence to the standard (Fig. 2). Phase 1 included 22 physical therapists, with 7 adhering to the standard in ⬎50% of their charts, 5 adhering in ⱕ50% of their charts, and 10 not adhering to the standard in any of their charts. In contrast, phase 2 included 17 physical therapists, with 16 adhering in ⱖ50% of their charts and 1 adhering in ⬍50% of the charts.
Discussion The implementation of a departmental policy on the use of TFDG represents a way to make tools for decision making regarding treatment frequency and duration available to pediatric physical therapists. Using guidelines inclusive of duration guidelines, as used in this case report, also helps to provide decision-making tools to guide episodic care. This administrative case report suggests that using adult learning strategies, focused on individual and organizational change, may improve adherence among staff.17–21 Educational strategies targeted at promoting learning and changing clinical practice culture included in-person education, providing opportunities for individual and group learning, as well as discussion and reflection. The strategies used in phase 2 to educate the staff appear to be the more efficient and effective approach to effect change in the clinicians’ practice and is the approach that is recommended to implement this type of change in clinician behavior. These strategies are supported in the literature focused on professional learning resulting in organizational and cultural change in practice.17–19 This component may be an important contributing factor to successfully using TFDG to guide physical therapy frequency and duration prescription in pediatric settings. The use of comprehensive education resulted in 90% adher-
ence, a substantial improvement over phase 1. The assumptions that can be drawn from this administrative case report are limited by the QI approach used. We were able to implement a formal program modeled after existing frequency guidelines and provide therapists with the tools to use TFDG to guide plans of care. For some therapists, this approach represents a shift in philosophy of pediatric physical therapy care from ongoing therapy throughout a child’s life span to episodic care.2 We acknowledge that there is often resistance when new guidelines or policies are implemented in an established clinical department, and various forms of ongoing education are necessary to ensure continued adherence to such a change.19 Based on the outcome of this project and the desire of the leadership to foster a continued cultural shift toward episodic care, every new outpatient staff member is provided with education regarding the use of TFDG. In addition, the PowerPoint educational materials were added to the annual department education for all outpatient staff. By providing general guidelines to apply across patient populations, TFDG may improve therapists’ ability to prescribe appropriate frequency and duration of care. Although the original TFG were published previously, they were adapted for use in our facility, with the addition of discussion of duration in the guidelines. We do not have data to inform how the use of TFDG affects patient outcomes or quality of care; however, this administrative case report demonstrates therapists’ ability to change behavior by implementing TFDG to guide plans of care. Future work will focus on the provision of appropriate dosing and timing of rehabilitation services in line with health care reform.13,14,23
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Implementing Treatment Frequency and Duration Guidelines The outcomes of this administrative case report provide support for the feasibility of implementing and applying TFDG in a hospital-based pediatric outpatient setting. The information from this case report may provide the basis for future research examining the use of the TFDG in pediatric practice. Future work may evaluate the accuracy of physical therapists’ ability to predict the treatment frequency and duration of episodes of care by comparing prescribed versus actual numbers of weeks and sessions. Future work also may evaluate the effect on quality of care for various populations, patient outcomes, and cost of care or reimbursement24 when TFDG are used to guide pediatric physical therapy care. It also will be important to examine therapists’, physicians’, and parents’ perceptions of a culture shift to using TFDG. All authors provided concept/idea/project design, writing, and data collection and analysis. Dr Hanson provided project management. Dr Nixon-Cave provided consultation (including review of manuscript before submission). The authors acknowledge all physical therapy outpatient staff who participated and supported this project, as well as department leadership in supporting this initiative. DOI: 10.2522/ptj.20130360
