In recent years there has been a growing interest in the role of

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1 Primary Care Physical Therapy Practice Models Brian P. Murphy, PT, MPT 1 David Greathouse, PT, PhD, ECS 2 Ivan Matsui, PT, FAAOMPT 3 Journal of Orthopaedic & Sports Physical Therapy The purpose of this paper is to provide a brief background on the concept of primary care physical therapy, describe 3 existing models of primary care physical therapy, explore their similarities and differences, and discuss the potential implications and opportunities for the profession. The programs at US Army medical facilities, Kaiser Permanente Northern California, and the Department of Veterans Affairs Salt Lake City Health Care System are presented by the author affiliated with each respective program. J Orthop Sports Phys Ther 2005;35: Key Words: differential diagnosis, direct access, health policy In recent years there has been a growing interest in the role of physical therapists in primary care. 5,12,13,18 But the notion of physical therapists having a role in primary care is not new. In fact, the US Army has utilized physical therapists as primary care providers for neuromusculoskeletal conditions since 1971, with demonstrated successes both in quality of care and cost containment. 12,18 Kaiser Permanente Northern California has similarly utilized physical therapists for these conditions. 35 Several papers have been published that describe utilization of physical therapists as screeners for specialty clinics such as orthopedics, or, as in the US Army, as triage for neuromusculoskeletal disorders. 9,12,18,19,21,23-27,29,35,43,44 In 2002 the American Physical Therapy Association (APTA) House of Delegates (HOD) adopted a resolution that stated, Physical therapists participate in and make unique contributions as individuals or members of primary care teams to the provision of primary care. 6 Since 2002 there has been much debate and controversy regarding this position and its meaning for both individual therapists and the profession at large. The Guide to Physical Therapist Practice 5 also contains language that clearly describes roles for physical therapists in the provision of primary care. The Institute of Medicine has defined primary care as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing within the context of family and community. 22 The American Academy 1 Acting Associate Director, VA Salt Lake City Health Care System, Department of Veterans Affairs, Salt Lake City, UT. 2 Professor and Chairman, School of Physical Therapy, Belmont University, Nashville, TN. 3 Faculty, Kaiser Permanente Hayward Physical Therapy Fellowship in Advanced Orthopedic Manual Therapy, Hayward, CA; Clinical Specialist Adult Primary Care and Supervisor Department of Rehabilitation Services, Kaiser Hayward Medical Center, Hayward, CA. Address correspondence to Brian P. Murphy, VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT brian.murphy@med.va.gov of Family Physicians has recognized that health care is a complex and dynamic environment and that an integrated and interdependent team of health care providers is best suited to meet patient s needs. 1 This is in part due to both the complexity of patient care and ever increasing demands on provider time. In addition, it has been shown that the average primary care provider only spends 20 minutes per visit with the patient. 34 While it is likely that there are many additional instances where physical therapists have some role in primary care, the following 3 models are all well established and specifically claim a primary care role. Each of these models represents a unique practice situation and all offer some ideas that may be applicable to practice elsewhere. The purpose of this paper is to provide a brief background on the concept of primary care physical therapy, describe 3 existing models of primary care physical therapy, explore their similarities and differences, and discuss the potential implications and opportunities for the profession. THE UNITED STATES ARMY MODEL Background The primary mission of United States Army physical therapists is to provide physical therapy evalua- Journal of Orthopaedic & Sports Physical Therapy 699

2 tion and treatment to correct or prevent physical impairments resulting from injury, disease, or preexisting problems. 12,18 Since the early 1970s, Army physical therapists have successfully served as nonphysician health care providers or in a physicianextender role when performing primary care (ie, evaluation and treatment for patients with neuromusculoskeletal conditions). 12,18 Additionally, Army physical therapists serve as technical advisors to commanders of troop units, providing guidance in the areas of physical fitness and wellness, physical training, and injury prevention. In the event of a mass casualty situation, Army physical therapists assist in managing patients categorized as delayed or minor and augment the orthopedic surgery department of the military hospital or clinic. 9,12,18,19,39,37 At present, Army physical therapists continue to serve as nonphysician health care providers in military medical facilities at home and abroad, during peace and conflict. Army physical therapist participation in the evaluation and treatment of patients with neuromusculoskeletal dysfunction first occurred during the Vietnam conflict. 