You do have a huge role as a physical therapists and promoting days at home. Which is a great outcome metric for research. How long are people staying at home at the end of life? And that’s really what it comes down to. We want to see people in their homes setting, aging in place with dignity and I think physical therapy is a great place to start. To really promotes that idea.
Welcome to FOXcast Physical Therapy. A podcast for clinicians made by clinicians. It’s brought to you by FOX Rehabilitation. Find out more at FOXRehab.org.
Jimmy McKay, PT, DPT: Here we go. On FOXcast physical therapy you host JimmyJas McKay on the program we bring in Jason Falvey. Jason welcome to the show.
Jason Falvey, PT, PhD: Good to be here. Thanks for the invite.
Jimmy: You were one of our first couple episodes. CSM last year when we when we kicked this thing off. Thanks for coming back again. What’s been new. Let’s let’s catch everybody up. You’ve got a really cool PT journey. Where are you now and where do you come from?
Jason: That’s the last time we talked. I was finishing my PhD at the univeristy of Colorado medical school. Since then I interviewed for and was accepted to a two year postdoctoral fellowship out of Yale University working with among other people married Mary Tinetti. Who is probably very familiar to a lot of listeners and really doing some good research kind of linking physician disability research. That they’re doing Yale and bringing our rehabilitation component to a lot of our great work that they’re doing.
Jimmy: So since I don’t know a ton about that kind of sphere in your group in that in that program it’s not just PT Right? There’s some other professionals as well.
Jason: In fact I’m the only PT. Yeah. Well the fun story is I’ve had to specifically e-mail the the IT people at Yale because all the professional designations they had in the database including music therapist. There wasn’t one for physical therapists that had been on the faculty and staff directory. So I work exclusively with physicians or bio statisticians and really do work with a lot longitudinal datasets related to tracking disability and hospitalizations over time. A unique dataset that also has Medicare linkages to rehab data which is what I’m helping them analyze now.
Jimmy: All right. Well that’s cool you’re rewriting the record books out there Yale getting a PT on the team. I love to hear that man. But we wanted to bring on the show to talk about something that’s what came out in 2016. So incase the readers want to check it out PTJ April 2016 Vol. 96 and it was titled “The Role of physical therapists in reducing hospital readmissions optimizing outcomes for older adults during care transitions from hospital to community” would you want to give a nod to some of your co-authors. We’ve got Robert Burke Daniel Malone Kyle Ridgeway who has had on my show before Beth McManus and Jennifer Stephens Lapsly where this come out of the neck we’ll dig into the article.
Jason: I’ve had you know as a home health therapist in my previous life somewhat my PhD I really had a media interest in this idea of how physical therapists contribute to hospital readmission reductions. And there have been some other literature suggesting that among a lot of the risk factors for readmissions were a physical function. So people with higher levels of functional impairment are more likely to get readmitted. That was a pretty robust connection that was independent of medical complexity and comorbidity medications etc.. It’s a feeling to really target that because it’s modifiable and potentially to something that’s in our wheelhouse of PT. Working with my PhD mentor who is Dr. Steven Leslie and Dr. Robert Burke who really has spearheaded a lot of work in transitions to skilled nursing facilities. We’ve kind of borrowed some of the material we’ve developed and with his guidance we made a case that PT need to be more involved in that process.
Jimmy: Drawing right from the article really the purposes twofold. First off describe the need for physical therapists input during care transitions for older adults. I know everybody listening here PT OT SLP’s that care for older adults I’d love to hear that. And then to outline strategies for expanding physical therapy participation in care transition for older adults with an overall goal of reducing avoidable 30 day hospital readmissions. Where do you want to start?
Jason: What we really tried to target looking at some of the current evidence around physical function and readmissions like we talked about using a theoretical model that has drawn from a lot of other physician literature kind of identifying where in these processes a physical therapist can be involved. Especially in the things that may be outside of home health care we might not see a lot of. Like medication reconciliation. Any home health providers understanding that medication safety is a big component of what you do during evaluations but in outpatient or skilled nursing facility settings or an inpatient rehab where older adults are often treated. That that may not be central to the practice and something that I think when people transition to home care or outpatient settings for the transition from a skilled nursing facility even to an outpatient setting. Are we really doing a good job looking at those medications? Things like advance care planning and palliative and hospice care. PTs could be providing input. We’re not directing those services that are leading the charge by any means but we certainly have valuable input.