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References 1 Effgen SK. Serving the needs of children and their families. In: Meeting the Physical Therapy Needs of Children. 2nd ed. Philadelphia, PA: FA Davis Co; 2013:3– 40. 2 Palisano RJ, Murr S. Intensity of therapy services: what are the considerations? Phys Occup Ther Pediatr. 2009;29:107– 112. 3 US Department of Health & Human Services. Read the law. Available at: http:// www.hhs.gov/healthcare/rights/law/. Accessed January 27, 2015. 4 Manchikanti L, Caraway D, Parr AT, et al. Patient Protection and Affordable Care Act of 2010: reforming the health care reform for the new decade. Pain Physician. 2011;14:E35–E67. 5 Lamberts H, Hofmans-Okkes I. Episode of care: a core concept in family practice. J Fam Pract. 1996;42:161–169. 6 Guide to Physical Therapist Practice. Version 3.0. Alexandria, VA: American Physical Therapy Association; 2014. Available at: http://guidetoptpractice.apta.org. Acceseed February 23, 2015. 7 Guide to Physical Therapist Practice. Rev 2nd ed. Alexandria, VA: American Physical Therapy Association; 2003. 8 Christy JB, Saleem N, Turner PH, Wilson J. Parent and therapist perceptions of an intense model of physical therapy. Pediatr Phys Ther. 2010;22:207–213. 9 Gagliardi C, Maghini C, Germiniasi C, et al. The effect of frequency of cerebral palsy treatment: a matched-pair pilot study. Pediatr Neurol. 2008;39:335–340. 10 Trahan J, Malouin F. Intermittent intensive physiotherapy in children with cerebral palsy: a pilot study. Dev Med Child Neurol. 2002;44:233–239. 11 Bailes AF, Reder R, Burch C. Development of guidelines for determining frequency of therapy services in a pediatric medical setting. Pediatr Phys Ther. 2008;20:194 – 198. 12 American Physical Therapy Association, Section on Pediatrics. Section on Pediatrics: strategic plan 2013-2016. Published October 16, 2012. Available at: http:// pediatricapta.org/about-pediatric-physicaltherapy/policies-procedures/index.cfm. Accessed May 16, 2014.
13 Gannotti ME, Christy JB, Heathcock JC, Kolobe THA. A path model for evaluating dosing parameters for children with cerebral palsy. Phys Ther. 2014;94:411– 421. 14 Kolobe THA, Christy JB, Gannotti ME, et al; for the Research Summit III Participants. Research Summit III proceedings on dosing in children with an injured brain or cerebral palsy: executive summary. Phys Ther. 2014;94:907–920. 15 Cheng JC, Wong MW, Tang SP, et al. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants: a prospective study of eight hundred and twenty-one cases. J Bone Joint Surg Am. 2001;83:679 – 687. 16 Emery C. The determinants of treatment duration for congenital muscular torticollis. Phys Ther. 1994;74:921–929. 17 Fox RD, Bennett NL. Learning and change: implications for continuing medical education. BMJ. 1998;316:466 – 468. 18 Fox RD, Rankin R, Costie KA, et al. Learning and the adoption of innovations among Canadian radiologists. J Contin Educ Health Prof. 1997;17:173–186. 19 Bloor G. Organisational culture, organisational learning and total quality management: a literature review and synthesis. Aust Health Rev. 1999;22:162–179. 20 Merriam SB, Caffarella, RS. Learning in Adulthood: A Comprehensive Guide. 2nd ed. San Francisco, CA: Jossey-Bass; 1999. 21 Merriam SB. Andragogy and self-directed learning: pillars of adult learning theory. New Directions for Adult & Continuing Education. 2001;89:3–14. 22 Cook SD, Yanow D. Culture and organizational learning. Journal of Management Inquiry. 1993;2:373–390. 23 American Physical Therapy Association. Health care reform. Updated December 31, 2013. Available at: http://www.apta. org/healthcarereform/. Accessed June 25, 2014. 24 Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff. 2008;27:759 –769.