18,19,21,24 The success of the Army physical therapist neuromusculoskeletal experience during this conflict and the shortage of Army orthopedic surgeons following this conflict prompted the expansion of these physical therapist neuromusculoskeletal programs into most Army medical treatment facilities by the early 1970s. 13,18,19 The success of Army physical therapists performing as nonphysician health care providers in the evaluation and treatment of patients with neuromusculoskeletal dysfunction is now well documented. 7,12,16,18,19,26 The historical perspective of the Army physical therapist neuromusculoskeletal model is found in Physical Therapy in a Wartime Environment (Textbook of Military Medicine: Rehabilitation of the Injured Combatant) 19 and Army Medical Specialist Corps 45th Anniversary Commemorative Monograph. 21 The purpose of this section of the manuscript is to describe the role of Army physical therapists as nonphysician health care providers in the evaluation and treatment of patients with neuromusculoskeletal conditions. Model and Clinical Privileges Neuromusculoskeletal Evaluation: Triage Model In the United States Army health care system, the traditional system of triage for patients with neuromusculoskeletal conditions is an initial evaluation and diagnosis by a primary care physician, physician assistant, or nurse practitioner, followed by referral to an orthopedic surgeon, followed by referral to physical therapy for services. The modified system of triage for patients with neuromusculoskeletal problems includes an entry point triage in a physical therapy outpatient clinic, followed by evaluation, diagnosis, and treatment by physical therapists. 12,18 Following initial evaluation by the physical therapist, intervention or treatment of the neuromusculoskeletal dysfunction may occur or an appropriate referral to orthopedic surgery or other medical specialties may be made, as deemed necessary by the physical therapist. 12,18 Entry point personnel to the military health care system are often enlisted corpsmen comparable in skill levels to nurse s aides and licensed practical nurses. These personnel would record vital signs, record the area of complaint, and channel patients with neuromusculoskeletal problems to the physical therapists. Certainly, physicians, physician assistants, podiatrists, dentists, and nurse clinicians would also refer to the physical therapist in the traditional manner. A major concern in both the direct access and referral environments is that patients with serious pathologies that mimic neuromusculoskeletal complaints might be missed. Clearly, the physical therapist s responsibility to their patients is the same in either system. 12,18 Experienced physical therapists, both civilian and military, can recall instances of misdiagnosed or undiagnosed patients that have been referred to them. 8,17,26,31 A perceived strength of the Army neuromusculoskeletal program is the efficiency with which patients with nonmusculoskeletal conditions are recognized and referred to the appropriate medical specialty. 12,18,23,24 The US Army model for providing expeditious and effective evaluation and treatment of patients with neuromusculoskeletal dysfunction is based on a system of quality assurance that involves 3 components: expanded clinical privileges, the use of a physical therapist or physician supervisor, and progressive educational experiences. 12,18 Clinical Privileges Expanded privileges beyond the typical scope of physical therapy practice are mandatory if physical therapists are to efficiently perform neuromusculoskeletal evaluations. In addition to the standard privileges included in the scope of physical therapy practice, Army physical therapists, in accordance with Army Regulations, 37,38 are credentialed to (1) refer patients to radiology for appropriate imaging evaluations (radiographs, MRIs, CT scans, and bone scans), (2) restrict patients to their living quarters for up to 72 hours, (3) restrict work and training for up to 30 days, and (4) refer patients to all medical specialty clinics. In some medical treatment facilities, physical therapists may be credentialed to order certain analgesic and nonsteroidal anti-inflammatory medications. 9,18,37 Credentialing System Implementation of the role that Army physical therapists play in the management of patients with neuromusculoskeletal dysfunction required formalizing extensive training and privileging protocols. The regulation that documents the Army physical therapist practice and the nonphysician health care provider role is Army Regulation (AR) 700 J Orthop Sports Phys Ther Volume 35 Number 11 November 2005

