iDoes patient centered care conflict with outcome based care?
The current model of payment (fee for service) certainly has the ability to be manipulated without the focus on the patient. Things are time based and technique based. More time, more techniques… means we did more for the patient. (right?) It is easy to see how this can be skewed.
Now I don’t mean to get on a tangent, but motor learning principles support us doing LESS for a patient and having them LEARN for long term outcomes. Our Assessment notes could read “PT provided environment for pt to develop motor solutions. No tactile or verbal cues were given. Pt did the work.” (an exaggeration because knowledge-of-performance and knowledge-of-results are indeed important, but you get my point). Sometimes doing less is better… but how you gonna get paid wit dat?
Enter Outcome Based Care. Focus on customer satisfaction and the outcomes from care.
Let’s just look at the outcomes, for which it is proposed we will be monetarily judged and rewarded.
As an empathetic biopsychoscoial physical therapist I take patient preference quite seriously. I must ask, however, what happens when outcomes are reduced because of patient preference? That can happen now, of course (patient just wants hotpacks and ESTIM) but we are getting paid for time, so we try to limit it, but no significant harm is done to either party. We can bill, the patient gets what they want and it’s likely a gait-way to patient trust in going forward in effective treatment. As long as the treatment is not dangerous or detrimental to the patient’s health, no problem right?
That equation changes when outcomes are the primary focus. Hotpacks never cured a thing. Yes they may relax a patient or you can choose to use it as a reward, but it’s not progress towards an outcome.
Some current scenarios that may affect outcomes: 1) A patient that doesn’t prefer to complete tasks (shown by research to improve their condition) in a timely manner. 2) Patients that have significant co-morbidities that are not picked up on an intake form and easily computed into a payment algorithm (sorry FOTO). 3) Patients that don’t want to get better, they prefer to be taken care of and the benefits of being disabled outweigh a return to function. And, 4) a smaller portion of patients want to litigate their way into prosperity and thereby need to demonstrate worsening physical health.
None of the above scenarios are unique to an outcome based system. But an outcome based system is unique to those scenarios. Outcomes seem to be going towards a bundled payment system, where payment is made in a “bundle” for a specific problem/deficit. I fear the hospital model of surgical care is to be the future. (total knee in the morning, discharged by 4pm to home health). This may work in the hospital because their “outcome” is “new metal parts placed inside body.” Outcome met. Our outcomes are return to function.
Will we try to get them in and out even quicker? (I’m a big fan of creating independent patients, not just in function, but also in recovery management and self efficacy, so a proper discharge is the ultimate goal… jussayin) If we do get them out quicker, who do we pass them to? A hospital PT can refer to home health, inpatient rehab, skilled nursing, home and then to outpatient care… all to lessen their cost burden and continue to “care” for the patient’s recovery needs. Shall we in Outpatient expect to pass down to personal trainers and the like? This topic may be a digression again… but it seems appropriate to the discussion.
Either way, to get back to the patient’s perspective, how do outcomes play into patient thoughts on what care should be? If they don’t care how it goes and just want the end result, well, that might work just fine. Or it might not, since you may not get the outcomes you and they want, so their expectations will not be met.
Contrast that with a patient who wants things done a certain way (lots of explanation, those glenohumeral mobs you do and some ESTIM at the end of treatment). Well, if you get them back to 85% (15% shy of the outcome) they may be more satisfied with care. We have all had patients thank us and recommend us to others even though their specific outcomes were not attained.
Customer satisfaction is whole other conversation… although uniquely and deeply tied to this post. Let’s assume that it’s tied into patient preference, from their perspective, and not worry about how it’s measured from our perspective, for right now.
Perhaps the real problem lies in trying to tie payment to outcomes… in the real world, conversation solves these issues. I can discuss Plan Of Care and it’s merits, make concessions with a patient on scheduling or other experience aspects, etc. A conversation between two people is how the direction of the ship is charted. Where the marketplace finds value in that… well it’s left to be seen.
A good outcome is only patient centered if the patient prefers a good outcome.
Thoughts?…
-Matt D
PTbraintrust 
Matt,
I love the theme.
As a rule, we don’t republish things, but we do run them as original commentary (and then encourage republishing :))
Ed.
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Ed,
Thanks for reading! Can you please explain your comment further, I’m unclear as to your perspective and context, thanks!
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Matt great discussion and I think to your point we have to not only just depend on self-report measures but also need to look at performance test when assessing improvement. Obviously, as you know there are a lot of self-report outcome measures to assess a patient’s perception of improvement. Moreover there are tons of performance tests too. I personally like to use both in measuring success of PT intervention. One can believe that pain tends to influence a patients perception of function. If pain decreases then obviously their function increases. But I have found this to not be the case. I have seen it where patient score high on an self reported outcome measure and still score poorly or show minimal improvement in a performance test. The vice versa of that occurs more often, where patients perceive they aren’t any better, but their function has improved. That is where using both of these measures is valuable to show the patient that they are getting better. I feel that self reported outcome measures are biased by pain. The fact of the matter is using a performance test shows a patient they can actually do something and they feel themselves achieving this because they are actually do it, rather than just filling out some questionnaire and trying to answer a question that they are not sure if they can do. Moreover, since they don’t have pain and they really like us as a PT they might score it higher because they want to be better and they want us to succeed in our treatments too. That score is skewed in a way
Furthermore, using both self report and functional performance test measures give us a better idea of what the patient can really do and how they perceive their overall level of function when performing certain ADL’s. The important thing here is that we as PT’S are using the correct outcome measure and know how to interpret it and correlate those finding to a couple functional performance test such as the 6 min walk test; 40 m self pace test; TUG; Five Times Sit to stand test, SL hop test for distance/ time, piva ecc step step test and the stair test just to name a few and depending on your pt population All this allows us to show our patients that they are improving further proving value of PT and having them “buy in to our treatments.” The fact of the matter is we are soon going to be living in the world of not just pay for performance but pay for outcomes. These outcomes have to be meaningful for us as PT’s, the patient, and insurance company’s. They have to prove our value as PT’s, help us meet our pt’s goals and hopefully we get good reimbursement for our services.
RON MASRI
http://www.totalmotionpt.net
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Thank you for providing a form to discuss a challenging area of patient care. I continue to struggle to provide both evidence based care and patient centered care. My understanding is patient centered care focuses on patient expectations; whereas evidence based care may not meet patient’s expectations.
I agree with Ron Masri regarding the importance of using standardized self-reported disability measures and standardized functional objective performance measures.
It is important to distinguish between satisfaction and engagement. Satisfaction is happiness with the current situation. Engagement is an emotional commitment to the situation. A patient can be very satisfied but not engaged or a patient can be very dissatisfied and highly engaged. There is a growing body of literature developing standardized patient surveys designed to measure the degree of patient engagement. Judith Hibbard has done work developing a “Patient Activation Measure”. Preetinder Singh Gill developed a Patient Engagement Survey for Primary Care Clinic (International Journal of General Medicine 2013:6 85-98) which can be adapted for Physical Therapy.
An ideal comprehensive patient assessment would include standardized self-reported disability measure; standardized functional objective performance measure, documentation of patient’s expectations, standardized self-reported patient engagement measure, and patient satisfaction measure. Given the potential data points we can collect, as James Irrgang PT expressed the opinion in the Paris Distiquished Service Award Lecture (Orthopaedic Practice Vol 27;3-15) “when implementing an outcomes data collection the process you need to carefully consider the amount of information that is being collected. Only that information that is needed to inform clinical decision making and performance and quality improvements initiatives should be collected”.
Damien Howell PT, DPT, OCS
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