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Implementing Treatment Frequency and Duration Guidelines in a Hospital-Based Pediatric Outpatient Setting: Administrative Case Report Heather Hanson, Ann Tokay Harrington and Kim Nixon-Cave PHYS THER. 2015; 95:678-684. Originally published online January 8, 2015 doi: 10.2522/ptj.20130360
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Implementing Treatment Frequency and Duration Guidelines in a HospitalBased Pediatric Outpatient Setting: Administrative Case Report Heather Hanson, Ann Tokay Harrington, Kim Nixon-Cave H. Hanson, PT, DPT, PCS, Step by Step Developmental Services, Rochester, New York. At the time this case report was written, Dr Hanson was affiliated with the Department of Physical Therapy, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania. A.T. Harrington, PT, DPT, PhD, PCS, Department of Physical Therapy, The Children’s Hospital of Philadelphia. K. Nixon-Cave, PT, PhD, PCS, Doctor of Physical Therapy Program and Post Professional Experiential Learning, Department of Physical Therapy, Jefferson School of Health Professions, Thomas Jefferson University, 901 Walnut St, Room 522, Philadelphia, PA 19107 (USA). At the time this case report was written, Dr Nixon-Cave was affiliated with the Department of Physical Therapy, The Children’s Hospital of Philadelphia. Address all correspondence to Dr Nixon-Cave at: [email protected]. [Hanson H, Harrington AT, NixonCave K. Implementing treatment frequency and duration guidelines in a hospital-based pediatric outpatient setting: administrative case report. Phys Ther. 2015;95:678 – 684.]
Background and Purpose. Determining treatment frequency and duration of physical therapist services is an important component of outpatient pediatric physical therapist practice, yet there is little research available to inform these decisions. Treatment frequency guidelines (TFG) can assist decision making in guiding pediatric physical therapy. The purpose of this project was to examine the feasibility and application of implementing TFG in hospital-based pediatric outpatient physical therapy. Project Description. Previously developed TFG were modified for use in our pediatric outpatient physical therapy department to include duration and were referred to as treatment frequency and duration guidelines (TFDG). In order to successfully implement the TFDG, there were 2 phases to the project. In phase 1, the staff were provided the guidelines and procedures in a staff meeting and via email using a PowerPoint presentation. Phase 2 was initiated due to the poor response of the staff in implementing the guidelines in their practice after phase 1. The format was changed to include formal re-education via small-group and one-on-one education sessions (phase 2). Chart reviews were completed to assess therapists’ adherence to using TFDG.
Outcomes. Therapists’ adherence to use of TFDG increased following re-education: phase 1 (n⫽225 charts, 31% adherence) and phase 2 (n⫽197 charts, 90% adherence).
Discussion. Treatment frequency and duration guidelines may assist in guiding frequency and duration decisions in pediatric physical therapy. Education via in-person meetings may improve adherence among staff.
© 2015 American Physical Therapy Association Published Ahead of Print: January 8, 2015 Accepted: December 21, 2014 Submitted: October 16, 2013 Post a Rapid Response to this article at: ptjournal.apta.org 678
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etermining appropriate treatment frequency and duration of physical therapist services is an important component of pediatric physical therapist practice, yet there is little research available on inform the best way to make these decisions.1 The treatment frequency and duration of care determined for various pediatric conditions can lead to opposing views between care providers and families, particularly in the absence of evidence to inform these decisions.2 The determination of treatment frequency and duration of care has become increasingly important due to the Affordable Care Act,3,4 which has led to changes in health care and insurance benefits. In addition to planning care and intervention for the patient, pediatric physical therapists have the responsibility of showing the value for their services to the patient and family, the facility where services are delivered, other health care providers, and insurance and third-party payers. Determining the frequency and duration of care is essential in all settings for patient care but is extremely important in an outpatient pediatric setting, given a history of service provision without clear evidence for frequency and duration of care.2 In an effort to provide the appropriate, patient-specific level of services, episodic care is important to consider when discussing frequency and duration of services. Episodic care refers to the delivery of specific health care services for a specific medical problem or illness for a specific period of time. In patients with long-term health problems, episodic care can be utilized to address a specific need related to that health problem.5 The Guide to Physical Therapist Practice (Guide 3.0) defines an episode of physical therapy care as “The managed care provided for a specific problem or condition during a set time period. The episode can be April 2015