3 40-68 (Clinical Quality Management, 2004). 38 AR (Nonphysician Health care Providers) is the regulation that originally outlined the role of the physical therapist as a nonphysician health care provider, but this regulation has been replaced with AR All physical therapists, both military and civilian, must be credentialed at the Army Medical Department Activity (hospital or clinic) to practice as a physical therapist. The credentialing process includes evaluation of all educational and professional experiences by the chief of the physical therapy clinic and the Credentials Committee of the local medical facility. 38 All military and civilian physical therapists have conditional privileges to practice as a physical therapist for a period of 1 year, with re-evaluation for full privileges to occur at the end of the first year of practice. 38 Army physical therapists that serve as nonphysician health care providers in the evaluation and treatment of patients with neuromusculoskeletal dysfunction must also be credentialed at the Army Medical Department Activity (clinic or hospital) to serve in this role. All educational and professional experiences for the physical therapist to serve as a neuromusculoskeletal evaluator are also evaluated by the chief of the physical therapy clinic and medical facility Credentials Committee. In most cases, there is a 6-month training period that includes additional coursework and clinical experience under the supervision of an Army physical therapist that is credentialed as a nonphysician health care provider for the physical therapist to be approved with full privileges as a neuromusculoskeletal evaluator. In specific cases where an Army physical therapist is the only physical therapist assigned to a clinic or hospital, a physician (typically an orthopaedic surgeon or family practitioner) may serve as the supervisor for these neuromusculoskeletal experiences. 38 Periodic re-evaluation of a physical therapist s credentials by the Chief of Physical Therapy and Credentials Committee occurs on a 2-year cycle. Physical therapists in the US Navy and US Air Force also have a similar credentialing process to function as nonphysician health care providers: Navy Bureau of Medicine Instructions d (March 2003, pages G-28 and G-29, 5-3) and the Air Force Instruction (chapter 6, section 6A, 6.16) Physical Therapist or Physician Supervisor AR requires that a physical therapist or physician supervisor be assigned to physical therapists performing primary neuromusculoskeletal evaluations. 38 This requirement is similar to one used for physician assistants and nurse practitioners serving in expanded roles. The physical therapist supervisor is always credentialed as a nonphysician health care provider in the evaluation and treatment of patients with neuromusculoskeletal dysfunction and is typically the chief physical therapist. The physical therapist or physician supervisor is appointed by the medical facility commander and must be available for consultation in person or by telephone and, if absent, must have an alternate. 38 From the medical commander s point of view, the physical therapist or physician supervisor ensures that physical therapist practice remains within the privileges granted and provides periodic written evaluation of the physical therapist serving as a nonphysician health care provider, and addresses the provider s diagnostic techniques, therapeutic practice, and physical therapy documentation. Orthopedic surgeons and family practice physicians are excellent choices to serve as physician supervisors for physical therapists in situations when there is only 1 Army physical therapist. 18 Physical Therapist Education The US Army has a professional educational program to prepare physical therapists for their role in evaluating and treating patients with neuromusculoskeletal dysfunction. 12,18 The US Army-Baylor University Doctoral Program in Physical Therapy, located at Fort Sam Houston, Texas, is a professional doctoral degree in physical therapy (DPT) program accredited by the Commission on Accreditation for Physical Therapy Education (CAPTE). The US Army-Baylor University Doctoral Program in Physical Therapy has a quad-service mission to prepare professional physical therapists for active duty service in the Army, Navy, Air Force, and Public Health Service. At present, AR specifically states that following their professional education, all Army military and civilian physical therapists, including the US Army- Baylor University Doctoral Program in Physical Therapy program graduates and other Army physical therapists accessed either through the Reserve Officer Training Program (ROTC) or by direct accession, will have a 6-month training period prior to being credentialed as a nonphysician health care provider in the evaluation and treatment of patients with neuromusculoskeletal dysfunction. The physical therapist or physician supervisor evaluates the physical therapist s educational and professional credentials and determines the training program that the physical therapist practitioner must complete to become credentialed as a neuromusculoskeletal evaluator. 38 Additional training experiences may include educational courses in pharmacology, diagnostic imaging and medical screening, as well as a supervised clinical experience by a credentialed physical therapist serving as a nonphysician health care provider. Following successful completion of the educational and clinical phase of neuromusculoskeletal training, the physical therapist is credentialed by the hospital or clinic Credentials Committee to perform in the role of nonphysician J Orthop Sports Phys Ther Volume 35 Number 11 November

