In January of 2013, Centers for Medicare and Medicaid services began requiring clinicians providing therapy services to report on outcomes via functional limitation reporting and severity code modifiers. Five years ago the majority of the rehabilitation industry scrambled to understand patient reported outcome measures and how to determine functional limitations.

What has happened in the last 5 years?

---

From 5 years ago to today: what’s the trend?

---

I’d like to think about trends within a framework of who is using outcomes management data. What has changed within five areas: payer, organization, clinician, mentorship and patient sectors?

Payer Sector

Centers for Medicare and Medicaid Services moved from functional limitation and severity code modifiers to actually requiring the reporting of functional outcome measures. Physical therapists became eligible clinicians for reporting all patient outcomes via the Merit-Based Incentive Payment System (MIPS). If participating in the program, all patient outcomes are required to be reported. For physical therapists, the measures listed in the final rule included measures created by Focus On Therapeutic Outcomes. Incentives will actually begin to be related to the final outcomes achieved. Another aspect within MIPS included a defined completion rate. A research study analyzing 2014 indicated that less than 50% of patients did not have interim or discharge data. MIPS requires a level of 60% completeness in outcomes data. The federal payer trend moved from sticking its toes into the water to requiring full participation for eligible clinicians who exceed low threshold requirements.

I believe the trend will probably lead to bundled payment for commonly treated conditions with an expectation of the final outcome. Via MIPS the payer now has defined results of care compared to predicted outcomes along with the cost of that care. This data may jump start bundled payments for rehabilitative services. If this were to happen, hopefully the payer would be able to categorize subscribers as very healthy, average health, and poor health so that the subscribers are adequately tiered for the bundled payment.

Performance Defined Bundled Payments

Every state has multiple payers. I am unable to share trends outside of the federal payment system due to the inability to clearly substantiate an actual trend. I can speak about the largest private payer in Michigan: Blue Cross Blue Shield (BCBSM). If I recall, BCBSM contracted Landmark in 2008 to categorize physical therapists based on their outcomes. The program continues today with eviCore at the helm in determining utilization categorization of physical therapists. To this date, utilization categorization separates physical therapists who practice in a private practice from those in a hospital setting. Although the program suggests “outcomes,” the process discludes the final result of care. The primary components involved in determining clinician categorization include number of visits and cost of care. Although the utilization categorization includes a risk adjustment process, the defining variables seem to be gender, age and a loose categorization of the type of care and body part.  Due to lack of transparency, the risk adjustment factors and impact remain private. None of the patient factors that actually affect clinical outcomes play a role in the process. The reconsideration process for utilization category ignores the cost of care provided and downstream savings. The whole program places attention on the number of visits provided to the patient. The goal of the program focuses on elimination of physical therapists who provide the worst outcomes (based on number of visits). BCBSM desires the program to be expanded to require prior authorization prior to providing any treatments to all BCBSM subscribers.

The trend occurring in Michigan with BCBSM indicates less and less visits are being provided to subscribers. This will lead to minimal positive functional outcomes and an actual increase in cost because patients will hop to a new provider to attain desired gains. The disconnect in care that requires a new initial evaluation and new rehabilitation providers will increase the long term cost of care.

Prior Authorizations

Organization Sector

In the last five years, the outcomes management software industry growth requires organizations to delve into specific needs. The diversity in the available options affects decisions. All the products can track outcomes. Outcomes management has expanded to include far more than just tracking outcomes. Are time and efficiency for completing the assessments factors? Science progression now includes measures designed specifically for computer adaption testing. Will the organization choose to value legacy tools (measurements originally designed to be completed via paper and pencil) or computer adaptive testing? Is it more important for the organization to initially know the likelihood of failure to progress? Is it more important for the organization to know the average outcome for specific categories of patients? Does the organization desire a risk adjustment process with an immediate predicted outcome? Does the organization need an option with a Qualified Clinical Data Registry? Which has more value: a stand alone product or a product designed as an optional electronic medical record subscription?

