Physical Therapy and Lifestyle Management: A Solution for Chronic Disease Participation
Medical Neighborhoods: Physical Therapy, Population Health, and Chronic Disease Management
By Russell Certo, PT
I recently returned home from the 11th Annual Graham Sessions where some of the discussion was related to physical therapy services expanding into the area of population health and chronic disease management. Last year at the 10th Graham Sessions there was plenty of conversation about physical therapists being involved in collaborative efforts with other medical providers to create “medical neighborhoods” to improve community health, now being referred to as population health. I believe these two issues are intertwined and are not mutually exclusive. Medical Fitness, Lifestyle Management, and Lifestyle Medicine are all descriptive terms for similar services.
At the most recent Graham Sessions, two presentations specifically concerned the idea of physical therapy services within population health. The first presentation was a skit that mirrored the popular TV show Shark Tank. In this presentation two therapists presented to the “Sharks” the concept of opening a CrossFit gym with their physical therapy practice as a way to participate in improving the health of their community. As an owner of a practice that has been providing medical fitness services, I have had 14 years of successes and failures. The first piece of advice I would recommend is to stay physical therapy centric, meaning that the physical therapy service is your core business. Don’t try to be a fitness center with a physical therapist embedded. Allow your PT business to drive the fitness model so that you are transitioning patients into your memberships and therefore never discharging income. Second, create your own lifestyle medicine service and integrate it into your practice. Cutting corners by buying a fitness club franchise or partnering with a fitness club is wasting time, energy, and money. Those business models are primarily selling memberships and are not concerned with health.
The second presentation was the ever popular “I Believe” speech, a tradition of the Graham Sessions. Nicole Stout, DPT, gave compelling evidence as to why we as a profession should be leading the charge to deliver appropriate services in terms of exercise and fitness to at-risk populations. Both presentations were extremely well done, and it would be hard for any knowledgeable physical therapist to argue that this profession should not be providing population health services.
Why we should care
As has often been stated in Impact magazine, physical therapists are experts at movement and experts at developing exercise programs for those with chronic disease and dysfunction. In fact, the American Physical Therapy Association’s mission now includes “to further the profession’s role in the prevention, diagnosis, and treatment of movement dysfunctions and the enhancement of the physical health and functional abilities of members of the public.” As often happens with new ideas, business models to capitalize on a culture shift begin to appear. Two years ago nobody spoke about population health. Now population health is the next great elixir to hit health care. Every fringe health care provider is offering some form of community health service. Chiropractors, athletic trainers, and the fitness industry are all trying to be the “expert” in delivering better health through behavioral change. As a profession we can sit back and watch as less skilled providers take away market share and opportunity. The top 10 most costly diseases that drive health care expenditures (e.g., diabetes, cardiovascular) all have evidence that proves exercise is very effective in improving the health of the individual and lowering the total cost of care. The challenge for us is our willingness to step outside of our traditional role of rehabilitation and take our expertise into a world of prevention and meaningful health intervention.
We can all participate
I have been developing a medical fitness and lifestyle management service for the past 14 years. There are a handful of very good therapists in our profession who have been leading in this area for many years. Initially it seemed to me that this service was better suited for the private practice setting than any other service setting. However, I have now come to understand that any physical therapist in just about any setting can deliver meaningful medical fitness services to their patient populations. Private practices and hospital-based practices should be discussing with primary care physicians and groups how to develop and deliver evaluations and treatment plans for chronic disease. Physical therapists working in school systems and with adult patients with disabilities should be adding exercise programs to improve cardiovascular health as well as strength, range of motion, and gait improvements. Physical therapists working in industry providing workers compensation services and pre-employment screenings can provide a much better health and wellness program than most corporations providing employee wellness. The list goes on. If you treat patients, you can do better by providing a treatment plan that includes an overall fitness and exercise program, a plan for nutrition services, and a connection to health care providers we have not previously collaborated with such as behavioral health and sleep centers.