4 health care provider in the evaluation and treatment of patients with neuromusculoskeletal dysfunction. 12,18,38 AR is currently being re-evaluated by the Army physical therapy leadership to determine if the educational and clinical experiences of graduates of the US Army-Baylor University Doctoral Program in Physical Therapy and other Doctor of Physical Therapy programs are sufficient to warrant eliminating the 6-month training period before an Army physical therapist may be credentialed as a nonphysician health care provider in evaluating and treating patients with neuromusculoskeletal dysfunction (Personal Communication: Colonel Theresa Schneider, Chief Physical Therapist, US Army). However, according to AR 40-68, the 6-month training period for a physical therapist to be credentialed as a nonphysician health care provider in evaluating and treating patients with neuromusculoskeletal dysfunction is still in effect. 38 Army Model for Neuromusculoskeletal Evaluation: Outcomes The use of US Army physical therapists as nonphysician health care providers in evaluation and treatment of patients with neuromusculoskeletal dysfunction has been an overwhelming success. 8,12,16,18,19,21,26 The advantages of having physical therapists perform neuromusculoskeletal evaluation and treatment in their role as nonphysician health care providers include 9,12,18 (1) prompt evaluation and treatment for patients with neuromusculoskeletal complaints, 9,12,18 (2) promotion of quality health care, 9,12,18 (3) decrease in sick call visits, 9,12,18 (4) more appropriate use of physicians, 9,12,18 and (5) more appropriate use of physical therapist education, training, and experience. 9,12,18 The peacetime utilization of Army physical therapists as primary neuromusculoskeletal screeners was studied by James and Stuart 24 in 1973 and James and Abshier 23 in Both studies confirmed the program s efficiency, effectiveness, and acceptability. More recent studies have demonstrated the efficiency, effectiveness, and acceptance of Army physical therapists serving as primary neuromusculoskeletal screeners in both peace and war, including deployments in Operation Desert Shield and Desert Storm, Bosnia, and Operation Iraqi Freedom. 8,15,16 It is in the best interests of the Army Medical Department not only to get patients better, but to get them better quicker and keep them better. It is interesting that prepaid health care providers, such as the Kaiser system, have their own historical experience yet independently came to the same conclusion as the Army Medical Department. Both systems advocate orthopedic manual therapy as an effective way to evaluate and treat patients with neuromusculoskeletal dysfunction; both consider the use of other modalities as, at most, an adjunct to physical therapy; and both demonstrate that physical therapists with advanced education and training and board certification make superior neuromusculoskeletal evaluators. 12 Conclusion Since its implementation in the early 1970s, the use of Army physical therapists as nonphysician health care providers serving in the evaluation and treatment of patients with neuromusculoskeletal dysfunction has been a resounding success with high acceptance by patients and practitioners. To protect patients and support physical therapists, a system is in place in the US Army Medical Department that includes specialized training, expanded clinical privileges, and the physician supervisor role. KAISER PERMANENTE MODEL Kaiser Permanente was founded in 1945 and was born from the concept adopted by Dr Sydney Garfield and Henry J. Kaiser in the shipyards and other large engineering projects during World War II. Kaiser Permanente currently operates in 5 states serving 8.9 million members and is the largest nonmilitary, not-for-profit health maintenance organization in the United States. 29 Kaiser Permanente Northern California has developed a model of physical therapy practice that is integrated into the primary care environment. The following is a description of this model in practice in the Northern California region that currently serves over 3.2 million members. The model allows physical therapists to be in close proximity to other medical providers through shared clinic space and an integrated referral and medical record system. Another factor related to the success of the model is the fact that clinical management of patients is the responsibility of clinicians. The organization establishes the mission for its membership as a whole (eg, quality, accessibility, affordability, and patient satisfaction), but the health plan does not issue mandates regarding individual clinical care. Physical therapists, in collaboration with a patient s physician or nurse practitioner, practice autonomously within the context of the organization s mission, based on the medical needs of each patient. Evolution of the Primary Care Model In an increasingly competitive market for health care organizations, Kaiser Permanente Northern California undertook a redesign utilizing a multidisciplinary team. A prime driver for Kaiser Permanente Northern California to redesign the adult primary care clinic (APC) was the many prac- 702 J Orthop Sports Phys Ther Volume 35 Number 11 November 2005

