American College of Physicians: Internal Medicine — Doctors for Adults ®

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Refine your referrals to physical rehab with thought, timeliness

From the April ACP Internist, copyright © 2014 by the American College of Physicians

By Stacey Butterfield

Referring a patient to physical rehabilitation takes only a moment, but putting just a bit more thought and time into the referral process can significantly increase the benefits of therapy for patients.

From whom to refer to what to write to how to follow up, therapy experts offered their advice to internists on optimizing rehab referrals.

Evidence supports that occupational therapy can be...

If the number of visits is limited, it may be more effective for a therapist to see a patient once a week for a longer period, with a home program in between visits. Photo by Wavebreak Media



“The major flaw in referral is that [physicians] tend to wait longer than they need to,” said Alberto Esquenazi, MD, chair of the department of physical medicine and rehabilitation at MossRehab in Philadelphia.

“Oftentimes physicians wait until a patient has made a very significant decline in their functional status before referring to therapy,” agreed Amy Lamb, OTD, vice president of the American Occupational Therapy Association and an assistant professor of occupational therapy at Eastern Michigan University in Ann Arbor.

“With occupational therapy, we have an ability to help when we start to see the first signs of decline and are instrumental in preventing decline from occurring, so I think that we’re missing opportunities,” she added. Even patients in the beginnings of cognitive decline may be appropriate for an occupational therapy referral, she added.

For example, she said, evidence supports that occupational therapy is appropriate for patients with chronic diseases, including chronic obstructive pulmonary disease or diabetes, who need help implementing a healthy lifestyle.

As for rehab physicians, they could help more patients with neurological problems or back pain than are typically referred to them, according to Dr. Esquenazi.

Speaking of back pain patients, physical therapists can improve both cost and outcomes if they are involved in treatment sooner, according to Jim Dunleavy, MS, director of rehabilitation services at Trinitas Regional Medical Center in Elizabeth, N.J.

“Don’t be so quick to send them for an MRI,” he said. “In many cases, in low back pain and cervical pain, there’s little or no need for the MRI and it probably delays the start of care.”

A physical therapist may be able to diagnose a patient with a physical exam and begin treatment to relieve his or her pain immediately. If not, the patient can always be sent for imaging later, Mr. Dunleavy said.

On the other hand, some categories of patients should be referred to physical therapy with more restraint, for example, those with chronic pain and those with severe immobility or dementia.

“We want to work with the patient, but we have to show progress,” Mr. Dunleavy said. “We have to show positive change in a reasonable amount of time. Otherwise, we’re going to get dinged [by insurers].”

Insurance issues should also be a consideration in how physicians word their referral to rehabilitation.

“We see a lot of docs who put down on referrals the number of visits per week and the number of weeks,” said Mr. Dunleavy. “In most cases, with the possible exception of Medicare, we have to get authorization for every visit that we do. To say 3 times a week for 4 weeks, I can’t guarantee that. We have to go with what the insurance company is going to give us.”

If the number of visits is limited, it may be more effective for a therapist to see a patient once a week for a longer period, with a home program in between visits. “Medicare and many other insurances are putting a cap on the number of dollars or sessions that can be provided for a particular condition in a given year,” said Dr. Esquenazi.

Rehabilitation clinicians are highly knowledgeable about the insurance limitations affecting their care and the information necessary to justify treatment.

“As a specialist, I can document the need for continued therapy,” said Dr. Esquenazi. “If I am an effective rehabilitation physician, I might know what the charge for rehab is at different facilities and may be able to help the patient and the internist select the most efficient and effective place.”

For these reasons, it may make sense to leave some of the specifics up to the rehab clinician, rather than specifying them in the referral. “I really try to ask our referral sources to just put down ‘evaluate and treat,’” said Mr. Dunleavy.

Dr. Lamb, however, sometimes wishes that referring physicians would get more specific. “A typical referral reads ‘OT eval and treat’ and something that I think is oftentimes overlooked is a home assessment to look at how we can increase the safety of clients in their homes. Or perhaps articulating that they need an ergonomic evaluation of their work station,” she said.

These rehabilitation clinicians’ differences of opinion highlight the importance of an open line of communication between referring physicians and therapists. “On the more complex cases, the dialogue between the therapist and the physician is critical,” said Mr. Dunleavy.

“One of the more frustrating things is when I call a physician and it gets intercepted by somebody in the office and I can’t talk to the doctor. ... If he’s with a bunch of patients, I’m not expecting him to take my call right then and there,” but a return call is important, he said.

“It’s helpful when a physician gives a way to be able to get back in touch with them, however they would prefer,” agreed Dr. Lamb. Electronic communication is fine, as long as it is answered quickly and is HIPAA-compliant, said Mr. Dunleavy, who would ideally like to exchange text messages with referring physicians.

In addition to questions, rehab clinicians may have observations that would be useful to the referring physician.

“If a person comes in to me with a knee problem and as I’m examining them, the patient gets diaphoretic, what else is going on?” said Mr. Dunleavy. “We find a fair number of people who need emergent medical intervention either because they didn’t buy the medication that the doctor gave them or they don’t take it appropriately. Diabetic or hypertensive medication is a biggie in that area.”

Any such medical comorbidities that could affect rehab should be mentioned in a referral. “For example, with back pain, if the patient has a history of cancer and underwent radiation therapy, you want to know that, because that complaint of back pain may be linked to that other diagnosis,” said Dr. Esquenazi.

A sense of team can be facilitated by getting to know rehabilitation clinicians and their work, both individually and as a specialty. “I recommend that [primary care physicians] pick one or two [rehabilitation physicians] that they can develop a good working relationship with, to be sure that those physicians are communicating back to them on the progress of their patients and the needs of their patients,” said Dr. Esquenazi.

That communication should be ongoing during treatment, Dr. Lamb agreed. “If they’re identifying things that the patient is challenged with, we could incorporate that into our treatment,” she said. “We really do enjoy being part of the treatment team.”

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