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The Florida Physical Therapists in Private Practice (FLPTPP) presents,[object Object],How Physical Therapists Can Thrive Under Health Care Reform,[object Object],August 20-21, 2011,[object Object],Orlando, Florida,[object Object],Tim Richardson, PT,[object Object],TimRichPT@BulletproofPT.com,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],1,[object Object]
Downloadable slide show at http://www.BulletproofPT.com,[object Object],2,[object Object],The Florida Physical Therapists in Private Practice (FLPTPP) presents,[object Object],Armin Loges, PT,[object Object],Chris Mulvey, PT,[object Object],Tim Richardson, PTDiane Hartely, PTEric Douglass, PTRobert Dragan, PT Stephen Trinque, PTTom Zeller, PTTricia Trinque, PT,[object Object]
Can We Do Better?,[object Object],[object Object]
America spends more than any other country in the worlds, almost 17% of Gross Domestic Product (GDP), on healthcare.
But, America ranks #37 in Quality and Fairness according to the World Health Organization (WHO). Click the link for the 2008 PBS Frontline documentary Sick Around The World.Downloadable slide show at http://www.BulletproofPT.com,[object Object],3,[object Object]
Can We Do Better?,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],4,[object Object]
Can We Do Better?,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],5,[object Object]
Can We Do Better?,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],6,[object Object]
What is an Accountable Care Organization (ACO)? ,[object Object],The Shared Savings Program is designed to improve beneficiary outcomes and increase value of care by:,[object Object],[object Object]
   Requiring coordinated care for all services provided to a population of people under Medicare Fee-For-Service.
   Encouraging investment in infrastructure and redesigned care processes in order to reduce the per-capita cost of healthcare.Eligible providers, hospitals and suppliers may participate in the Shared Savings Program by creating or joining an Accountable Care Organization, also called an ACO. The ACO is expected to transition to population-based  payment arrangements,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],7,[object Object]
What is an Accountable Care Organization (ACO)? ,[object Object],Section 3022 of the Affordable Care Act that was signed into law by President Barack Obama on March 23, 2010 requires the Centers for Medicare and Medicaid Services (CMS) to establish a Shared Savings Program to facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service beneficiaries and reduce unnecessary costs.  ,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],8,[object Object]
What is an Accountable Care Organization (ACO)? ,[object Object],Risk & Reward,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],9,[object Object]
ACO Quality Measures,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],10,[object Object],Five Domains,[object Object],Patient/Care Giver Experience,[object Object],Care Coordination,[object Object],Patient Safety,[object Object],Preventative Health,[object Object],At-risk Population/ Frail Elderly,[object Object]
ACO Quality Measures,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],11,[object Object]
ACO Quality Measures,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],12,[object Object]
ACO Quality Measures,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],13,[object Object]
ACO Quality Measures,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],14,[object Object]
ACO Quality Measures,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],15,[object Object]
ACO Quality Measures,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],16,[object Object]
ACO Quality Measures,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],17,[object Object]
ACO Quality Measures,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],CMS is proposing to define the first quality performance period as beginning January 1, 2012, and ending December 31, 2012.,[object Object],For the first year of the Shared Savings Program, CMS proposes to set the quality ,[object Object],performance standard at the reporting level.,[object Object],18,[object Object]
What is an Accountable Care Organization (ACO)? ,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],The Physician Group Practice (PGP) Demonstration was the first pay-for-performance initiative for physicians under the Medicare program.,[object Object],Billings Clinic, Billings, Montana,[object Object],Dartmouth-Hitchcock Clinic, Bedford, New Hampshire,[object Object],The Everett Clinic, Everett, Washington,[object Object],Forsyth Medical Group, Winston-Salem, North Carolina ,[object Object],Geisinger Health System, Danville, Pennsylvania ,[object Object],Marshfield Clinic, Marshfield, Wisconsin,[object Object],Middlesex Health System, Middletown, Connecticut ,[object Object],Park Nicollet Health Services, St. Louis Park, Minnesota ,[object Object],St. John’s Health System, Springfield, Missouri ,[object Object],University of Michigan Faculty Group Practice, Ann Arbor, Michigan,[object Object],19,[object Object]
