Partnering With Therapists: Improving Patient Access and Outcomes Through Collaboration

Nicolas Ferrara, DPT, once treated a patient with a transtibial amputation who had constant skin breakdown and ongoing issues with his socket. He eventually stopped coming to Ferrara for physical therapy due to the wounds on his residual limb. Ferrara, still early in his career at that time, says he didn't think to call the patient's prosthetist to discuss the issue.

He eventually lost touch with his patient. "I can't help thinking that a phone call could have gotten this patient back on his feet quicker," says Ferrara.

Patient care can be complicated; each patient's circumstances are best addressed by an integrated team of professionals with distinct training and backgrounds. Patients who have orthotic or prosthetic needs often also have chronic conditions or multiple traumas. When it comes to optimal patient care, the best recipe for patient success involves physical and occupational therapists and O&P providers working hand in hand.

One challenge to adequate therapy and rehabilitation is that many third-party payers restrict the number of sessions available to those they insure—a constraint that can hamper the effectiveness of care. Teamwork between O&P providers, PTs, and OTs can help improve patients' access to therapy services and use the available sessions to the best advantage. The O&P EDGE spoke with several therapists and O&P providers to learn their tips to improve patients' access to adequate therapy services and how the providers can work in partnership to improve patient outcomes.

The Alliance

Vicky Graham, DPT, OCS, NCS, has been practicing physical therapy in a variety of clinical settings since earning her bachelor's degree in 1988. She believes collaboration is at the heart of quality healthcare.

"I've been fortunate to work collaboratively with occupational therapists to coordinate care of patients with upper-extremity orthotic or prosthetic needs," says Graham. "We know that coordinated care works for several reasons. It has less errors, it is more cost effective, and is more enjoyable for the patient and the healthcare providers."

She works extensively with O&P professionals to deliver coordinated care. "This patient population needs healthcare practitioners to communicate regarding comfort, fit, and training," she says. "In my experience, most patients have dramatically improved function immediately after receiving orthotic or prosthetic devices."

And though it can be an exciting time for such a patient, "using these devices is not innate and nearly always requires some training to achieve all the benefits," says Graham, who was certified by the American Board of Clinical Specialists as an orthopedic clinical specialist in 2002, with a ten-year recertification in 2012 and as a neurological clinical specialist in 2009, joining a small group of PTs nationwide with a dual specialization in orthotics and neurology. She also teaches clinical courses in the physical therapy program at California State University, Northridge.

Matt Calendrillo, DPT, BOCOP, owns LIVE EVERY DAY, Avon, Connecticut, a private practice with five locations across the state that combines physical and occupational therapy and O&P care. "Everything is on-site and that helps with the continuum of care," he says.

At LIVE EVERY DAY, which Calendrillo cofounded with his brother, Anthony, 11 years ago, gait training with an individual who is new to AFO use, or a patient with an amputation training with an updated device are two common scenarios that utilize the on-site therapy services. "While good alignment modifications and initial gait training occurs at an O&P office, working through movement deviations in rehab is essential," says Calendrillo, who also teaches physical therapy at Springfield College and is the executive director of LIVE EVERY DAY's orthopedic residency program. "Finding and utilizing therapists who are trained with these skillsets is easier and easier as entry-level programs are now covering the material, and greater opportunities for interdisciplinary learning is occurring."

A Single Setting

The benefits of having O&P and physical and occupational care in a single setting has tremendous advantages, and collaboration between rehabilitation therapists and O&P providers is vital to the patient's success, clinicians agree.

"Throughout the course of a patient's rehabilitation, many issues will come up that will require a team approach, and all members of that patient's healthcare team need to be on the same page," says Ferrara, who has been with First Step Physical Therapy, Long Island, New York, since 2016. First Step Physical Therapy receives many referrals for patients with amputations. Ferrara says when there's an issue with a patient's prosthetic device not fitting properly, a malalignment, or the patient has excessive skin breakdown, a PT would usually be the first to recognize the problem. "I typically see patients with lower-limb amputations two to three times per week, which may be more frequent than visits to a prosthetist," he says. "When there's open lines of communication between all team members, these issues can be solved much quicker."