either for a short period or on a continuous basis, or it may consist of a series of intervals marked by 1 or more brief separations from care.”6 Some patients may require multiple episodes of care, at various frequencies, throughout their life span given the nature of their diagnoses (eg, cerebral palsy).7 Episodic care for pediatric patients has been studied in terms of intermittent intensity of treatment, frequency of treatment, and the perception of the parents and therapists. Researchers have found that short-duration, intensive, and episodic physical therapy models followed by rest periods resulted in higher adherence and improvement in motor performance, as well as both parents and therapists perceiving that the child attained their goals more rapidly.8 –10 An episodic care approach also may be more amenable to parents of children with chronic conditions, who may prefer breaks between episodes of therapy to allow for a rest period and to participate in other community activities as opposed to receiving therapy for an indefinite length of time.8 According to the Guide 3.0, “The plan of care consists of statements that specify the goals, predicted level of optimal improvement, specific interventions to be used, and proposed duration and frequency of the interventions that are required to reach the goals and outcomes.6 As stated in the second edition of the Guide, “The plan of care therefore describes the specific patient/client management and the timing for patient/client management for the episode of physical therapy care.”7(p38) The plan of care is a component of the clinical decisions that physical therapists must make in appropriately serving their patients. Specifically, several factors have been identified that should guide a pediatric physical therapy plan of care, including: the child’s and family’s ability and readiness to partici-
pate, the potential benefit of a current episode of care, the current stage of development, the level of therapist skill needed, a method and setting of service delivery, and frequency and duration.1,2,11 Recently, the American Physical Therapy Association (APTA) Section on Pediatrics convened a research summit that identified a need to address ways to determine appropriate dosing for pediatric patients. Dosing was defined as intensity, time, and type of intervention as well as the frequency of services; all of the variables listed were noted as having the potential to increase the treatment efficacy.12–14 Bailes and colleagues11 developed treatment frequency guidelines (TFG), which can assist with treatment frequency decision making in pediatric settings. The TFG were developed at a large pediatric hospital based on task force meetings to meet the needs of the institution. The guidelines are designed to be used across inpatient and outpatient settings and include the factors previously discussed: readiness of children and family, potential to benefit from therapy, and amount of therapist skill required. The TFG focus on frequency, with frequency categories based on the level of need for physical therapist services, and are defined as follows: intensive (3–11 times per week), weekly/bimonthly (1–2 times per week or 2 times per month), periodic (monthly or regularly scheduled intervals), and consultative (as needed). These guidelines provide a good starting point for decision making regarding frequency for pediatric patients but do not include guidelines for duration of care or define end points for therapy. The purpose of this administrative case report is to describe a quality improvement (QI) initiative that examines the implementation of
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Implementing Treatment Frequency and Duration Guidelines Table. Modified Treatment Frequency and Duration Guidelines Intensity
Definition
Criteria
Intensive
3–5 times per week
Frequent visits for limited length of time, typically of short duration: 2–6 wk
Weekly
1–2 times per week
Depends on length of time required to meet goals: at least 4 wk, and no more than 12 wk
Bimonthly
2 times per month
Typically longer in nature, often 1–3 mo
Periodic
Monthly or regularly scheduled intervals
Typically longer in nature, up to 3–6 mo
Consultative
As needed
Patient has been discharged from regularly scheduled therapy and consults with therapist only when certain needs arise
treatment frequency and duration guidelines (TFDG) to guide episodes of care in a hospital-based pediatric outpatient physical therapy department. Specifically, the goal of this project was to implement and monitor the use of the TFDG.