What is an Accountable Care Organization (ACO)? ,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],There are three primary ways for an ACO to achieve savings on the care of the assigned Medicare population:,[object Object],Reducing emergency room visits and hospital inpatient admissions.,[object Object],Reducing the provision of specialty care for the assigned Medicare patient population,[object Object],Reducing the provision of imaging and other special tests,[object Object],20,[object Object]
What is an Accountable Care Organization (ACO)? ,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],Preventing Avoidable Hospital Re-admissions ,[object Object],Preventable readmissions can occur because of... ,[object Object],[object Object]
Inadequate post-discharge follow-up
Lack of coordination between inpatient and outpatient healthcare teams.21,[object Object]
What is an Accountable Care Organization (ACO)? ,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],Smith et al reported on the discharge recommendations of 40 physical therapists treating 762 patients at a large, acute care hospital. Smith wanted to see how often the therapists’ recommendations were followed.,[object Object],The therapists’ discharge recommendations were followed 83% of the time. There was a mismatch in PT recommendation and patient discharge location in 124 of 743 cases .,[object Object],When the therapists’ recommendations were NOT followed, the patients were 2.9 times MORE likely to be readmitted than when the recommendations were followed.,[object Object],The hospital had an 18% 30-day re-admission rate, which is consistent with the literature.,[object Object],22,[object Object]
What is an Accountable Care Organization (ACO)? ,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],Specialist Costs,[object Object],23,[object Object]
What is an Accountable Care Organization (ACO)? ,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],Imaging Costs,[object Object],Overutilization of CAT scans: ,[object Object],Double billing the Medicare program,[object Object],24,[object Object]
Downloadable slide show at http://www.BulletproofPT.com,[object Object],What is an Accountable Care Organization (ACO)? ,[object Object],Imaging Costs,[object Object],25,[object Object]
What is an Accountable Care Organization (ACO)? ,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],26,[object Object]
What is an Accountable Care Organization (ACO)? ,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],27,[object Object]
How to Manage a Patient Population,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],28,[object Object]
How to Manage a Patient Population,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],29,[object Object],Epidemiology,[object Object],The branch of medical science dealing with the transmission and control of disease and the mathematics of the collection, organization, and interpretation of numerical data, especially the analysis of population characteristics by inference from sampling.,[object Object]
How to Manage a Patient Population,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],Population health has been defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”,[object Object],It is an approach to health that aims to improve the health of an entire population. ,[object Object],One major step in achieving this aim is to reduce health inequities among population groups. ,[object Object],Population health seeks to step beyond the individual-level focus of mainstream medicine and public health by addressing a broad range of factors that impact health on a population-level, such as environment, social structure, resource distribution, etc. ,[object Object],An important theme in population health is importance of social determinants of health and the relatively minor impact that medicine and healthcare have on improving health overall.,[object Object],From a population health perspective, health has been defined not simply as a state free from disease but as "the capacity of people to adapt to, respond to, or control life's challenges and changes“.,[object Object],30,[object Object]
How to Manage a Patient Population,[object Object],Diagnosis,[object Object],The process the clinician uses to move progressively from a region of low clinical certainty to a region of high clinical certainty.,[object Object],In low probability conditions, screening tests are used to generate diagnostic possibilities and to “rule out” improbable conditions.,[object Object],In high probability conditions, diagnostic tests are used to confirm, or “rule in” likely conditions.,[object Object],Both testing and treatment carry risk.,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],31,[object Object]
How to Manage a Patient Population,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],32,[object Object]
How to Manage a Patient Population,[object Object],How Are Physical Therapists Making Diagnoses?,[object Object],[object Object]
Treatment Based Classification
Pathological Conditions
Psycho-Social ConditionsDownloadable slide show at http://www.BulletproofPT.com,[object Object],33,[object Object]
How to Manage a Patient Population,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],34,[object Object]
How to Manage a Patient Population,[object Object],ODI,[object Object],SPADI,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],35,[object Object]
How to Manage a Patient Population,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],36,[object Object]