5 tice challenges faced by physicians in primary care. Kaiser Permanente Northern California believed that a change in the paradigm for care delivery would improve quality of care, accessibility to care, and patient satisfaction. Instead of having the patient see only a physician or nurse practitioner (NP) initially, Kaiser Permanente Northern California developed referral algorithms that enabled the patient to receive services by other providers as their first contact when appropriate. These included behavioral medicine specialists, clinical health educators, physical therapists, and in some cases, pharmacists. The inclusion of physical therapy services was partly due to the fact that between 20% and 25% of visits to the primary care clinic are for musculoskeletal complaints. 35 Kaiser Permanente Northern California recognized the diagnostic and treatment expertise of physical therapists in managing patients with musculoskeletal conditions/impairments and the potential benefit of making more time available for physicians and nurse practitioners to focus on the management of patients with nonmusculoskeletal conditions. Access to Physical Therapy Services Health plan members may see the physical therapist upon referral after seeing their physician, the physician and physical therapists may jointly consult on a patient during a routine medical examination, or the patient may be scheduled to see a physical therapist directly by a medical advice call center that utilizes a screening algorithm developed by a physician and physical therapist panel. During joint physical therapist/physician examinations, the physical therapist s role may include determining the etiology of musculoskeletal problems, providing input on work modifications, giving instructions for exercise, problem-solving body mechanics, discussing additional diagnostics and/or referrals to other departments, or recommending an appointment with the primary care physical therapist. The regionwide algorithm that determines who may be seen directly by a physical therapist includes (1) age 18 to 65 years, (2) nonindustrial injury, (3) non third-party liability, (4) afebrile, (5) denies chest pain, (6) denies abdominal pain, (7) not seeking medication intervention, and (8) willing to see a physical therapist versus a physician or nurse practitioner. To date, on average, approximately 30% of the patients are seen via this algorithm. Regardless of how the patient accesses the APC physical therapist, there are several components to the primary care physical therapy visit. These may include, but are not limited to: Screening for signs and symptoms that may require referral to and/or consultation with a physician or other provider Efficient historical and physical examination of the patient s primary problem area Consultation/discussion with the physician on the scope of the patient s problem areas to obtain a medical diagnosis and physician signature Manual therapy treatment if indicated Instruction in home exercise/self-management strategies Discussion with the physician on specialty referrals, work readiness, and other patient health issues Of the many experiences that may be unique in the primary care setting, a few will be mentioned. Patient Interview The APC environment, compared to the traditional physical therapy department at Kaiser Permanente Northern California, often has a faster pace (eg, 3 to 5 consecutive evaluations in span of 1.5 to 2 hours). A self-questionnaire is often used to supplement the physical therapist s interview. Patient Types, Acuity Patients seen in APC generally have more acute conditions and are often younger than patients typically seen in the physical therapy department. Many of these patients are part of a population that had not previously been referred to physical therapy because their episode resolved with the first line of intervention administered by the physician or nurse practitioner. This difference in acuity and prognosis of this patient population may be a factor to consider when interpreting literature that compares costs of services for patients seen via direct access versus physician referral. Intervention By design, appointments available for physical therapy in APC are intended to be for patients with more acute presentations. Patients with more chronic and stable conditions are seen in the traditional physical therapy department. The difference in acuity also dictates a difference in treatment intervention. The course of APC physical therapy treatment largely addresses primary sources of symptoms as opposed to focusing on various contributing factors. The initial goals of APC physical therapy are to select the intervention(s) that most quickly reduce the symptoms and disability to a level the patient can self-manage and to select interventions that might minimize recurrence. Most patients receive 1 or 2 physical therapy visits in the primary care clinic. Physical therapists with strong orthopedic manual skills and good teaching ability are ideally suited for this setting. Therapist Preparation for the Primary Care Clinic Kaiser Permanente Northern California developed competencies (eg, continuing education posttests, J Orthop Sports Phys Ther Volume 35 Number 11 November