Over the years, the trend indicates most products include a risk adjustment process. Because of this trend, in my opinion, it is no longer good enough to check a box that risk adjustment happens. Savvy organizations ask how much variance is explained through the risk adjustment process. In order for an apples to apples comparison to happen, the risk adjustment process takes into account differences. In healthcare it is very unlikely that 100% of variance will be explained. The current processes take into account patient factors related to health. The range of variance explained probably comprises a spectrum from 5-40%. In time our industry may learn the impact of social determinants of health on outcomes. If social determinants affect clinical outcomes, the risk adjustment process will incorporate new variables potentially tagged with zip codes. The last factor that may require attention in the future includes the clinician. Certain clinician factors may impact outcomes. Incorporating these factors into the risk adjustment process may improve the explanation of variance.

Demands for Explanation of Variance and Improved Risk Adjustment Process

The current outcomes management system software solely uses patient reported outcome measures. These assessments bring to light a patient’s perspective. Although there is value in a patient’s perspective, a perspective alone does not always tell the full story. The future of outcomes management will expand to include physical performance data. Patients are wearing devices that have the ability to inform about number of steps and physical activity. Researchers are figuring out ways to measure vibrations in the home via floor sensors to capture changes in gait and falls. Some wearable sensors include accelerometers and gyroscopes to provide specific information about speed and orientation. The future will merge the patient’s perspective and data from wearable sensors or external devices capturing performance.

Incorporating Wearable Sensor Data into Outcomes Management

Clinician Sector

In the clinical world, historically “subjective” focused on the responses to clinical questions. Clinicians would evaluate the subjective and objective findings to determine a diagnosis. Consideration of the strength of the objective tests (sensitivity and specificity) influenced the clinicians’ level of confidence with the diagnosis. Evidence based practice or evidence informed practice became a priority to ensure a high level of quality of care. When the payer sector required outcome measures, the clinical sector initially focused on meeting the requirement. In some cases, the trend resided at a low level of going through the motions to meet regulations. In other cases, those who realized future payments would be dependent upon results began including the patient reported outcome measures within the clinical picture. Patient reported outcome measures were viewed to be valid and just as relevant as the typical subjective and objective information.

The extra piece of data, patient perspective, allowed clinicians to create care plans that were more individualized than what subjective and objective information provided. The patient’s perspective included details into how the patient was feeling about her current situation. Clinicians used the information to formulate communication strategies to minimize fear and anxiety, to determine frequency of treatment and to address specific activities that were problematic via graded exposure. Frequent reassessment gave insight into the patient’s response shift either positively or negatively. Clinicians improved their decisions on when to end an episode of care because they were armed with outcomes data.

When clinicians began truly incorporating patient reported outcome measures into practice, clinicians learned that a significant portion of their value included managing a patient’s perceptions.

Significant Value in Managing Patient Perspectives

The future for clinicians will include determining the appropriate frequency of in-person sessions. Because clinicians are now including the patient’s perspective during the evaluation process and intermittently to assess response shifts, clinicians will have more options when providing care. Clinicians will consider the intensity of the required services. Clinicians will determine if a patient requires in-office visits or if an app and telerehabilitation will be sufficient to improve the patient’s condition. More and more time will be spent analyzing data to insure the patient is progressing as would be expected. Data will include patient reported outcome measures, wearable sensor data, and performance based data.

Telerehabilitation and Data Analysis

Mentorship Sector

Professional development remained important over the last five years. Gurus, charismatic individuals and clinicians with years of experience continued to play a role in the learning process. The overall focus revolved around techniques: what techniques and how to perform the specific intervention.  Clinicians either traveled or subscribed for online courses. Learning experience were typically outsourced.

The future will rely heavily on performance based evidence: that of the individual clinician and that of the educator. Mentorship opportunities will more easily arise in-house. Two factors will improve the mentorship experience: outcomes data and the ability to self-reflect. A mentor armed with outcomes data and a mentee adequately self-reflecting will impact the individual’s professional development. The learning and growing will become very specific.

Because data provides accurate insight into performance, the situation may also flip-flop. A mentee can absolutely be a mentor to another individual. The mentee has both strengths and weaknesses. In one situation, the clinician may be a mentee, yet in a different situation the mentor.

Performance Based Evidence for Mentorship

Patient Sector

Over the last five years, the patient experience changed to include patient reported outcome measures and satisfaction surveys. Consultations and evaluations were not solely dependent upon in-person assessments. Patients were using their computer and mobile devices in preparation for in-office visits. Patient reported outcome measures tracked change.

