Coordinating Care With the Rehabilitation Team

[caption id="attachment_248304" align="alignright" width="300"] All art: Rudzhan/stock.adobe.com[/caption] When it comes to helping O&P patients in their rehabilitation, a coordinated effort between members of their care team can make all the difference. And by trusting, working alongside, and communicating with a team of medical professionals, O&P clinicians can help give their patients better outcomes, experts say. However, while the experts agree that coordinated care is optimal, they acknowledge that its execution can often be difficult. Members of the medical team may not know one another, they may have varying schedules, different methods of recordkeeping, or just don’t communicate well. “Unfortunately, it’s not infrequent when you have people in the medical team who won’t make the effort to reach out and communicate, and patients won’t get what they need,” says Chris Wallace, MHS, CPO, FAAOP, director of orthotics and prosthetics at Methodist Orthotics and Prosthetics, a division of Methodist Rehabilitation Center, Mississippi. “We see it often when we are waiting for feedback or a prescription and we are just not getting that communication back. It can be a struggle, and the patient is frustrated because their care has been delayed.” We asked the experts about their approaches to help facilitate the coordination of care with the patients. What Is Coordinated Care? Definitions of coordinated care can vary—the authors of the Agency for Healthcare Research and Quality’s Care Coordination Measure Atlas found 40 definitions while reviewing the related literature. They used that information to create their own definition: “Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care.” In essence, coordinated care is when a team of people works together to use their individual expertise to give patients high-quality, seamless care with strong communication between all parties. This model moves away from the idea that one medical professional knows all and instead relies on all parties to communicate and assist one another for the patient’s benefit. More and more, this has become accepted as a best practice, says Alex Hedquist, CPO, Bulow Orthotic & Prosthetic Solutions, South Carolina. “I would say there’s been a little bit of a culture shift where it’s not just a singular person who knows what is best, but that a team of people working together will provide the best outcome,” he says. Coordinated Care: A Perfect Scenario When all goes right in coordinated care for the patient, everyone is happy. Patients have a team of people watching over them and giving them consistent information, and clinicians and other healthcare providers feel respected in their roles and that they are doing good work. “In a perfect world, you have a team of people who can discuss the patient and share records,” Wallace says. “It’s patient-centric care. The patient is in the middle and the rest of us should be working around the patient.” Wallace says he has experienced this ideal scenario in real life. When a patient requires multidisciplinary care at Methodist Rehabilitation Center, the physical therapist, occupational therapist, rehabilitation physician, O&P clinician, other necessary professionals, and the patient hold a group meeting to collectively decide on a comprehensive treatment plan so the patient is not given contradictory information. “[The patient receives] a plan of care that extends to outpatient care,” he says. “So that transition is very seamless. We share notes and we share processes. It’s a really good continuum for the patient to know there is a plan in place for their ongoing care.” Jeffrey Denune, CP, also saw a great model when he practiced at Indiana University Health Center for Limb Loss. There, a team led by a physical medicine and rehabilitation physician assesses patients, monitors limb healing, delivers the prosthetic prescription, and coordinates with O&P clinicians and therapists to ensure a good fit and assess the patient’s gait. This system works well because the physician in charge, Whitney M. Pratt, MD, PhD, is dedicated to the patient’s rehabilitation outcomes and patient’s limb health and speaks directly to the surgeon through the entire process, Denune says. “What happens so often post-amputation is that the surgeon signs the script, makes sure the wound is healed, and sends the patient on their way,” says Denune, who now works at NuTech Institute, Indiana. “Dr. Pratt engages with the amputee directly.” He says that she will talk to prosthetists caring for her patients on a weekly basis to discuss any issues they may have. “I love that team approach,” he says. “What the patients tell me sometimes isn’t always what they tell the physician. So to have an open line of communication between the physician and prosthetist is a huge opportunity of success for the patients.” Coordinated Care: The More Common Scenario These are great examples of coordinated care for patients; unfortunately, they are often the exception more than the rule, especially when it comes to outpatient care. Denune remembers a patient who was forgotten by his healthcare team. The patient came in for an appointment years after a lower-limb amputation but didn’t know how to use socks and didn’t understand volume management. “He said his leg was amputated in March of 2020, he was sent home, and then COVID hit,” Denune says. “He got lost in the system. He had no physical therapy and no training.” While that patient’s experience is an extreme example, many patients who are no longer in a hospital setting routinely get mixed messages from their healthcare teams or have delayed treatment because of a lack of coordination between the physicians, therapists, and O&P clinicians. A busy physician, juggling several patients with various referrals, might not be great at communicating with all the involved medical providers. “They might be working with five different prosthetist groups and ten therapy groups,” says Bobby Latham, CP, BOCO, regional manager at Bulow Orthotic & Prosthetic Solutions, South Carolina. “If they have not established their go-to place, it can be difficult to have communication with them.” These patients need help coordinating their care, Wallace says, and sometimes that help has to come from their O&P clinicians. “It’s not uncommon, in Mississippi at least, when a patient has an amputation and they just get a prescription,” Wallace says. “There is no direction from the physician as to where to go or what to expect next or what to ask for. This is a new world for these patients, and they are faced with this daunting challenge to care for themselves. We’re adding to that burden if we don’t help them coordinate that effort.” Hedquist, who works with Latham, says his office often helps coordinate between physicians and therapists. “We do our best to stay in the loop with the patient’s progress from the physician side to physical therapy,” he says. “We try to almost be a liaison with the physician and the therapist and say: ‘This is about where they are as far as healing goes. Here’s the timeline we think we see.’ We try to be a member of that team that can help communicate between the various facets.” Coordination From the Start When O&P clinics are not inside the walls of the hospital, it can be more of a challenge to keep up the coordinated effort. Information may be delayed or tough to get. This is even more of a challenge considering that a patient with a recent amputation won’t be fitted for a device for months. It’s a delay that can cause further miscommunication. To help combat these issues, the team at Bulow will talk to new limb-loss patients within a day of their surgeries. Even though it may be months before the patients are fitted for their devices, it’s still important to start the communication early, Latham says. His team meets with patients to fill them in on what to expect in the coming months, get help managing their and their family’s expectations, and show them examples of people who are successful and have a similar level of mobility. “We cast a vision of what they can do months from now,” Latham says. This vision gives patients a goal to work toward, says Hedquist. With that in mind, they may be more motivated as they take the first steps of their recovery. “If you can speak with a patient early and cast a vision of what they are able to achieve, they will work harder in physical therapy and be more present in mind, and their overall physical outcomes will be better,” Hedquist says. Then, when they are ready to receive their device, they will be prepared. “They will be in the game from the beginning.” With that good start, they try to keep coordinating the effort between members of the medical team. “Because we see them so early, we sometimes become the de facto guide from the physician to the rehabilitation center and then the referral to the physical therapist,” Hedquist says. “It reminds me of Greek mythology where there is a guide, Charon, who guides people crossing the River Styx. We want to help be that guide for them.” When everyone on the team is onboard, the healthcare team helps one another and helps to address issues before they become serious, Hedquist says. “Sometimes we might see some issues with healing that the home healthcare team didn’t catch, and we can contact a physician or wound care [specialist],” he says. “We become an extra set of eyes.” Those extra eyes can help the O&P team as well. For example, when a patient is in intensive therapy, that therapist might be able to spot gait or socket fit issues before the O&P clinician. “We use the therapists as our eyes sometimes,” Hedquist says. “We may only get to see [patients] for an hour, and the therapists might get to see them over multiple sessions a week.” Those extra eyes can be critical for limb health, says Denune. “The faster we spot an issue, the better off a patient will be,” he says. “If a patient presents an issue with a physician and I haven’t seen them for two to three months, that physician might catch something I didn’t because the patient didn’t come in.” The Benefits and Challenges of Communication Communication is the key to excellent coordinated care, the experts say, but it is also the most difficult part of the process. In each step, there is a place where communication can break down: Everyone on the team likely has a busy schedule, patients may or may not remember what they’ve been told, and medical records might not be passed on as they should. Yet even when it’s a challenge, communication is still essential, Wallace says. “We are all challenged with competition for our time,” Wallace says. “We are trying to provide patient care; we’re fighting with insurance companies. There are a lot of things competing for our attention, but a high priority needs to be communication with other team members. That will distinguish us and show that we’re not just delivering a product.” Wallace often helps lecture about O&P topics at physical therapy schools. No matter the focus of his lecture of the day, he always includes information about how therapists can work with O&P staff. He shows a picture of a team of medical professionals discussing the patients and tells the students they should strive for the same level of communication, even if they don’t work in a hospital. He tells them that with advances in communication technologies, there’s no excuse when it doesn’t happen. “There are so many ways to coordinate with other health professionals that if it’s not happening, it’s because the effort is not being put forth,” Wallace says. The challenge of communication is constant, he says. Even when things seem to be going well, turnover may bring in new people who don’t have a relationship with O&P clinicians. Wallace says that there has been turnover recently at Methodist Rehabilitation Center, as there has been at many hospitals post-COVID, and now it’s his clinic’s job to show the new staff how its O&P services can benefit patients. “We were just having a meeting and discussing our own inpatient therapy turnover,” he says. “We have to train [new therapy staff members] how to make referrals to O&P and how to communicate with us, rather than just saying ‘this patient needs a brace.’ We have to market to physical therapists and other organizations outside of the hospital, but we even need to market to our own people, so they understand our capabilities and how to utilize us.” He encourages other clinicians to put in the time and effort needed to keep the healthcare team talking. It will be a continual, but necessary, process. “We’re not perfect, we still struggle,” Wallace says. “It has to be an ongoing process. You don’t do it once and you’re a good communicator. It takes effort.” Building relationships between team members can make a big difference in better communication, Denune says. “Relationships are critical,” Denune says. “Don’t be afraid to build relationships with physicians. It’s more critical today to have a relationship with the prescribing physician. Seek out that relationship. Don’t be afraid.” Latham says when he has a good relationship with providers, they are more likely to contact him quickly when he reaches out. “This comes with trust,” he says. “The people we work with regularly know that I will only ask for things that I need to do my job and only when I absolutely need it. And vice versa.” When there is no relationship, and no trust, care may be delayed to the detriment of the patient, Latham says. “In other markets I’ve been in, there has been almost zero communication from the physicians, and that set us back,” he says. “It delayed care.” Part of building that trust, and building that team, is checking egos at the door, Denune says. No one person is going to save the patient, he says. Instead, the difference will come from a coordinated effort between all team members, and a willingness for everyone to work together and improve. “Don’t be afraid to build a team, Denune says. “Don’t be afraid to reach out and build that team and be a big enough person to accept that there are areas you need to improve upon. At the end of the day, if we work together patients will have better outcomes.” Maria St. Louis-Sanchez can be contacted at msantray@yahoo.com.

Coordinating Care With the Rehabilitation Team

Editor’s Note–October 2023

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Editor’s Note–October 2023

The Importance of a Multidisciplinary Team

The Importance of a Multidisciplinary Team

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CERTIFIED ORTHOTIST or PROSTHETIST/ORTHOTIST

Multiple Locations- Resident Prosthetist / Board Eligible Prosthetist CP/LP

Prosthetic Technician

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