6 performance evaluations) for the primary care physical therapists, and established a policy that those functioning in this role should have a minimum of 4 years of outpatient orthopedic experience and have demonstrated ability to work with a team. Kaiser Permanente Northern California provides various forms of continuing education in selected practice areas, which include a written exam to ensure competency. This education includes courses on differential diagnosis of musculoskeletal versus nonmusculoskeletal conditions, acute musculoskeletal injuries of peripheral joints, radiological review of plain films and MRI for physical therapists, laboratory values relevant to primary care practice, and pharmacology. Summary In summary, Kaiser Permanente Northern California made a regionwide commitment to change a delivery system when it chose to move physical therapy into primary care. The move toward primary care required physical therapy leadership to envision, advocate, and choreograph physical therapy services within the organization. For physical therapists within Kaiser Permanente Northern California this is the single most important evolution that has occurred in their role as professionals. DEPARTMENT OF VETERANS AFFAIRS SALT LAKE CITY HEALTH CARE SYSTEM (VASLCHCS) MODEL The primary care physical therapy model developed at the VASLCHCS began as an effort to duplicate the model used by the US Army. 12 This decision was based on the experience of one of the physical therapists who had received physical therapy while on active duty in the US Army. However, as the details of the model evolved, it became apparent that a broader approach was needed. In most VA medical centers primary care is delivered by a team that often includes a physician, a dietician, a social worker, and sometimes a psychologist. 27,41 Other providers of specialty care, including physical therapists, are only utilized when there is an additional, perceived need for their services. 41 A central responsibility of primary care is the primary and secondary prevention of diseases that shorten life span and cause debility. 40,41 These include diseases such as diabetes, hypertension, hyperlipidemia, and heart disease. 40,41 These conditions are common in the veteran population and are increasing in the general population due to the rise in obesity and aging. 2,4,20,28,32 Primary and secondary prevention of all of these conditions is usually approached using pharmacological intervention, dietary modification, behavior modification, and exercise. 2,3,10,20 The typical primary care team described above has experts in the first 3 domains, but the team lacks an expert in the domain of exercise/mobility. Because of this, it was determined that the intervention of mobility/exercise was often limited to verbal encouragement from the physician to be more active or walk more, an approach that may limit its effectiveness in adult learners, and did not reflect consideration for the complexity of this patient population. 33 It was felt that physical therapists are uniquely qualified to intervene directly in this area and to address any barriers a patient might have that prevent them from exercising, whether they be integumentary, cardiopulmonary, neurological, or musculoskeletal in nature. In addition to this need for an expert in mobility/ exercise as part of the primary care team described above, it was also determined that patients would frequently present to the primary care or the emergency department with neuromusculoskeletal complaints and receive an immediate referral to orthopedics or neurosurgery departments. This practice contributed to extensive waiting lists for those clinics and delayed the patients access to needed care. Additionally, in many cases, when the patients were finally seen in those clinics, they were simply referred to a physical therapist for conservative treatment. This sort of practice may be due to a lack of adequate training of physicians in musculoskeletal evaluation and has led to a call for changes in physician education. 15 An examination of the nature of the relationship between primary care and the physical therapy department identified a disconnect between them such that the two appeared to operate in isolation rather than in concert to address the patient s needs. To change this relationship it was first necessary to better understand how primary care managed patient care and then educate the primary care providers as to the role physical therapists could play as part of the primary care team. The physical therapists believed that to integrate physical therapy practice with primary care and to truly function as an interdependent health care team, they needed to have at least a fundamental understanding of the health care goals that the primary care providers were trying to achieve. These included the primary and secondary prevention goals for disorders common in this population, such as hypertension, hyperlipidemia, diabetes, and heart disease. There are well-established national guidelines for management of these disorders that the VA has adopted. 36,40 Education Needs A competency assessment tool was developed to ensure a baseline level of clinical knowledge across all domains of practice for all physical therapists. This tool identified knowledge deficits that were later addressed through in-services prior to physical therapists assuming a role in primary care. These knowledge areas included all of the health care goals that 704 J Orthop Sports Phys Ther Volume 35 Number 11 November 2005