Case Description: Target Setting The Children’s Hospital of Philadelphia (CHOP) is a large academic pediatric health care system in an urban setting. The physical therapy department provides services in the acute care, inpatient rehabilitation, sports medicine, and hospital-based outpatient settings. We initially targeted only the outpatient sites to roll out the TFDG in our department. The hospital-based outpatient services primarily meet the physical therapy needs associated with a medical diagnosis, procedure, or intervention, in contrast to community pediatric services, which are often more developmental in nature. All CHOP outpatient physical therapy settings: main hospital (Philadelphia) and satellite locations in Pennsylvania and New Jersey, with the exception of sports medicine, were targeted for this QI project. Approximately 2,000 to 2,500 patients are seen in the outpatient physical therapy department each year. In today’s era of accountable health care, our physical therapy department began to discuss ways to demonstrate the value of physical therapist services in terms of providing 680
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appropriate levels of services as opposed to providing services based on standard practice of weekly therapy over the course of several years. Improving frequency and duration decision making for the pediatric population may allow families and health care professionals to see the value of the physical therapist services and support families in understanding how to utilize the services for their child with chronic disabilities. The original frequency guidelines developed by Bailes et al11 were generally applicable to our setting and could assist in plan of care decision making; however, the absence of duration guidelines made it difficult to apply them to episodic care, which is a focus of outpatient service delivery at our institution. Thus, in discussion with physical therapist departmental leadership, we modified the original guidelines to include duration recommendations (ie, TFDG). Together with the outpatient supervisor, we identified TFDG as a way to provide a tool for outpatient therapists to make decisions about treatment frequency and duration. Prior to this project, some therapists were using the TFG created by Bailes et al11 but without a formal departmental standard in place. A group consisting of outpatient physical therapy leadership and several outpatient staff members developed the TFDG by adding duration recommendations and discussing how the recommendations would be used. The
physical therapy department leadership team agreed that the departmental standard would be to use TFDG to inform plan of care decision making in the outpatient practice areas, and that a QI initiative monitoring implementation was indicated. Development of the Process We developed a standardized method for using the guidelines in our facility to allow for implementation and monitoring of the use of TFDG. First, together with the physical therapy leadership team, we set a departmental policy, defining the use of TFDG as the standard of practice for all outpatient therapists, including the main hospital and all satellite locations. Sports medicine patients and outpatient research participants were excluded, as the frequency of care provided in these programs is guided by specific multidisciplinary clinical guidelines, algorithms, treatment protocols, and research intervention protocols. Second, we modified the TFG by adding duration guidelines for each treatment frequency category (Table). Duration guidelines were based on current practice by clinical specialists at our facility and informed by the limited literature regarding pediatric duration recommendations.9,10,15,16 Third, we developed a brochure describing TFDG to distribute to patients and families at the time of initial physical therapist evaluation (typically, the patient’s first interaction with the outpatient phys-
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Implementing Treatment Frequency and Duration Guidelines Implemented Treatment Frequency Guidelines (Phase 1)
Phase 1 Chart Reviews: n=225
Comprehensive Re-education Sessions – 1:1 or Small Group (Phase 2)
Phase 2 Chart Reviews: n=197
Preliminary Analysis
Figure 1. Evaluation process.
ical therapy staff). The outpatient physical therapy supervisor and physical therapy department manager set the standard that each family would receive the brochure and education regarding TFDG at the initial evaluation, and therapists would document distribution and discussion of TFDG in the electronic medical record system (EMRS). Finally, to decrease the burden on therapists, we and the outpatient physical therapy supervisor developed a folder with all pertinent documents for families to receive, and therapists to review, at the initial evaluation. The folder contained the TFDG brochure, a welcome letter, the attendance policy, and a Health Insurance Portability and Accountability Act (HIPAA) form. This folder was distributed to families by support staff at check-in for the initial appointment. The policy and procedure, folder distribution, and information regarding TFDG were introduced to therapists in phase 1 of the QI project. Application of the Process Figure 1 illustrates the process used to evaluate the implementation of TFDG.
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Phase 1: initial implementation. For the initial implementation of the TFDG, we chose a straightforward approach to inform the staff of the new policy and procedures. The outpatient supervisor provided the outpatient physical therapy staff with information and philosophy for the TFDG, describing the role and use of TFDG, the frequency and duration categories, the policy and procedure standard for implementation of the brochure and folders, and the method for documentation. Approximately half of the outpatient therapists were presented the information at an on-site staff meeting, whereas the remaining staff, who were primarily located at satellite offices, received an e-mail with the information attached in a PowerPoint presentation. The approach selected to inform the staff is a traditional model of continuing education using learning principles for practicing clinicians.17,18 This traditional method, using a Power Point presentation, appeared to be appropriate to meet our objectives of implementing the new TFDG and to promote change in practice behavior of the physical therapists while meeting the time constraints of daily operations.17 We used these strategies based on adult learning theories that have been
used for many years in continuing education instruction. To evaluate therapist adherence and implementation of the TFDG, EMRS chart reviews of 10 consecutive initial evaluations per outpatient therapist were completed. The chart reviews assessed for therapist adherence to the guidelines, which was defined as clear documentation that the TFDG were reviewed with the patient and family. The chart reviews began 2 weeks after an informational session was provided to outpatient staff members. Reviews of charts from every treating outpatient therapist at all outpatient locations were included. For therapists who treated patients at multiple locations, the first 10 consecutive evaluations completed by each therapist, regardless of site, were used. This method was chosen to capture the “typical” patient population at any given time by each therapist and within our outpatient setting as a whole. Each therapist’s schedule was examined to identify the initial evaluations. Then, using the EMRS, we reviewed charts to determine inclusion and documentation of TFDG use. Only charts that resulted in an episode of care were included; one-time evaluations, specialty multidisciplinary clinic
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Figure 2. Adherence to departmental policy for the use of treatment frequency guidelines.