The data from outcomes management systems touched communities. Patients had opportunities to choose providers based on data. Because of increased cost sharing in most health care plans, patients began shopping prior to initiating services. With the inclusion of outcomes data, patients could learn both the estimated cost of care along with the projected results from services.

Estimated Cost AND Expected Results of Care

Outcomes management has changed over the last five years. An impact occurred in all touch points: patient, payers and providers. The overall trend indicates more and more data driven decisions: clinically, educationally and financially.

Until next time,

~Selena

The post 5 Trends in Outcomes Management appeared first on FOTO Patient Outcomes.

Let me share with you a few examples of what may happen if a disgruntled patient discontinues the episode of care.

Do You Consistently Give Your Patients a Way to Share Their Experience?

The findings in a 2009 study by Convergys Corp. found that it only takes ONE negative online review to lose 30 customers. Could there be a better way for your patients to communicate dissatisfaction with you? Can you minimize negative experiences before the “ranting online” tipping point is reached? 

The FOTO Team has figured out a way to help reduce the chances of your organization experiencing early self-discharge and low online reviews. You are possibly thinking that you don’t ask for online reviews, so this may not be relevant. What if a disgruntled patient decided to share the experience in social media with all their family, friends and neighbors? 83% of people say they generally trust recommendations from family, colleagues, and friends about products and services – making these recommendations the most trustworthy. [Nielsen] Do you track whether your patients would recommend you to their family and friends? On the opposite end of the spectrum, if your patients would not recommend your organization to those they know, do you know why?

The FOTO Team created a Marketing Suite that includes the Net Promoter Score (NPS) Dashboard. The Net Promoter Score has been available since August 2018. The dashboard provides 2 opportunities: 1) to market comments from your patients and 2) to immediately address issues when NPS is at or below a defined threshold that indicates risk for self-discharge, poor online reviews and/or spread of negative word of mouth.

The ability to receive real-time email alerts for cut-off NPS scores allows you to set up processes to help alleviate patient concerns. If your organization sets up Outcomes Management to automatically email patients to complete functional assessments (and the NPS with the combined optional comments), you will be acquiring both clinical and patient experience information in a very timely manner. You will need processes in place to address concerns with NPS scores and comments.

{{cta(‘5bce360d-f465-4a6b-b563-59c109481267′,’justifycenter’)}}

You can easily use patient comments as testimonials. You can monitor the NPS score by clinician, clinic and organization. One of the best features of the NPS Dashboard is the real-time email alerts. You can be proactive when a patient is feeling disloyal to your organization. You have the opportunity to learn what your patient perceives about the whole package experience. If you take time to reach out to the patient and genuinely care, you may receive pearls of insight that will help you improve processes within your organization. It is probably far less stressful to reach out, adjust and change versus learning about the poor experience online. Once the patient shares a negative experience online, you have a difficult problem to overcome. 

Until next time,

~Selena

The post Don’t Lose 30 Potential Patients appeared first on FOTO Patient Outcomes.

Years ago when the rules of engagement were different, physicians were spoiled with all sorts of goodies. Food, golf, tickets to events, and medication samples were all fair game. Although times have changed, physicians continue to have appointments with individuals representing businesses that have something or another that the physician should be interested in having, using, or prescribing.

In order to “flip it,” so that physicians are reaching out to you, you need something that speaks to them. You also need to reach them within their own time and space that doesn’t feel intrusive or interruptive. Do you think physicians wonder about what happens after a patient is sent for rehabilitative services? Do patients respond to treatment? Are patients satisfied with the referral?

Physicians may wonder: “Do my patients improve with rehabilitative services?“

If physicians typically wonder about this question, you have a perfect way to answer that question by easily sending information to their inbox. The information is specific for each top referrer about their patients referred to your organization. All of us appreciate knowing that we made a good choice. A good referral is a positive reflection upon the referrer. Seeing the results of care solidifies the decision-making process for top referrers to 1) continue to suggest patients receive services at your facility and 2) share information about your organization among their colleagues and peers.

When you “flip it,” your top referring physicians now have the opportunity to reach out to you to learn more. You snagged their attention. They have an interest in learning more. The first time you send a Referral Report to a physician, there is a high likelihood that someone in the office will reach out to you to learn more. Of course, the best thing you can do is set up a time to meet face-to-face with your top referrer. You now have a wonderful opportunity to really have time with the physician to begin building an even stronger relationship.

