This document discusses utilizing patient reported outcome measures (PROs) to improve physical therapy care and market a practice. It outlines a 3-phase process: 1) Preparation by determining what to measure; 2) Collecting PRO data at initial and discharge visits; 3) Analyzing the collected data to identify outcomes, compare treatment effectiveness for different conditions/joints, and inform clinical decisions and marketing strategies. Barriers like adding time/effort are addressed by involving clinicians and valuing their judgment.

1. You Don’t Know What You Don’t Know! How to Utilize Evidence Based Patient Reported Outcome Measures to Improve Care and Market Your Practice Selena Horner, PT [email_address] www.RedCedarPhysicalTherapy.com Part 1

5. Really, what are outcomes? A process of measuring from how the patient was… to how the patient is. ** results may not be this dramatic!

6. Who Needs Clinical Outcomes?

8. Third Party Payers Who Needs Clinical Outcomes?

10. Third Party Payers Clinicians Who Needs Clinical Outcomes?

12. Clinicians Third Party Payers Consumers Who Needs Clinical Outcomes?

13. www.cartoonstock.com

14. Consumers Clinicians Third Party Payers Department Administrators Who Needs Clinical Outcomes?

15. Department Administrators and Clinicians Department Administrators Department Administrators Consumers Clinicians Third Party Payers Who Needs Clinical Outcomes?

16. Determining quality of services Rewarding Making clinical decisions Comparing with evidence Choosing a provider Marketing Receiving financial incentives Evaluating clinical performance Setting quality standards Determining needs Improving performance Department Administrators and Clinicians Department Administrators Department Administrators Consumers Clinicians Third Party Payers Who Needs Clinical Outcomes?

19. Phase I: Preparation Phase II: Altering Processes During the Delivery of Care Phase III: Procedural Changes After the Episode of Care

20. Phase I: Preparation What questions are you asking? What will you do with what you learn?

21. Garbage In Garbage Out

24. Orthopaedic Impairments: FOTO Data Courtesy of: Dennis L. Hart, PhD, PT

25. Orthopaedic Impairments: CMS Data Final Report 6/1/2006 Pay for Performance for PT and OT: Medicare Part B Services

26. Orthopaedic Impairments: My Data Red Cedar Physical Therapy, LLC 6/1/2005 through 9/29/2008

28. Patient Demographics Characteristics of Condition Treated Patient Reported Outcome Episode of Care

29. Patient Demographics What patient factors might impact the outcome of services? Will age or gender? Will insurance coverage? Will work status? Will educational level? Will annual income? Will exercise habits? Will alcohol or drug use? Will co-morbidities? Will # of prescription medications? Will being a smoker? Will fear? Readiness for PT? Belief can improve?

30. Characteristics of Condition Treated If there is a defined classification system for the condition, does this matter? Does the body part matter? Does the length of time between when the complaint began and initiating services matter? Does the diagnosis matter? Does whether the condition will progressively worsen over time matter? Are there aspects of what is being treated that will affect outcomes?

31. Patient Reported Outcome Is there a Patient Reported Outcome (PRO) for the population you are interested? Does the PRO have a ceiling or floor effect that will impact what you can learn about the services provided? Does the PRO have a minimal clinically important difference? Is the PRO standardized, responsive, valid, & reliable? Is it easy to score? Is there an interpretation available for the score? Is the PRO readily available? Is the PRO in current literature? Can the value of the PRO outweigh the hassle of change?