evaluations, and re-evaluations were excluded. Chart reviews from the initial implementation phase revealed that TFDG were distributed and documented in only 31% of the charts reviewed (Fig. 2). As a result, we reviewed the implementation process and determined that a different educational approach was needed to improve adherence to the TFDG and to promote change in clinical practice.16 –18 Phase 2. Phase 2 was initiated due to the poor response from the clinicians in implementing the TFDG during phase 1. The low implementation rate suggested that changing clinicians’ practice for a longstanding cultural practice in pediatric physical therapy (ie, treating pediatric patients with chronic disabilities for an extended period of time) was going to be a challenge.18 In reviewing the literature on learning strategies and changing clinicians’ practice, we recognized that it would require essentially changing the cultural practice of the clinicians as a group. According to Fox and 682
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Bennett,17 traditional approaches to continuing medical education, which is what we used in phase 1, have limited impact on learning and professional development and result only in change in clinicians’ practice when used in conjunction with other strategies, including organizational learning and self-directed learning. We reviewed adult learning theory (andragogy), focusing on behavioral change and the experience of the clinicians,20,21 with the goal of influencing clinicians’ behavior and promoting organizational learning by infusing a change into the clinicians’ practice and the culture of practice.17,19 Cook and Yanow21 defined organizational learning in the following manner: “Organizations are seen as cultures, they are seen to learn through activities involving cultural artifacts, and that learning, in turn, is understood to entail organizations’ acquiring, changing, or preserving their abilities to do what they know how to do.”22(p386) In an attempt to promote the organizational change and effect a
change in a long-standing cultural practice, we used adult learning strategies with transformational learning theories.18,19 We included the 3 key elements of transformational learning identified by Merriam and Caffarella20: experience, critical reflection, and development. In transformational learning, the clinicians needed additional education to understand why the new guidelines were being instituted and to understand the concept and philosophy of episodic care. They needed the opportunity to use the guidelines to work through philosophical or clinical decision-making challenges, as well as support as they reflected and worked through a potential cultural shift in clinical practice. Finally, the clinicians needed to use the guidelines immediately after receiving one-on-one education so that any questions could be addressed or problems solved as they worked through the cultural shift.20,21 In contrast to the large-group staff meeting informational session or email correspondence in phase 1, in phase 2 therapists were re-educated
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Implementing Treatment Frequency and Duration Guidelines via small groups, which provided the opportunity for group learning, and one-on-one sessions based on their practice location and schedules. The educational sessions included a review of the role of TFDG, initial findings from phase 1, the rationale and philosophy for an episodic care model, and a discussion on the application of TFDG in their clinical practice. The sessions took place in the therapists’ practice location; thus, 3 therapists received one-on-one education, and the majority (n⫽14) participated in small groups of 2 to 7 therapists. We reviewed the educational materials (folder, brochure, PowerPoint presentation that was used in phase 1 expanded to include additional background information, and phase 1 adherence data). We provided these sessions to encourage clinicians to openly voice any concerns or questions regarding the use of TFDG with individuals or as a group. Following the sessions, staff signed off that they understood the TFDG was the standard of practice at our facility. The in-person education format allowed for an interactive dialogue with therapists regarding the rationale for use of TFDG, examples of how and when to apply certain TFDG categories, strategies to initiate conversations with families who may be resistant to TFDG, and documentation options. Two weeks after completion of the staff education component of phase 2, chart reviews were completed in the EMRS in the same manner as the chart reviews completed following phase 1 (see “Development of the Process” section for details on chart reviews).