Jimmy: Agreed right there. OK. Going off of that from the article functional deficits represent an independent risk factor for hospital readmissions. We know that and potentially addressable with physical therapy interventions. We love that. So what’s the big Why? Why aren’t you? Why weren’t we involved? And then I’ll ask a follow-up. How do we get involved? Because this is your wheelhouse.
Jason: Yes I think the reasons that we haven’t been involved are partly our fault right. We haven’t been assertive to get to the table. I think that’s common among a lot of advocacy pieces of physical therapy and a reason and good plug to join APTA is you know you can get more involved with those kinds of advocacy efforts. But also a lot of this early research you know from starting with Dr. Eric Coleman’s work from the early 2000s recognizing like all the care handoffs that happen among these older adults and all of the problems that occur. Communication breakdowns physicians started this line of research and really have looked at it from a medical lens. And I think more recent research over the last 10 years after that it started really started to identify as the physical function which accelerated when Medicare started penalizing hospitals for excessive levels of readmission. So then the scramble began for modifiable risk factors. But yet physical therapists still didn’t come to the table even though there is a clear opening. There’s a myriad of reasons but I think we’re doing a much better job of getting involved now. How do we get involved? Still an open question right.
Jimmy: Well one from the article is physical therapists do play a critical role in educating older adults about mobility-related red flags such as slowing gait speed or new impairments and strength or ADL function that occurs during care transitions. We love to say that we’re great educating patients with the general public. Maybe that’s one area we need. We need to do more. We know we’re good at it but maybe we need to do more maybe that’s the role we can play being more assertive everywhere.
Jason: There’s a lot of role for doing a better job measuring physical function during hospitalizations and making sure patients have that information in hand because if you read the article you can tell that there is a lot of breakdown in communication between hospital discharged and patient files going off the primary care physician. Some of that breakdown is because the information that’s important during hospitalization function is often not included in hospital discharge summaries. Recommendations for equipment and devices. We send people home with these recommendations and they never get followed up. I think some of the breakdowns of the communication is avoidable and some of it really takes the systems I right? So some physical therapists are involved not just in the actual clinical pieces but maybe in the health informatics pieces. How do we get information more readily available and help our physicians colleagues and how do we get it in the hands of patients in a really understandable meaningful practical format.
Jimmy: Practical and everybody’s got one of these things. They got a smartphone that counts or steps are you wearing something on your wrist like a Fitbit or a Garmin or an Apple Watch. Evidence from a small prospective study suggests that older adults who walk less than four thousand six hundred ninety-one steps per day. There were very exact in this. The older adults who walked less than forty-six hundred steps per day over the first-week post-discharge are approximately six times more likely to be readmitted within 30 days. Is that something I don’t know a little more tangible that we should be hammering home that forty-six hundred plus step goal.
Jason: So from that study I was partially drawn statistically not necessarily from like a hard clinical guideline or a very small study but one of the first really kind of show ambulatory activity is important and I think a lot of other people have started to follow up on these things. Research in COPD and that’s really kind of pointing towards physical activity levels as being a predictor of readmission. So getting patients to be active. I think it’s a more is a better approach. I don’t think setting targets is necessarily always the best as you’re going to have a wide variety of patients and a wide variety of goals. I think more like because it’s a generally pushing people to increase activity each day you know and making sure that really you’re monitoring the trajectory. If people start to decline a week or two after they leave and they start to decrease the number of steps taken every day that’s your yellow flag to check and say hey are we getting this means pretty confusion or are we having pain or are we getting weak? What’s going on? Why is there we’d expect the physical activity of change to improve over time? And if it’s not that can be a window for us to intervene.