32. GROC LEFS MCID DASH NDI ODI NPRS Chat Zone KOS TTYL BRB LOL IDK CU RMDQ

33. Numeric Pain Rating Scale Childs et al. 2005

34. Oswestry Disability Index Fritz et al. 2001 Roland-Morris Disability Questionnaire Stratford et al. 1998

35. Neck Disability Index Hains et al. 1989 Cleland et al. 2008

36. Disabilities of the Arm, Shoulder & Hand Beaton et al. 2001 Shoulder Pain and Disability Index Heald et al. 1997

37. Lower Extremity Functional Scale Binkley et al. 1999 Knee Outcome Survey Marx et al. 2001

38. Global Rating of Change □ A very great deal worse □ A great deal worse □ Quite a bit worse □ Moderately worse □ Somewhat worse □ A little bit worse □ A tiny bit worse (almost the same) □ About the same □ A tiny bit better (almost the same) □ A little bit better □ Somewhat better □ Moderately better □ Quite a bit better □ A great deal better □ A very great deal better Jaeschke et al. 1989

39. Numeric Pain Rating Scale Global Rating of Change Knee Outcome Survey Lower Extremity Functional Scale Neck Disability Index Oswestry Disability Index Roland-Morris Disability Questionnaire Disabilities of the Arm, Shoulder & Hand Shoulder Pain and Disability Index

40. http://www.myphysicaltherapyspace.com/

41. All Groups » Outcome Measures Outcome Measures For sharing information and tools related to outcome measures and current evidence to support them. This group can be a resource where practitioners can go to find an appropriate tool for the specific population of interest and get input on its characteristics and ideas for implementation. Founded by childsjd | 9 Discussions 25 Files 0 Meetings 66 Members

43. Episode of Care Are there certain factors you think are important to capture for each episode of care? Is it important to know the number of visits and/or the duration per each episode of care? Would you be interested in the interventions provided during an episode of care? Is the clinician important? Does it matter why a patient was discharged? Is the primary care physician or surgeon relevant?

44. Piecing it together so far…

45. Patient Demographics Characteristics of Condition Treated Patient Reported Outcome Measures Episode of Care Create Data Collection Form

46. For each orthopaedic patient age, gender, work status, insurance, exercise habit… diagnosis, body part, classification, onset of complaint patient reported outcome measure(s) PT, interventions, physician, visits, duration, discharge reason Create Data Collection Form

47. Discharge Reason? Huh? Is this relevant? ? ? ? ? Ottawa Ankle Rules Bone chips Myocardial infarction Excellent outcome

48. You Don’t Know What You Don’t Know!

49. Red Cedar Physical Therapy, LLC 6/1/2005 – 9/29/2008

50. Patient Demographics Characteristics of Condition Treated Patient Reported Outcome Measures Episode of Care Create Data Collection Form Create Database

52. Outcome Table Physical Therapist Table Body Part Table Patient Reported Outcome Measure Table Discharge Reason Table Physician Table 1 1 1 ∞ 1 1 ∞

53. Outcome Table Initial Function Discharge Function Initial PF-10 Discharge PF-10 Conditions Specific Tool ID Initial Score Discharge Score Factors that Impacted # Heat/Cold # Electrical Stimulation # Iontophoresis # Manual Therapy # Exercise # Traction Discharge Reason ID ID Age Gender ID PT ID PT Site ID Physician ID Date of Eval Date of Last Visit # of Visits Stage of Healing ID Condition ID Body Part ID Initial Average Pain Initial Best Pain Initial Worst Pain DC Average Pain DC Best Pain DC Worst Pain

54. Physical Therapist ID Physical therapist name Year graduated Highest level of education Specialty certifications Hire date with RCPT Physical Therapist Table Physical Therapist Therapist Choices to Input

55. Body Part ID Body part Body Part Table Cervical spine Shoulder joint Elbow joint Wrist/hand Thoracic spine Lumbar spine Hip joint Knee joint Foot/ankle joint Other Body Part Choices to Input

56. PRO ID PRO Maximum score Minimum score MCID Patient Reported Outcome Measure Table SFI DASH LEFS None PRO Choices to Input

57. Physician ID Physician name Specialty Physician Table List of Physicians That Refer Physician Choices to Input

58. Discharge Reason ID Discharge reason Discharge Reason Table Functional Goals Met Educational Goals Met Minimal Progress/Plateau Condition Worse Change in Symptoms Not Responding Recommend Diagnostic Testing Services Inappropriate Patient Choice Moved Never Returned Attendance Issues Insurance Issues Discharge Choices to Input