How to Manage a Patient Population,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],37,[object Object]
How to Manage a Patient Population,[object Object],Clinical Decision Rules,[object Object],Prediction of Community Acquired Pneumonia (CAP),[object Object],Temperature > 100.04o,[object Object],Pulse > 100bpm,[object Object],Crackles/Rales on auscultation,[object Object],Decreased breath sounds on auscultation,[object Object],No asthma,[object Object],The clinician assigns one point for each of the findings that is present.,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],38,[object Object]
How to Manage a Patient Population,[object Object],Clinical Decision Rules,[object Object],Prediction of Community Acquired Pneumonia (CAP),[object Object],Prevalence of Pneumonia in Primary Care = 2%,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],39,[object Object]
How to Manage a Patient Population,[object Object],Clinical Decision Rules,[object Object],Prediction of Community Acquired Pneumonia (CAP),[object Object],Prevalence  of Pneumonia in the Emergency setting = 8%,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],40,[object Object]
How to Manage a Patient Population,[object Object],Prediction of Community Acquired Pneumonia (CAP),[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],41,[object Object]
How to Manage a Patient Population,[object Object],Prediction of Community Acquired Pneumonia (CAP),[object Object],Lung Sounds: Normal,[object Object],Lung Sounds: Crackles/Rales,[object Object],Lung Sounds: Wheezing,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],42,[object Object]
How to Manage a Patient Population,[object Object],Prediction of Community Acquired Pneumonia (CAP),[object Object],...compared with... ,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],43,[object Object]
How to Manage a Patient Population,[object Object],Derive Sn, Sp, +LR, -LR with a 2x2 table,[object Object],Need Pneumonia numbers,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],44,[object Object]
How to Manage a Patient Population,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],45,[object Object]
Downloadable slide show at http://www.BulletproofPT.com,[object Object],46,[object Object]
Disruptive Innovation,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],“The business models of health are frozen in the hospital and the doctors’ office. The path to fixing the system is to disrupt those models.”,[object Object],Clayton Christensen,[object Object],The Innovator’s Prescription ,[object Object],There are really three business model under one roof in the hospital:,[object Object],Precision medicine that can be “Routinized”. The goal is to identify areas where automation of repetitive tasks can improve care and save costs. Example: Total Knee Replacements.,[object Object],Intuitive medicine that requires highly trained specialists using costly diagnostic testing machines to discover the best treatment approach. Example: Gregory House, MD.,[object Object],Empirical medicine is the costly trial-and-error realm of chronic disease management. Christensen predicts an increase in patient autonomy, self-diagnosis and self-care choices. The rise of social networks will feature prominently in this realm. Example: Outpatient Physical Therapy.,[object Object],47,[object Object]
Disruptive Innovation,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],48,[object Object]
Disruptive Innovation,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],49,[object Object],Non-physician professionals, like Registered Nurses, Physical Therapists and Physicians Assistants, will tend to disrupt the business practices of primary care physicians,[object Object],Primary care physicians will tend to disrupt the business practices of specialist physicians ,[object Object],Specialist physicians,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],Exercise is generally NOT harmful. Power training.,[object Object],Increased, self-directed activity is essential to reducing disability. ,[object Object],Promote activity: walking, yoga, running, lifting, resistance programs, Zumba, Pilates, gardening, golf, fishing. ,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],50,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],Hurt ≠ Harm. ,[object Object],Emotional/Mental factors may drive 30-55% of musculoskeletal outcomes. ,[object Object],Behavioral training more important than Cognitive training,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],51,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],Adequate physical activity is linked with important health outcomes…,[object Object],Reduced cardiovascular disease,[object Object],Type 2 diabetes,[object Object],Some cancers,[object Object],Future falls risk,[object Object],Osteoporotic fractures,[object Object],Depression,[object Object],Physical function scores on standardized self report measures,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],52,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],Behavior Change Assumptions,[object Object],Education,[object Object],Knowledge,[object Object],Behavior Change,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],53,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],Behavioral interventions MORE effective than educational interventions. ,[object Object],[object Object]