Jimmy: Good opportunity for that education right there. Yes, I will say that was a very small prospective study but I think for me when my watch tells me hey your 2000 steps short of your goal today and it’s like 10:00 at night. Yes, I do. I go around the block a few times because I hate having that thing say that I missed my streak of days in a row hitting my step goal. We can add a little gamification with older adults as well. Talking about the communication discharge planning process encompasses more than a recommendation of discharge location services older adults being discharged for community settings also includes collaboration with community health care practitioners that could also read physical therapists. But synchronous communication like by telephone occurs only 3 percent of the time between hospital physicians and community physicians. Why was that lack? Is it is it EHR? Is it simply that you’re too busy or where’s the breakdown in communication that seems so vital?
Jason: So if you look at it physician to physician communication a lot of it is just time right. Like hospitalists are working on 24-hour shifts think patient out discharging doing paperwork talking with patients and families doing you know a good hospitalist is really in constant communication with the entire care team. But it’s difficult for that hospitalist to call a primary care physician if those primary care physicians not immediately available. You talk about the patient especially with more routine cases that definitely don’t happen. A lot of the barriers time some of it is you know there are no other available options like you know you can have dyssynchronous communication you know like a recorded video message for that physician. But a lot of that technology just doesn’t exist. You think about physical therapy communication. We’ve published another article that really looked at that geriatric PT journal. And really acute care physical therapists are not afforded productivity Standard Time to call clinicians at other levels of care. It’s not considered a productive time and they potentially could be penalized for using the time that they could be treating patients to call and follow up with other providers in the community which we think is really major to a disservice to good patient care.
Jimmy: Yeah it’s just reality. I mean you know even the APTA has a position statement on encouraging PTs to implement standardized handoff communications to ensure just the situation happening appropriate care but life happens. I mean as you mentioned it could be even penalized you know for being not as productive. That’s really sad. It’s disheartening especially for somebody I imagine like yourself who focuses so much on the research and making sure we know what’s right and then only to find that’s not getting implemented simply because of a productivity standard or just things to get in the way that’s got to be really frustrating.
Jason: Yeah and I think that really opens the door for physical therapists and people who are doing boots on the ground research like dissemination implementation research which I find very important. I don’t particularly do that line of research. But I have colleagues who do and I really think there’s a role for a lot of working clinicians to join academic partnerships to really figure out what the yeah what the barriers are to implementing the best practices that are identified in the literature and why they don’t work. And sometimes its researchers are just so far removed from actual day to day clinical practice that they don’t recognize these things. So I find myself lucky that I’ve been a clinician and still actively do some patient time. So I actually can kind of remind myself of those barriers while I’m doing my research.
Jimmy: One more thing about education that I liked from this particular PT perspective piece teaching older adults and caregivers about their medical condition and required follow up care is the next essential step. I love that mention of that focus on that.
Jason: It’s something that feels very patient-centered to say right? That you’re you’re going to teach patients about their medical conditions and how often to get on in reality? How often you’re really giving good detailed information about the medical conditions as far as physical contact and are you tracking your own physical function? Do you know to trigger your physician or notify them if you’re getting weaker or slower? That’s not a normal part of aging right? I’m not just looking at heart failure, do you gain three pounds. But also is it harder for you to climb upstairs to get short of breath quicker. You know things that are functionally related could really be good indicators of your medical condition too. So I think we’re really helping our physician colleagues and our patients by doing that extra step and really doing a good job educating patients and family on what I call functional red and yellow flags.
Jimmy: I’m a visual learner so I love that Golden Gate Bridge picture you had in the article from hospital to community and really it was all the steps that went into that from discharge planning from the hospital all the way to the community and outpatient follow up and all those steps in between. There’s a lot more than I even thought.
Jason: Yeah I think that’s a powerful figure. I mean I have to give some credit to Dr. Robert Burke who designed the original figure. I mean published it in one of the parts of the early work of his role with the Denver V.A. Medical Center and we’d worked together to adapt it and really write this article that made it made it a little bit more relevant to PT. What their role is on these different steps which are definitely different than the physician role. But we’ve been very complimentary and all in all, I think the message is how do we work collaboratively with the other members of the team and provide our input. Not how do we go about this alone and do better than what’s already done? And I think that’s really important take-home how we tried to frame the article as the bridge metaphor is how can we all help patients get across that bridge safely.