What can you do during this meeting to continue an engaging discussion? You can take advantage of Outcomes2Go. Outcomes2Go is an application-like tool that will allow you to showcase your bright spots while on the fly. With this marketing tool, you pre-load your device with all the areas that you shine. You can then broaden your discussion from the top referral’s patients to all patients referred to your facility. Because physicians are well-aware of value based health care, you can delve into effectiveness, efficiency and utilization.

The ability to send Referral Reports is something new for 2019. The new Marketing Suite has expanded to include more ways to engage and delight both your referrers and your patients.

Until next time,

~Selena

The post How Do You Interact with Your Top Referrals? appeared first on FOTO Patient Outcomes.

My best friend has been employed within the same rehabilitation organization for 25 years. She will be leaving the organization before the beginning of June. The main reason was because of a sale and a change of direct oversight. As she spoke of the upcoming changes, we both knew that she could not stay.

There are definitely many, many employment opportunities for physical therapists. A major factor when choosing employment seems to be the focus of organization. Do organizations really focus on what matters the most? I actually had to text my best friend that it appeared she had to choose the lesser of two evils. It shouldn’t be that way, should it?

What matters most for rehabilitation providers? First and foremost an organization’s culture should focus on the patient. I’m not talking the number of units that should be billed per visit… nor am I talking the number of patients that need to be seen per day. A culture that meets the needs of each is what matters most.

What a patient needs fits perfectly into our skill set: they want to get back to life. They want to have someone address their pain; they need someone to educate them. Many want to be actively engaged in their care – they want to be involved in making decisions. They want to be heard. When you meet their needs and create a strong therapeutic relationship, you become their provider for the rest of their life. You will be the person that they seek out whenever your services are needed. If you really knock it out of the park, your patients will demonstrate high loyalty and tell their family and friends to choose you when services are needed.

Each patient is an N=1 opportunity. Each N=1 opportunity is an important step. What if all the N=1 could be pulled together into a big bundle of data? This is definitely possible with the right system. Each N=1 can be measured. A reasonably simple way is to use patient-reported outcome measures. If the system includes a risk adjustment process to predict an outcome, this is a huge added value because you now have a way to compare the actual results with the predicted result. You can do so much with that kind of data.

Your data can be used to help persuade someone to choose you. If you can demonstrate that your services are both effective and efficient, you may gain new referrals. Your potential patients are searching online for options – they have higher financial responsibilities and are more engaged in making health care decisions. If you are able to provide social messages revolving around the quality of the care you provide, you make it easy for your loyal patients to share your messages. You can share results with physicians. You can negotiate higher payments. You can more easily target continuing education needs. You have specific data at your fingertips to help drive decisions to continually improve the quality of the care you provide.

I wonder about organizations with a strong focus on productivity. Are these organizations able to meet patient needs? Are these organizations able to create highly loyal patients? And… in this health care world focusing on value, will these organizations survive? I don’t know, but it seems a high focus on productivity equates to short term profit. Longevity requires long term vision that includes more data than just productivity and profit. It costs more to attain new patients than it does to retain patients for life. Retaining and creating loyalty requires high quality of care and strong therapeutic alliance. The cool thing about quality is that there is a way to implement a system into an organization to help with strategies focused on longevity.

Until next time,

The post Rehabilitation Services: What Matters the Most? appeared first on FOTO Patient Outcomes.

The research continues to strongly indicate exactly what FOTO team takes into consideration in the risk adjustment process. When a patient begins services, the amount of perceived disability matters with regard to the outcome of care.  The level of functional ability is a very strong predictor. The research below indicates it was the highest predictor of outcome.

 The next findings are interesting. How often do you ask if the patient believes services will be beneficial and that their condition will improve? This proves to be a powerful question. Patients who expected services to be beneficial had better outcomes.

Pain self-efficacy also proved to be valuable.  Although the patients were experiencing pain, their belief about their ability to complete tasks while in pain provided insight into outcomes. Those who had high pain self-efficacy beliefs tended to attain better outcomes.

The findings suggest that gaining information from patients about expectations and pain self-efficacy are helpful pieces of information to help in providing care or making care decisions. FOTO does have self-efficacy measures included as optional assessments for you to include when gaining baseline information.

The abstract is included below for you to review.