7 primary care uses for their patients, diagnostic imaging, screening for nonmusculoskeletal pathology, ECG monitoring, pharmacology, and pathophysiology of chronic disease states such as diabetes, hypertension, and heart disease. Learning the language and goals of primary care was crucial to achieving more open communication between the team members. Learning materials that covered the identified knowledge deficits were developed, which all staff members successfully completed prior to working in the primary care clinics. Access to Physical Therapists in Primary Care The equivalent of 1 full-time physical therapist was allocated for primary care. The responsibility for primary care rotates amongst several staff members on a daily basis. This person carries a digital pager, the number for which is posted prominently in all the clinical spaces in the hospital. If a patient walks into primary care or the emergency room with a neuromusculoskeletal complaint, the triage nurse or provider may page the on-call primary care physical therapist. The patient may be seen in either of those departments, if space/time allows, or may be transported to the dedicated physical therapy clinic. When patients can be collaboratively evaluated in the primary care clinic, it facilitates the learning process of all other team members as to what physical therapists do. Patients may also access physical therapist s services through the hospital s telephone triage system. A patient with a condition appropriate for physical therapy may be directed to report directly to the physical therapy clinic to be seen as a walk-in. The on-call primary care physical therapist will screen the patient for appropriateness, treat the patient, refer the patient to another provider, or treat the patient and refer the patient to another provider as needed. If a patient needs to begin an exercise program, either for weight loss or to enhance the medical treatment of his or her medical condition, the patient is risk-stratified using the American College of Sports Medicine criteria and, if necessary, is given a monitored, graded-exercise test performed by the physical therapist. 14 This test, when indicated, is considered part of the original physical therapy referral. Physical Therapist Practice at the VASLCHCS Physical therapists function as part of an interdependent health care team. They are expected to understand the global patient management that primary care provides, their role, and the roles of all the other team members. This gives them the opportunity to reinforce any patient education that the other members provide, encourages the patients to work toward their goals, and perhaps more importantly, allows the physical therapist to assist the patient s primary care provider in optimally managing the patient s health. This patient care model has been particularly effective in that regard because all physical therapists know and understand the guidelines for management of the most common primary care health problems their patients possess. If a physical therapist identifies a problem area that needs the attention of the primary care provider, they can communicate that need to the primary care provider so that it can be dealt with. Despite initial concerns that the patient s primary care provider might not welcome this feedback, it is to the provider s credit that it was consistently greeted with thanks from the provider and resulted in enhanced patient care. The physical therapists that participated in the development of this program focused on the opportunity to elevate their clinical practice to a more holistic level, rather than confine their focus to neuromusculoskeletal disorders, while educating others about what physical therapists are capable of doing. Convincing the hospital administration and other providers that integrating physical therapy with primary care was a good idea was relatively simple due to the problems of lengthy specialty clinic waits and delays. The primary care providers welcomed the additional support of a physical therapist on the team, due to the limited time they have to see the patient. Initial Outcomes Though the impact of this program on overall patient care has not been formally studied, there were several perceived positive outcomes. All of the physical therapists who participate in this program are required to approach patient care in a more holistic manner that integrates what they do with every other member of the primary care team. By screening patients for orthopedics and neurosurgery prior to referral, the physical therapists were able to assist in reducing the backlog that had existed from greater than 90 days to less than 30. The physical therapists who participated in this program all noted a significant increase in job satisfaction due to the more collegial relationships they shared with other providers, the challenge of working with complex patients in a direct-access manner, and the additional learning that took place during the implementation of, and continued participation in, the program. The success of an interdependent primary care team is highly dependent upon the ability of the team members to communicate. The VA is very fortunate to have a computerized patient record system that allows for chart flags, identifying another provider as a cosigner on a note or order, and bringing important issues to another provider s attention. It also allows any provider, including the physical therapist, to have immediate access to the patient s complete medical record, including other provider s notes, lab J Orthop Sports Phys Ther Volume 35 Number 11 November