Christopher Bollinger, MOT, OTR, and Michelle Intintoli, MSPO, CPO/L, are with Arm Dynamics, Northeast Center of Excellence, Philadelphia, one of seven locations nationwide. Arm Dynamics focuses exclusively on treating patients with upper-limb loss and difference. Collaboration between PTs, OTs, and O&P providers is vital to achieving successful patient outcomes, Bollinger and Intintoli agree.

"Our multicenter experience in a specialized setting allows for on-site collaborative care to those with upper-limb difference," Intintoli says. "We work together, therapist alongside prosthetist, toward the same goal of optimizing function for our patients."

"When a therapist and a prosthetist have a good working relationship and practice effective communication, they gain much more awareness into their mutual patients," Bollinger says.

O&P practitioners typically only have a 60- to 90-minute appointment window dedicated to optimizing fit and alignment of the device, says Intintoli. She has practiced general orthotics and prosthetics, but now specializes in upper-limb prosthetic rehabilitation, where she and the prosthetist usually spend many hours each day over consecutive days with patients. "The industry approach to scheduling creates a limited opportunity to foster an effective rapport with the patient," she says. "Patients' weekly appointments with their therapists provide an opportunity to share feelings, frustrations, or complaints that they aren't always comfortable sharing with their O&P providers. This insightful honesty is important to meet patient goals and expectations for improved success."

Third-party Payer Challenge

Rehabilitation care, especially in an outpatient environment after amputation or neurological damage, is different than a joint replacement or rotator cuff pathology patient, Calendrillo says. "Third-party payers get it," he says. "They get that there's a difference, a lifelong difference. With this understanding, third-party payers have appropriate rubrics to outline expected care for those individuals dealing with common pathologies. An amputation or a stroke is far more impactful to a patient and carries a lot more variability in its presentation and outcome."

As a result, from a rehabilitation perspective, it is important for clinicians to establish accurate prognostic factors to best utilize their time with their patients, as well as outline a care plan for the insurer, Calendrillo says. "When all parties are focused on the best evidence-based care for the patient, the patient wins," he says.

Third-party payers determine the number of appointments allotted to patients through a "by-visit" stipend, which is based on their plan coverage, among other factors. The by-visit approach to patient care can be restrictive to a patient, which is why Arm Dynamics typically does not structure their care plans within the stipend model, Bollinger says. "Pre-prosthetic training is just as important as prosthetic training, and a set number of visits can be limiting to patient rehabilitation."

When it comes to third-party payers, Ferrara says it's best to be proactive. "The reality of physical therapy is that much of the time the number of visits allowed is completely dictated by insurance companies and third-party payers," he says. "I often discuss this on the very first visit with my patients, especially if their insurance is known to be relatively conservative with how many visits they will allow."

Get Creative

For patients who have reached their allotted number of sessions, there are creative ways to still offer quality care, clinicians say.

Calendrillo says Connecticut is a direct access state for physical therapy. "Here most insurers will pre-approve initial examinations for physical therapy and then enter a conversation for further services based on findings," he says. "This drives up the efficiency and access to care dramatically. It also helps alleviate much of the prior red tape and allows care quicker to the patients who require it."

Ferrara gives an example at his office of a patient who has a transfemoral amputation and uses a microprocessor- controlled prosthesis. The patient was on private insurance and quickly ran out of visits, he says. "We went through all the usual channels of applying for more visits, appealing the denials, and maximizing his use of private insurance," he says. "Eventually my supervisors and I worked out a private payment plan for him to avoid third-party payers."