Whether you own a single practice or a large corporate practice with a thousand clinics, you should be adopting medical fitness and lifestyle medicine components as a routine addition to traditional physical therapy. Research out of the University of New England demonstrated that 90 percent of the patients presenting to an outpatient physical therapy facility had one other medical condition that would respond to exercise, and 60 percent had two. The patients for medical fitness services are already in our offices. The American Medical Association in 2009 began encouraging their member physicians to make referrals for medical fitness for their chronic disease patients. In 2015 Medicare began paid “wellness” visits with primary care physicians for all their Medicare patients. This wellness visit is an annual visit outside of the yearly physical to specifically address patients’ activity and lifestyle choices. Starting in 2018, Medicare is paying for prediabetic patients to participate in fitness and exercise programs that are certified to deliver such a program. Where will your primary care referral sources send those patients in need of lifestyle changes? The YMCA, the fitness industry, or some other unqualified provider who markets better than you do. If we don’t see the opportunity, shame on us.
Physical therapy–centric medical fitness is both a place and a service. It is a place where lifestyle management and medical fitness is integrated with traditional physical therapy, a place that delivers evidence-based interventions with appropriate outcome measures. It is a place that attracts the 85 percent of the population that will never join a fitness club. This is a service that solves a problem for primary care physicians who are in desperate need of a collaborative partner with the expertise to assist in managing chronic disease. This intervention, if done appropriately, has proven to reduce the cost of health care for at-risk populations. It has proven that high-risk populations can move to lower-risk pools.
Your question should be “How do I start?” If you are working with primary care doctors or have referral sources that manage chronic disease, I suggest you meet with them and simply ask them if they would support a service you can provide that will design and develop exercise and fitness for chronic disease patients. Will they support a service that will educate and assist patients in making healthier lifestyle choices including nutrition choices? I have yet to hear a physician say they would not support such a service. Then it is up to you to determine what exactly it is your staff will provide. Will you provide medical fitness for diabetes only or will you include obesity and heart disease as well? Is someone on your staff interested in cancer care and would like to work with cancer patients who desperately need exercise during and after cancer treatment? If you provide a women’s health service, it would make sense to provide a lifestyle management program for these patients once the pelvic floor issues are addressed. Once the program is developed and meaningful outcomes are determined, start collecting your outcome data. Data will provide you the opportunity to begin to build a collaborative provider association or medical neighborhood. Our medical neighborhood includes Primary Care, Physical Therapy, Medical Fitness and Lifestyle Management, Behavior Health, Pharmacy, and Dietitian Nutrition and Sleep Center services. We are independent practices that collaborate more like a group practice. We include community-based programs and have become attractive to self-insured companies looking for better health management for their employees.
It may be hard to believe that we as physical therapists can expand our community footprint beyond traditional physical therapy services. Our profession has a long-standing and successful history in solving problems in health care. We have always found ways to effectively provide intervention that improves the quality of people’s lives. Imagine yourself delivering a chronic disease exercise program that improves the biometrics and independence of chronic disease populations. With that success, you find yourself collaborating with primary care physicians to develop your own medical neighborhood. Along the way you obtain reimbursements for your physical therapy–directed medical fitness service. As part of your community outreach, you become the expert in Lifestyle Management and self-insured companies begin talking to you about taking over their employee health and wellness program. Corporations that provide care for adults with disabilities with group homes and adult day care facilities start seeking you out to provide fitness and exercise services to their adult clients. And the Holy Grail, insurance payers begin calling you to refer your medical fitness service to specific diagnostic groups that they spend too much money on. This is happening; you don’t have to imagine it. The challenge for each of us and to the profession as a whole is this: Are you willing to step outside the traditional role of rehabilitation and participate in the evolution of physical therapy?
Russell Certo, PT, is founder of the Medically Oriented Gym (MOG) at Grand Island Physical Therapy in Grand Island, New York. He can reached at firstname.lastname@example.org.