Self-monitoring
Feedback – Functional Scales
Consequences/rewards
Exercise prescription
CuesDownloadable slide show at http://www.BulletproofPT.com,[object Object],54,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],Goals,[object Object],Do single leg standing x 30sec. three times per day to improve balance.,[object Object],Cues,[object Object],First thing in the morning do single leg standing x 30sec. in the kitchen while the coffee percolates.,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],55,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],Educational/cognitive interventions LESS effective at promoting physical activity,[object Object],Targeting knowledge, attitudes or beliefs,[object Object],Mass media (vs. individualized instruction).,[object Object],Train-the-trainer models (vs. staff providing interventions directly to patients). ,[object Object],Idiosyncratic provider interventions (vs. standardized recommendations).,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],56,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],“Medical Theater” ,[object Object],Real treatment effects/outcomes due to some aspect of the medical intervention other than the physiologic effect. NOT a placebo!,[object Object],“A placebo is a substance or procedure…that is objectively without specific activity for the condition being treated…”,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],57,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],What drives outcomes in addition to the intended treatment?,[object Object],Dress: The white coast and stethoscope,[object Object],Language: Medical jargon based in Latin,[object Object],Diagnosis and Expectation: The effect on functional status over time of a diagnosis of “disc degeneration”,[object Object],Cost: More costly medical treatments have a higher cost and a higher perceived benefit,[object Object],Color: Blue pill vs. Red pill study by Blackwell,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],58,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],“Medical Theater”,[object Object],[object Object]
Branded Analgesics for Headache (1981)
Red pill vs. Blue Pill for Mood Alteration (1972)
Internal Mammary Artery Ligation for Chest Pain (1959, 1960)Downloadable slide show at http://www.BulletproofPT.com,[object Object],59,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],“Medical Theater”,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],60,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],“Medical Theater”,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],61,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],“Medical Theater”,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],62,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],“Medical Theater”,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],63,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],Health Coaching,[object Object],Hotspots by AtulGawande, MD featuring Jeffrey Brenner, MD,[object Object],New Yorker magazine article,[object Object],Frontline “Hotspotters” Video,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],64,[object Object]
How Physical Therapists Can Drive Better Outcomes,[object Object],The Six Sources of Influence,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],65,[object Object]
Downloadable slide show at http://www.BulletproofPT.com,[object Object],66,[object Object],How Physical Therapists Can Drive Better Outcomes,[object Object],How to Persuade your Patient,[object Object],[object Object]
Lectured the students: “Use Condoms!” – didn’t work
Had college students make an educational video to teach high school students about protected sex.
Technique worked.
80% of the college students bought condoms immediately and the amount of condoms purchased was greater than a control group.
Technique known as Cognitive Dissonance.,[object Object]
Critical Pathways of Care: ,[object Object],Starbucks/Aetna Saves Money, Improves Outcomes,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],68,[object Object],How Physical Therapists Can Drive Better Outcomes,[object Object]
Costs and Productivity,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],69,[object Object]
Structured Data,[object Object],Structured data is another way of referring to data that is entered into a specific field as opposed to free text in a chart note.,[object Object],60% of the narrative note data is lost to the EMR.,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],70,[object Object]
Structured Data,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],71,[object Object]
Structured Data,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],72,[object Object]
Structured Data,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],73,[object Object]
Structured Data,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],74,[object Object]
Structured Data,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],75,[object Object]
Structured Data,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],76,[object Object]
Structured Data,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],77,[object Object]
Structured Data,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],78,[object Object],[object Object]
Which structured data point is predictive of future disablement?