Since his patient required a lot of one-on-one time, Ferrara and a coworker team-treated the patient to maximize their time and ensure that he received the therapy he needed. "We were also constantly in touch with his prosthetist," he says. "He needed multiple socket revisions and repairs to his [prosthetic] knee. Since we were constantly communicating, we were able to plan his sessions accordingly." Graham says she closely monitors the amount of therapy sessions approved for her patients and what third-party payers will cover. She informs the patient and the rest of the healthcare team if more care is needed. "I believe in creative solutions such as distributing therapy sessions out over time and encouraging other members of the team to work on different aspects of rehabilitation to maximize often limited resources," she says.

Graham offers other inventive solutions for overcoming third-payer restrictions: Do not use all the therapy sessions before the patient receives the orthosis or prosthesis so that some sessions include training with the new device; spread the therapy sessions farther apart as appropriate; and give ample home exercises. She also seeks out regular and adaptive gym programs, free training from organizations such as the Orthotic & Prosthetic Activities Foundation First Clinics, as well as utilizing peer visits and adaptive recreation opportunities for her patients.

"I advocate for more therapy when appropriate for my patients," Graham says. "My documentation emphasizes the value of learning to use the new device, reduced complications after a course of therapy, and the relatively low cost of training when compared to the purchase of expensive orthotic or prosthetic [devices]."

Third-party payers often deny upper-limb prostheses that they deem experimental, Intintoli says. The best way to combat this perception is to publish peer-reviewed research, she says. Arm Dynamics publishes research specific to patients with upper-limb difference, including validated outcome measure testing that will provide payers with objective data, Intintoli says. "We do this to educate payers so that they can assess the true value of their investment," she says.

Outcome measure testing is often implemented to help with the justification of lower-limb prostheses as well, Intintoli says. "When I was previously working in general practice, I formed relationships with specialized physical therapists who would test my patients using the Amputee Mobility Predictor that demonstrates K-level for patients with lower-limb difference," she says. "Demonstrating an objective measure of K-level would support the type of device chosen and legitimize the associated costs for the patient," she says.

Room for Improvement

Ways therapists and O&P providers can improve on the care they deliver could include implementing patient population-specific outcome measures throughout the different phases of rehabilitation to show objective improvements, Intintoli says. Interpreting the results helps guide each patient's care and scientifically evaluate aggregate data to inform future patient care decisions, she says. "At Arm Dynamics we do this through performance-based outcomes and patient-perspective surveys," Intintoli says.

The limited amount of literature with objective data for those with upper-limb loss has led Arm Dynamics to design and administer three propriety outcome measures that contribute to data on patient norms, The Comprehensive Arm Prosthesis and Rehabilitation Outcome Questionnaire, an interview-based assessment about the patient's overall satisfaction with their prosthetic rehabilitation; the Capacity Assessment of Prosthetic Performance for Upper Limb, a performance-based measure that evaluates factors impacting the use of the prosthesis during multiple tasks and scientifically substantiates the long-term success of patients; and the Wellness Inventory, an assessment that examines different factors impacting recovery for patients after trauma, including areas such as post-traumatic stress disorder, depression, anxiety, pain management, and other factors.

Graham says it has been determined via international research in the area of interprofessional patient care that a team is most effective when everyone understands the roles and responsibilities of each member, communication is safe for each person on the team, and people share power and decision-making responsibilities.

According to Calendrillo, therapists and O&P providers "are at a wonderful crossroads. We are continually asked to provide value and evidence behind the care we deliver. The more collaborative research we can offer, the better," he says. "The combination of device, device design, and the overall function will best showcase the outcomes we achieve with the patient."

Finally, attending in-services and presentations on the latest in O&P technology would help therapists be better prepared to treat patients, Ferrara says. Improving patient care can be found by keeping the lines between therapists and O&P providers open, he says.

And with the perspective of a few more years of experience, Ferrara does things differently now when he treats a patient who is having prosthesis issues. He acts immediately. "I'll call or text that prosthetist that same day, within that same session, so they would be able to get there before my session was over or they could schedule a visit for the next one."

Betta Ferrendelli can be contacted at betta@opedge.com .

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