Jimmy: Going into further detail in this article was a great table which expands on that bridge metaphor, not only listing the domains of the ideal transition of care framework but going into the recommended care processes relevant to physical therapists and even deeper look at the future proposed expansion of physical therapist role during care transitions. So saying where we should now make sure you’re there and then this is possible this is somewhere along with these different domains that we also could be. I think this is really a must-read especially for clinicians in a practice like FOX Rehabilitation. Knowing where that client was before and where we could get them to after. So I like that table as well.
Jason: One of those things if I can give you a table or figure an article I can stand alone and you can describe it a little helpful reminder or something that really just kind of summarizes the whole article. I really think that the clinician-friendly article like the idea is to make what I recommend or what research team recommends as actionable. I want to be able, not present theoretical. You want to be that are present actionable practical things that you can really start to implement this research now. And we thought that was a good way to start.
Jimmy: Again that’s a PTJ August 2016 volume ninety-six the title role of physical therapists in reducing hospital readmissions optimizing outcomes of for older adults during care transitions from hospital to a community with Jason Falvey right here right now. Anything that surprised you or shocked you a little bit in doing the background for this?
Jason: I really was drawn to the fact that there’s really been no physical therapy research that was formalized about how the rehabilitation of physical function in that early post-consultation window could be beneficial. With all the risk factors that were laid out there was very little to suggest that if we get in and intervene quicker right if you’re a home health clinician you hear this term front-loaded multiple times and if you get an error in front load it’s like really almost no practical evidence it’s really rigorous that says that’s helpful but almost every clinician does it as part of a lot of guidelines. So it’s really compelling to me that I can go and start doing that research and really start to show how we get in there and improve function in that first 30 days. What’s the value of that. And that’s really what drives my research. I was shocked to see that that hadn’t even been started to address.
Jimmy: Glad you’re out there. What would you want to leave the audience with about this particular piece from PTJ? What’s the last thing that you’d want to leave an audience with?
Jason: Take the article and actually start implementing these things. You’re a clinician that does a lot of work on one side or the other of these terror transitions like actually track your practice and see are you doing these things. Are you actually asking questions about a lot of these things? And my guess is you’ll find holes. Holes might be an advance care plan thinking for example which I have seen a lot of things fall through where we’re not really doing a good job managing people who have low-level rehab goals or at end of life so maybe those are places sufficient clinical reflection but really examine your practice. But keep using this article as it is in the top 3 percent of shared articles that PTJ is ever published. So that tells me that the clinical community’s reading it doesn’t have anything to do with it the quality of the research I mean I’m sure it’s good but it really tells you that it’s compelling it’s actionable and clinicians really find the value of the conclusion for sharing it on social media and with each other. That’s probably the best compliment you can give a researcher. Saying hey I do use it in my practice in my courses and I really try to live these values.
Jimmy: I can see some FOX physical therapists that I know who carry around a clipboard the notebooks. I can see them taping this at the table and that that diagram to the inside cover to keep it handy so yeah that is a great compliment and great work on that. The last thing we do on the show is your FOXtale Jason. What drew you to this aspect of physical therapy along your journey? What was it about the people that you get to help with your research?
Jason: People who know me know me as a researcher but I started in rural Maine as an outpatient geriatric clinician and then worked in rural Wyoming as a home health care clinician. And part of that job was really treating medically vulnerable socio-economically depressed populations. And realizing that the people at the lowest level of the spectrum functionally are people that are probably most likely to benefit from what we do if we take the extra time and effort to really make sure we encourage by your patients that are depressed or frail or grumpy take the extra time and go the extra mile with those patients because they are probably the patients who need you the most. And you can make such a tremendous impact on the quality of life. Aging in a place like you and I talked about a year ago and I think the nice way to circle back is we do have a huge role as physical therapists and promoting days at home which is a great outcome metric for research. How long are people staying at home at the end of life? And that’s really what it comes down to. We want to keep people in their homes setting aging in place with dignity. I think physical therapy is the right place to start to really really promote that idea.
Jimmy: Again if you’d like to check this out the role of a physical therapist in reducing hospital readmissions optimizing outcomes for older adults during care transitions from hospital to community. Jason appreciates your tough spreading this and thanks for doing it. No doubt we’re going to check in again soon. When you have more stuff to share with us all right.
Jason: Thanks for having me.
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