Self-efficacy and risk of persistent shoulder pain:results of a Classification and Regression Tree (CART) analysis.

The post Risk of Persistent Shoulder Pain appeared first on FOTO Patient Outcomes.

Trying wrapping your head around this one. On twitter, I see tweets from across the globe that indicate researchers in the rehabilitation world are promoting muscle overload to be included in interventions. I’m sure we all agree that muscle overload has value. When you read “optimal load orientation concept” in the below abstract, you are not to be thinking about rehabilitation professionals. This term is derived from shoulder models and mathematical equations. The biomedical engineering goal is to use human models and mathematics to define the optimal length for each shoulder muscle in order to provide targeted overload. Because the shoulder has a wide range of possible positions, equations were used to determine the best angle or placement of an external load to more precisely achieve high muscle activation in each shoulder muscle. The simulations compare the calculated optimal load orientation with a typical resistive exercise performed in the clinic.  

What I am not able to readily comprehend in the full text is how the optimal load orientation concept looked in the simulation. It would be interesting to have seen a video of the simulated muscle overload. 

Engineers are truly focused on creating a robot to provide strengthening activities for the shoulder musculature for individuals with a shoulder problem. The article mentioned being used for individuals after having a stroke. I’m not sure how the robot will overcome the often concurrent problem of lack of coordination. I’m also not sure how a robot would be helpful when someone is experiencing pain. Then again, the robot may have artificial intelligence built into its programming. Are we indispensable? 

The abstract is included below for you to review.

A Muscle-Specific Rehabilitation Training Method Based on Muscle Activation and the Optimal Load Orientation Concept.

The post Will Robots Replace Clinicians? appeared first on FOTO Patient Outcomes.

As I think back to my undergraduate years, one class that seems to have immediate recall was my statistics class. The professor was quite picky with how we learned and completed statistical projects. One initial requirement was showing our work. I had pages of numbers and formulas and “long math.” Completing the projects was long, tedious and detail-focused. I can still feel the relief when a huge project was assigned with a new twist: SAS (statistical analysis software)! It was so magical to input numbers, wait a couple of days and receive a report with all the needed values.

I have similar feelings when it comes to outcomes. Yes, I have done the DIY method. Dang, time flies… I really dove into trying to learn my outcomes 18 years ago. It took me about 16 months to have a working plan in place before I could even begin to collect data. I mean, I had no idea what to even put the data into and had to learn Access. I chose to use the typical condition specific legacy measures (Oswestry Disability Index, Neck Disability Index, Disabilities of the Arm, Shoulder and Hand, and the Lower Extremity Functional Scale).  I also included a generic health legacy measure (Physical Function – 10 Item).  Talk about the volume of paper that went into my DIY project: paper legacy measures…. paper data collection forms… paper reports. I spent weekends and weekends completing data collection forms. I spent so many weekends entering data. I had to figure out how to analyze the data, but to do that meant I had to create queries which would then dump into Excel which then led to calculations which then lead to creating visual reports. 

And now, as I sit and reflect on this experience, what exactly did I learn? I learned that once I started, the data collection, the calculations and the report generation would be never ending. I learned quite a bit at the patient level. I never could quite figure out how to have my calculation process take into consideration older adults versus the younger population… or someone with a chronic problem versus a recent injury… or someone who had surgery versus someone who did not. I learned that I could not compare my results to anyone else in the industry. 

Because of “yesterday,” I truly appreciate the Do-It-For-You option. I very much appreciate the FOTO Team and the FOTO Research Advisory Board because they basically solved my calculation problems. I now no longer spend weekends completing data collection forms… I no longer spend weekends entering data into Access. I don’t have to create Excel spreadsheets or visual reports. 

In today’s world my simplistic DIY methodology would have failed to provide benefit with third party payers. My DIY methodology actually put me at risk. My outcomes data could not help compare my outcomes with any other clinician. The DIY methodology only provided information at the patient level. The Do-It-For-You option included the all-important risk adjustment process. 

Until next time,

~Selena 

The post DIY Outcomes or DIFY Outcomes appeared first on FOTO Patient Outcomes.

When someone goes to the emergency room, they have made the decision that their current problem is not something that they or their family is able to manage.  The patient and family will be worried and scared. The expectations will be high that something will be done.