Outcome A total of 225 charts were reviewed in phase 1, and 197 charts were reviewed in phase 2. In phase 1 chart reviews, 31% of the charts showed adherence to the standard (clear documentation that the frequency guidelines were reviewed with the April 2015
patient and family), whereas 90% of the phase 2 charts showed adherence to the standard (Fig. 2). Phase 1 included 22 physical therapists, with 7 adhering to the standard in ⬎50% of their charts, 5 adhering in ⱕ50% of their charts, and 10 not adhering to the standard in any of their charts. In contrast, phase 2 included 17 physical therapists, with 16 adhering in ⱖ50% of their charts and 1 adhering in ⬍50% of the charts.
Discussion The implementation of a departmental policy on the use of TFDG represents a way to make tools for decision making regarding treatment frequency and duration available to pediatric physical therapists. Using guidelines inclusive of duration guidelines, as used in this case report, also helps to provide decision-making tools to guide episodic care. This administrative case report suggests that using adult learning strategies, focused on individual and organizational change, may improve adherence among staff.17–21 Educational strategies targeted at promoting learning and changing clinical practice culture included in-person education, providing opportunities for individual and group learning, as well as discussion and reflection. The strategies used in phase 2 to educate the staff appear to be the more efficient and effective approach to effect change in the clinicians’ practice and is the approach that is recommended to implement this type of change in clinician behavior. These strategies are supported in the literature focused on professional learning resulting in organizational and cultural change in practice.17–19 This component may be an important contributing factor to successfully using TFDG to guide physical therapy frequency and duration prescription in pediatric settings. The use of comprehensive education resulted in 90% adher-
ence, a substantial improvement over phase 1. The assumptions that can be drawn from this administrative case report are limited by the QI approach used. We were able to implement a formal program modeled after existing frequency guidelines and provide therapists with the tools to use TFDG to guide plans of care. For some therapists, this approach represents a shift in philosophy of pediatric physical therapy care from ongoing therapy throughout a child’s life span to episodic care.2 We acknowledge that there is often resistance when new guidelines or policies are implemented in an established clinical department, and various forms of ongoing education are necessary to ensure continued adherence to such a change.19 Based on the outcome of this project and the desire of the leadership to foster a continued cultural shift toward episodic care, every new outpatient staff member is provided with education regarding the use of TFDG. In addition, the PowerPoint educational materials were added to the annual department education for all outpatient staff. By providing general guidelines to apply across patient populations, TFDG may improve therapists’ ability to prescribe appropriate frequency and duration of care. Although the original TFG were published previously, they were adapted for use in our facility, with the addition of discussion of duration in the guidelines. We do not have data to inform how the use of TFDG affects patient outcomes or quality of care; however, this administrative case report demonstrates therapists’ ability to change behavior by implementing TFDG to guide plans of care. Future work will focus on the provision of appropriate dosing and timing of rehabilitation services in line with health care reform.13,14,23
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Implementing Treatment Frequency and Duration Guidelines The outcomes of this administrative case report provide support for the feasibility of implementing and applying TFDG in a hospital-based pediatric outpatient setting. The information from this case report may provide the basis for future research examining the use of the TFDG in pediatric practice. Future work may evaluate the accuracy of physical therapists’ ability to predict the treatment frequency and duration of episodes of care by comparing prescribed versus actual numbers of weeks and sessions. Future work also may evaluate the effect on quality of care for various populations, patient outcomes, and cost of care or reimbursement24 when TFDG are used to guide pediatric physical therapy care. It also will be important to examine therapists’, physicians’, and parents’ perceptions of a culture shift to using TFDG. All authors provided concept/idea/project design, writing, and data collection and analysis. Dr Hanson provided project management. Dr Nixon-Cave provided consultation (including review of manuscript before submission). The authors acknowledge all physical therapy outpatient staff who participated and supported this project, as well as department leadership in supporting this initiative. DOI: 10.2522/ptj.20130360
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Implementing Treatment Frequency and Duration Guidelines in a Hospital-Based Pediatric Outpatient Setting: Administrative Case Report Heather Hanson, Ann Tokay Harrington and Kim Nixon-Cave PHYS THER. 2015; 95:678-684. Originally published online January 8, 2015 doi: 10.2522/ptj.20130360
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