8 data, imaging studies, and medication lists. Implementation of this practice model resulted in a rise in the number of referrals for physical therapy by more than 23%, as more providers began to understand the role physical therapists could play in the overall management of the patients. This required additional physical therapists as demand continued to climb. To ensure success, the physical therapists had to first overcome their fear of new and expanded roles and acknowledge and remediate deficits in their academic and clinical training. Despite several years of experience and the possession of strong manual therapy skills, none of the physical therapists who developed this program felt that they were adequately prepared to participate in this primary care model until significant new learning took place. 27 SUMMARY Three unique primary care physical therapy models have been presented. Each represents a practice setting with its own individual opportunities and obstacles to success. The US Army model is by far the most long-lived and well established, both in systemwide acceptance and outcomes research. 7,12,16,18,19 The Kaiser Permanente model has also been in place for a number of years, but with limited published outcomes. 35 These models are similar in that they emphasize screening for medical disease and direct access for neuromusculoskeletal disorders. The VASLCHS model similarly emphasizes screening for medical disease, but goes further in an attempt to define the physical therapist s role in the management of many of the more common medical diseases. The VASLCHCS model does not have true direct access, as the US Army does; yet an expedited referral model has been developed to achieve the same goals as the other 2 programs. There has not yet been any rigorous study of the outcomes of the VASLCHCS. Though these 3 models are all subtly different, they do have many things in common. Each of these programs was developed out of a need or desire to increase efficiency, reduce costs, and improve the delivery of patient care. 7,10,16,22,29 The work by James and Stewart 24 and James and Abshier 23 has validated the achievement of each of these objectives for the US Army and suggests that similar results may be achieved elsewhere. Further study of the other 2 models would be useful in assessing both their current impact on patient care, efficiency, cost containment, and exportability to other settings. All 3 of the models recognized the need to maintain quality care and patient safety. Interestingly, they all identified a range of additional competencies in the academic, clinical, and affective domains that were needed. This was based on the belief, whether valid or not, that current entry-level professional education does not adequately prepare new physical therapists to function in these settings. Further study of these programs may assist in providing an answer. Each of these primary care physical therapy models created a formal mechanism for assessing the competence of their practitioners and developed educational programming to address any identified deficits. It is hoped that, with the changes to physical therapist educational curricula associated with the transition to a doctoral degree, these perceived deficits will be eliminated. Another commonality of each of these models is the uncommon setting that each is in. The US Army and VASLCHCS models both represent a form of socialized medicine not found in the private sector in the United States at this time. Restrictions on practice and payment found in the private sector may limit the exportability of their models. Despite differences in setting and organizational structure, all 3 of these models have a core mission of maintaining highquality patient care in a manner that maximizes the use of the health care dollar. Each may offer insights and opportunities to achieve this that may benefit both the profession and the public. REFERENCES 1. American Academy of Family Physicians. Integrated Practice Arrangements. Available at: org/x6888.xml. Accessed July 18, American Diabetes Association. American Diabetes Association: clinical practice recommendations Diabetes Care. 1999;22 Suppl 1:S American Diabetes Association. Diabetes mellitus and exercise. Diabetes Care. 2001;24 (Supl1):s41-s American Diabetes Association. Economic consequences of diabetes in the US in Diabetes Care. 1993;21: American Physical Therapy Association. Guide to Physical Therapist Practice. Second Edition. Phys Ther. 2001;81: American Physical Therapy Association. Primary Care and the Role of the Physical Therapist (HOD ). 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