Which structured data point demonstrates Medical Neccesity for Physical Therapy to initiate a PT POC or to exceed the PT Cap using the –KX modifier?,[object Object]
Structured Data,[object Object],Downloadable slide show at http://www.BulletproofPT.com,[object Object],80,[object Object]
Downloadable slide show at http://www.BulletproofPT.com,[object Object],81,[object Object],Decision Rules,[object Object],CAGE Rule for Alcoholism Screening,[object Object],[object Object]
10% of those who drink have alcohol problems that adversely affect their lives and their families lives.
The mortality rate of those who drink 6 or more drinks per day is 50% than matched controls.
Alcohol is a major factor in suicides, homicides, violent crimes and motor vehicle accidents.
Physicians are about to recognize, without decision aids, only about half of the problem drinkers they encounter.

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How physical therapists can thrive under health care (1)

Notas del editor

  1. Pioneer Accountable Care Organization Model. Available at http://innovations.cms.gov/documents/pdf/Pioneer%20FSG%2005%2023%202011.pdf. Accessed 08/14/2011.Sick Around the World.Frontline. 2008. Available at http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/view/?autoplay
  2. Lakdawalla, D. N., J. Bhattacharya, and D. P. Goldman, Are the Young Becoming More Disabled? Health Affairs, Vol. 23, No. 1, January/February 2004, pp. 168-176.Sturm R, Ringel J, Lakdawalla D, Bhattacharya J, Goldman DP, Hurd M, Joyce GF, Panis C and Andreyeva T. Obesity and Disability: The Shape of Things to Come. Santa Monica, CA: RAND Corporation, 2007. http://www.rand.org/pubs/research_briefs/RB9043-1
  3. Overview Shared Savings Program. Available at https://www.cms.gov/sharedsavingsprogram/. Accessed 08/14/2011.Pioneer Accountable Care Organization Model. Available at http://innovations.cms.gov/documents/pdf/Pioneer%20FSG%2005%2023%202011.pdf. Accessed 08/14/2011.
  4. Rosenthal MB, Cutler DM, Feder J. The ACO Rules - Striking the Balance Between Participation and Transformative Potential. NEngl J Med. 2011;365;e6:p1-3.Consequences of Risk Sharing for ACOs That Accept Two-Sided Risk.The solid blue line indicates the level of shared-savings payments to an ACO (where the line is above the x axis) or obligations to repay Medicare (where the line is below the x axis) as a function of Medicare spending for the population of patients attributed to the ACO. Shared savings are capped at 7.5% of the target, and the ACO receives 60% of any savings above the minimum savings threshold, which is 2% of the target spending level. When Medicare spending exceeds the target, the ACO is obligated to pay 60% of the excess with a similar 2% threshold for payment. Payments to Medicare for excess spending in the ACO are capped at 5% in the first year, and the cap increases by 2.5 percentage points in each of the subsequent 2 years.
  5. Improving Quality of Care for Medicare Patients: Accountable Care Organizations. DHHS – CMS. April 2011. Available at https://www.cms.gov/MLNProducts/downloads/ACO_Quality_Factsheet_ICN906104.pdfCAHPS Clinician survey available at https://www.cahps.ahrq.gov/cahpskit/files/352a-4_AdultSpec_Eng_4pt_V1.pdf
  6. Improving Quality of Care for Medicare Patients: Accountable Care Organizations. DHHS – CMS. April 2011. Available at https://www.cms.gov/MLNProducts/downloads/ACO_Quality_Factsheet_ICN906104.pdf
  7. Smith BA. Physical Therapists’ Make Accurate and Appropriate Discharge Recommendations for Patients Who are Acutely Ill. Phys Ther. May 2010;90(5):693-703.