60. Phase II: Altering Processes During Delivery of Care I should be used to this new door by now!

61. Will there be a substantial change in the delivery of services?

63. What will change is…

65. Data will drive performance and decisions

66. What else will change?

67. The Process

68. #1 Patient initiates services #2 Patient completes PRO on first visit

69. #3 Patient receives physical therapy services #4 Patient completes PRO on discharge visit

70. The only change… completing a PRO on initial visit AND discharge visit

71. Biggest Barrier

72. The only change… completing a PRO on initial visit AND discharge visit

73. Recognize why implementing PRO = barrier

74. To Overcome Barriers: Include therapists in planning and implementation Really be a team – work together - share how information will be used Allow for clinical judgment and accountability Help therapists remember to use PRO

75. Allow physical therapists some control at initiation of services: □ PRO completed □ No appropriate PRO □ Therapist had no time □ Therapist forgot □ Patient has dementia □ Patient in high level of pain □ Patient unable to complete other forms □ Patient unable to speak English well □ Patient unable to read Allow for clinical judgment and accountability

76. PRO Choices Initial ID PRO Choice Initial PRO Initial Completion Table PRO Choices to Input PRO completed No appropriate PRO Therapist had no time Therapist forgot Patient has dementia Patient in high level of pain Patient unable to complete other forms Patient unable to speak English well Patient unable to read

77. Allow physical therapists some control at discharge from services: □ PRO completed □ PRO not initially completed □ Therapist made clinical decision without PRO □ Therapist had no time □ Therapist forgot □ Patient did not return for appointment as anticipated Allow for clinical judgment and accountability

78. PRO Choices Discharge ID PRO Choice Discharge PRO Discharge Completion Table PRO Choices to Input PRO completed PRO not initially completed Therapist made clinical decision without PRO Therapist had no time Therapist forgot Patient did not return for appointment as anticipated

79. Outcome Table Physical Therapist Table Body Part Table Patient Reported Outcome Measure Table Discharge Reason Table Physician Table 1 1 1 ∞ 1 1 ∞ PRO Initial Completion Table PRO Discharge Completion Table

81. This is when things get fun!

82. And potentially frustrating!

83. Phase III: Procedural Changes After the Episode of Care

84. Collect data Input data Run queries Present results of queries with eye appeal Analyze results

85. Frequency of age group seeking physical therapy services Age groups Distribution by Age Comparison of gender usage of physical therapy services Gender Distribution by Gender Frequency of when patients tend to begin physical therapy services after onset of complaint Onset of complaint Distribution by Duration of Complaints Frequency of clinical time spent treating individual joints Joint Distribution by Joint Frequency of clinical decisions and patient issues Discharge reason Discharge Reason Data Captures how consistently complete data collection occurred and the consistency in which the process was performed All records with complete information Completed Outcome Data What Information is Learned What to Query Focus General Descriptive Summary for All Records in Database

86. Analyze number of visits and duration of episode of care for specific joint with a level of clinical decision-making factored in the process for specific joint Query both discharge reasons for all records with complete information for specific joint Utilization Review Data for Goals Met and Minimal Progress/Plateau Analyze number of visits and duration of episode of care for specific joint Query for all records with complete information for specific joint Utilization Review Data – All Completed Records Compare initial level of function to discharge level of function with a level of clinical decision-making factored in the process for specific joint Both discharge reasons for all records with complete information for specific joint Goals Met and Minimal Progress/Plateau Compare initial level of function to discharge level of function for specific joint Records with complete information for specific joint All Completed Records What Information is Learned What to Query Focus Summary of Clinical Outcomes for Each Joint with n>20

87. Excel – statistical analysis and chart creation

88. Phase I: Preparation Phase II: Altering Processes During the Delivery of Care Phase III: Procedural Changes After the Episode of Care