The clinician needs to be able to listen and hear the patient’s story. High levels of fear and anxiety need to be managed. A skillful, thorough examination needs to happen.  Sometimes no intervention or diagnostic test is required. Sometimes only advice and education is required. The role of the emergency room clinician is to know is and when diagnostic testing is required. 

This particular article should pull together the information that is currently available to successfully manage patients who present to the emergency room with a knee injury.

The abstract is included below for you to review.

Review article: Best practice management of common knee injuries in the emergency department (part 3 of the musculoskeletal injuries rapid review series).

{{cta(‘c6ecd159-44e1-4eb3-9940-fbb5cb2761d5’)}}

The post Management of Common Knee Injuries in the Emergency Department appeared first on FOTO Patient Outcomes.

The ability to accurately predict incidences in health care is something many providers need. When I compare this abstract to what I know about predicting outcomes, there are similarities between models. The patient factor models that include very few patient factors have poor capability to actually predict.

It seems when it comes to predictive models thoughtful consideration about the various factors that may truly affect the outcome need to be included in the model. In this particular study use of corticosteroids was a component increasing predictive capability.

For the model in this study, what is helpful for you is to keep your eye on your patients who have had a replacement due to rheumatoid arthritis – probably because of the prescribed corticosteroids for the condition. At the same time, for anyone undergoing elective joint replacement surgery that has certain comorbidities, you will need to keep your eyes open for infection.

{{cta(‘f3a2fc62-1a26-407f-83a4-e729729b1483′,’justifycenter’)}}

The abstract is included below for you to review.

Identification of high-risk groups for complication after arthroplasty: predictive value of patient’s related risk factors.

{{cta(‘c6ecd159-44e1-4eb3-9940-fbb5cb2761d5’)}}

The post High Risk Groups for Complication after Joint Replacement appeared first on FOTO Patient Outcomes.

The rehabilitation industry has move ahead to assume more responsibility than just measuring a person’s functional ability. Systems are now in place to also predict how much change should occur for a person receiving rehabilitation services. This is the first paper that I am aware of that is asking the next question: How accurate is the prediction? In my opinion, a systematic review proves to be a challenging method to answer questions. When you think about it, systematic reviews typically have quite a bit of heterogeneity which makes it difficult for clinicians to actually apply what is learned into practice. This particular publication that I reviewed did it’s best to focus on what we in the United States would term risk adjustment. I was introduced to a new term: case-mix adjustment (which as I read the paper seems to be the same as risk adjustment).

Predictive ability across US study models ranged from 18-42% and in UK models from 23-30%, demonstrating moderate to strong predictive ability across models.

{{cta(‘f3a2fc62-1a26-407f-83a4-e729729b1483’)}}

 If we use common sense, a model that only focuses on patient factors will be 100% accurate. A final treatment outcome includes far more than just patient factors. If you think of what rehabilitation looks like, there are other factors that play a role in treatment outcomes: clinician factors, patient-clinician factors and clinic factors. I’d like to think that a clinician’s belief system affects an outcome. I’d like to believe that the strength of the therapeutic alliance has a role. I’d also like to think that the way an organization structures patient experience also has a role. In my mind, if a model that only focuses on patient factors is able to accurately predict the outcome 40-50% of the time, the model is very strong. 

Because there are now more products on the market that risk adjust, I take the stand that the industry needs to demand the percentage of variation in the product’s ability to predict the clinical outcome. The next step then includes defining the power of the product’s predictive ability. As an example 0-15% variation explained = poor; 16-25% variation explained = limited; 26-30% variation explained = average; 31-42% variation explained = good; >42% variation explained = excellent. Since I am just thinking out loud with this concept, I would also propose that 26-42% would be defined as the typical industry standard to meet when providing predictive analytics for clinicians. The reason I believe this is important is because outcomes are compared in aggregated data. If the risk adjustment process is not able to adequately capture the important factors to increase the predictive accuracy, then clinicians will be unfairly compared.

The abstract is included below for you to review.

Models used for case-mix adjustment of patient reported outcome measures (PROMs) in musculoskeletal healthcare: A systematic review of the literature.

{{cta(‘c6ecd159-44e1-4eb3-9940-fbb5cb2761d5’)}}

The post Models Used for Risk Adjustment appeared first on FOTO Patient Outcomes.