  8. Deyo RA et al. Trends, Major Medical Complications and Charges Associated with Surgery for Lumbar Spinal Stenosis in Older Adults. JAMA. 2010; 303(13): 1259-1265. Available at http://jama.ama-assn.org/content/303/13/1259.full.pdfResults: Overall, surgical rates declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100 000 beneficiaries. Life threatening complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.95 (95% confidence interval [CI], 2.50-3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74-2.17). Adjusted mean hospital charges for complex fusion procedures were US $80 888 compared with US $23 724 for decompression alone.The problem of “rouge specialists” was discussed at the 6th Annual South Florida Conference Empowering Healthcare, Engaging Consumers of the Florida Health Care Coalition on August 10th, 2011
  9. Medicare Claims Show Overuse for CT Scanning. New York Times by Walt Bogdanich and Jo Craven McGinty. Published: June 17, 2011. Available at http://www.nytimes.com/2011/06/18/health/18radiation.html
  10. Chou R, Qaseem A, Owens DK, Shekelle P. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Ann Intern Med. 2011;154:181-18. Available at http://www.annals.org/content/154/3/181.full.pdf+html
  11. http://www.fiercehealthcare.com/webinars/accountable-care-pilots-lessons-learned-multi-year-demonstrations
  12. http://www.fiercehealthcare.com/webinars/accountable-care-pilots-lessons-learned-multi-year-demonstrations
  13. The good news for clinicians is that we can manage populations the way we have been trained to manage patients, that is, one patient at a time.
  14. http://en.wikipedia.org/wiki/Population_health
  15. http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Practice/Diagnosis.pdf
  16. Tinetti ME et al. Shared Risk Factors for Falls, Incontinence and Functional Dependence: Unifying the Approach to Geriatric Syndromes. JAMA. 1995;273(17):pp1348-1353.
  17. Tinetti ME et al. Shared Risk Factors for Falls, Incontinence and Functional Dependence: Unifying the Approach to Geriatric Syndromes. JAMA. 1995;273(17):pp1348-1353. 927 community-dwelling adults aged 72 years and greater who completed baseline and follow-up examinations.Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and co-morbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.
  18. Stanton TR, Fritz JM, Hancock MJ et al. Evaluation of a Treatment Based Classification Algorithm for Low Back Pain: A Cross Sectional Study. Phys Ther 2011;91(4):pp.496-509.Cleland JA, Mintken PE, Carpenter K, Fritz JM, Glynn P, Whitman J, Childs J. Examination of a Clinical Prediction Rule to Identify Patients with Neck Pain Likely to Benefit from Thoracic Spine Thrust Manipulation and a General Cervical Range-of-Motion Exercise: Multi-center Randomized Clinical Trial. Phys Ther. 2010;90(9): 1239-1250.Whitman JM, Cleland JA et al. Predicting Short Term Response to Thrust and Non-thrust Manipulation and Exercise in Patients Post Inversion Ankle Sprain. JOSPT. March 2009;39(3):188-200.Currier LL et al. Development of a Clinical Prediction Rule to Identify Patients with Knee Pain and Clinical Evidence of Knee OA Who Demonstrate a Favorable Short-term Response to Hip Mobilization. Phys Ther, 2007;87(9):pp.1106-1119.
  19. Heckerling et al. Clinical Prediction Rule for Pulmonary Infiltrates. Ann Int Med. 1990;113(9):664-670. Crackles/Rales are caused by delayed opening of alveoli in deflated regions of pathologically inflammed lung.McGee S. Evidence-based Physical Diagnosis. 2nd ed. 2007. Saunders-Elsevier.The Rational Clinical Examination: Evidence Based Clinical Diagnosis. Simel DL and Rennie D. JAMA Evidence, McGraw-Hill, 2009
  20. Heckerling et al. Clinical Prediction Rule for Pulmonary Infiltrates. Ann Int Med. 1990;113(9):664-670.
  21. Heckerling et al. Clinical Prediction Rule for Pulmonary Infiltrates. Ann Int Med. 1990;113(9):664-670.
  22. According to clinical guidelines, the gold standard for diagnosing pneumonia is the presence of lung infiltrates indicated by chest radiography. The Centre for Evidence Based Medicine. Available at www.cebm.netNiederman DS. Recent advances in community-acquired pneumonia: inpatient and outpatient. Chest. 2007 Apr;131(4):1205-15.
  23. “Although elaborate scoring systems for breath sound intensity and for wheezing have been developed they are not clearly better than the customary normal vs. abnormal dichotomization.” (p.151)The Rational Clinical Examination: Evidence Based Clinical Diagnosis. Simel DL and Rennie D. JAMA Evidence, McGraw-Hill, 2009
  24. The LR is used to assess how good a diagnostic test is and to help in selecting an appropriate diagnostic test(s) or sequence of tests.A LR greater than 1 produces a post-test probability which is higher than the pre-test probability. An LR less than 1 produces a post-test probability which is lower than the pre-test probability. The Centre for Evidence Based Medicine. Available at www.cebm.net
  25. McGee S. Evidence Based Physical Diagnosis, 2nd Ed. 2007. Saunders/Elsevier.
  26. Christensen C. The Innovator’s Prescription. 2009. McGraw-Hill The Survivor. Forbes Magazine. March 14, 2011.
  27. Conn VS et al. Interventions to Increase Physical Activity Among Healthy Adults. Am J Pub Health. 2011; 101(4): 751-758. Meta-analysis of 358 reports of 99,011 patients. Effect size equal to 496 ambulatory steps per day.
  28. Conn VS et al. Interventions to Increase Physical Activity Among Healthy Adults. Am J Pub Health. 2011; 101(4): 751-758. Meta-analysis of 358 reports of 99,011 patients. Effect size equal to 496 ambulatory steps per day.
  29. Moerman DE. Deconstructing the Placebo Effect and Finding the Meaning Response. Ann Int Med. 2002;136: 471-476.
  30. Weschler ME et al. Active Albuterol or Placebo, Sham Acupuncture or No Intervention in Asthma. N Engl J Med. July 2011;365: 119-126.Moerman DE. Deconstructing the Placebo Effect and Finding the Meaning Response. Ann Int Med. 2002;136: 471-476.Blackwell et al. Demonstration to Medical Students of Placebo Responses and non-drug factors. Lancet. 1972;1:1279-82.Cobb et al. An Evaluation of Internal Mammary Artery Ligation by a Double Blind Technic. N Engl J Med. 1959;260:1115-8.
  31. Ingram D, Fell N, Cotton S, Elder S, Hollis L. Patient Preference, Perceived Practicality, and Confidence Associated with Physical Therapist Attire: A Preliminary Study. 2011.HPA Resource / HPA Journal: 11(2); ppJ2-J8.
  32. Ingram D, Fell N, Cotton S, Elder S, Hollis L. Patient Preference, Perceived Practicality, and Confidence Associated with Physical Therapist Attire: A Preliminary Study. 2011.HPA Resource / HPA Journal: 11(2); ppJ2-J8.
  33. Ingram D, Fell N, Cotton S, Elder S, Hollis L. Patient Preference, Perceived Practicality, and Confidence Associated with Physical Therapist Attire: A Preliminary Study. 2011.HPA Resource / HPA Journal: 11(2); ppJ2-J8.
  34. Ingram D, Fell N, Cotton S, Elder S, Hollis L. Patient Preference, Perceived Practicality, and Confidence Associated with Physical Therapist Attire: A Preliminary Study. 2011.HPA Resource / HPA Journal: 11(2); ppJ2-J8.
  35. The Six Sources of Influence (p.78), Influencer: The Power to Change Anything. Patterson et al. 2008, McGraw-Hill, NY.
  36. Tousman S. Patient Engagement: Building Effective Self-Management. 6th Annual South Florida Conference Florida Health Care Coalition. August 10, 2011.Teaching Tip Sheet: Cognitive Dissonance. American Psychological Association. Available at http://www.apa.org/pi/aids/resources/education/dissonance.aspx
  37. Patient Centered Primary Care Collaborative webinar. ACOs: What is all the noise about? July 13th, 2011. Available at http://pcpcc.net/webinar/acos-what-all-noise-about .Doctors respond very well to data that shows INDIVIDUAL (not aggregated) practice variation. These 12 primary care docs were from the SAME PRACTICE and this slide prompted important conversations AMONG DOCTORS that changed their prescribing behaviors and lowered costs. Payers and policymakers should take heed when attempting to influence physicians’ decisions.
  38. A Novel Plan Helps Hospital Wean Itself Off Pricey Tests.Fuhrmans V. WSJ. January 12, 2007
  39. 2009 PT Benchmark Report. HCS Consulting. Available at www.HCSConsulting.com
  40. Stavrinaki K. The Health Story Project: Clinical Narrative and Structured Data in the EHR: Venus and Mars live in Harmony with CDA4CDT. AHIMA Conference, October 2009
  41. SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms), is a systematically organized computer processable collection of medical terminology covering most areas of clinical information such as diseases, findings, procedures, microorganisms, pharmaceuticals etc. It allows a consistent way to index, store, retrieve, and aggregate clinical data across specialties and sites of care. It also helps organizing the content of medical records, reducing the variability in the way data is captured, encoded and used for clinical care of patients and research.
  42. The Rational Clinical Examination: Evidence Based Clinical Diagnosis. Simel DL and Rennie D. JAMA Evidence, McGraw-Hill, 2009
  43. Hippisley-Cox J, Coupland C. Development and validation of risk prediction algorithm (QThrombosis) to estimate future risk of venous thromboembolism: prospective cohort study. BMJ 2011; 343:d4656. doi: 10.1136/bmj.d4656 Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. AHRQ. August 2008. Available at http://www.ahrq.gov/qual/vtguide/
  44. Sixth Annual HealthGrades Patient Safety in American Hospitals Study. April 2009. Available at http://www.healthgrades.com/business/img/PatientSafetyInAmericanHospitalsStudy2009.pdf
  45. Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. AHRQ. August 2008. Available at http://www.ahrq.gov/qual/vtguide/
  46. Hart DL et al. Effect of Fear Avoidance Beliefs of Physical Activities on a Model That Predicts Risk-Adjusted Functional Status Outcomes in Patients Treated for a Lumbar Spine Dysfunction. JOSPT 2011;41(5):pp.336-345.Calley DQ, Jackson S, George SZ. Identifying Patients Fear-Avoidance Beliefs by Physical Therapists Managing Patients with Low Back Pain. JOSPT. 2010:40(12):pp.774-783.
  47. Waddell G et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic LBP and disability. Pain 1993; 52(2): 157-168.
  48. Haggman S, Maher CG, Refshauge KM. Screening for Symptoms of Depression by Physical Therapists Managing Low Back Pain. Phys Ther. 2004; 84:1157-1166.Nemececk D. Integrating Behavioral Health and Primary Care. 6th Annual South Florida Conference Empowering Healthcare, Engaging Consumers of the Florida Health Care Coalition on August 10th, 2011
  49. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and co-morbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.
  50. http://www.apta.org/PQRS/ (APTA log-in required)
  51. Improving Quality of Care for Medicare Patients: Accountable Care Organizations. DHHS – CMS. April 2011. Available at https://www.cms.gov/MLNProducts/downloads/ACO_Quality_Factsheet_ICN906104.pdf
  52. Direct Access: A Check List for Physical Therapist Clinicians. American Physical Therapy Association. Available at http://www.apta.org/DirectAccess/ClinicianChecklist.
  53. Leading Health Indicators for Healthy People 2020: Letter Report. March 2011. Institute of Medicine. Available at http://www.iom.edu/Reports/2011/Leading-Health-Indicators-for-Healthy-People-2020.aspx