So it's just about time, hopefully you can hear me, and welcome. And I feel bad for those folks who haven't quite shown up yet or who may not show up because they're going to miss, or maybe they'll come. Some really important data and discussions in terms of the role of physiatry and the role of physiatry in acute care, really significant. And so we're going to be talking about, you see the title of our talk, Improving Efficiency in Patient Throughput in Acute Care, Demonstrating the Value of Physiatry. That's what we're going to be talking about. And we have four speakers, myself being the fourth. Oh, I'll introduce them in a second. Just some housekeeping first. Forgive me, I meant to say welcome. I think I've done that already. Welcome. Cell phones, please, as you know. Mute them. Evaluation forms, you should fill out. Claim your CME credits. And reminder, visit the pavilion. My duty has been done. So let me introduce our speakers. So I finished my residency in 1999, so I've been around a little bit, and I've enjoyed coming and speaking, and I've been speaking at many conferences, et cetera. I get a little nervous. Of course, we all do when we get up here and stand and see an audience. So Sarah Welch, who I'm going to introduce in a second, is also experienced. She's been through this and understands what it's like to stand up at a podium and has done that many times. Alex, who's sitting towards the end, is a fourth year medical student. And so this is somewhat new. And you understand, because you've been to conferences, and maybe you've presented as well, what it's like as a fourth year medical student. And just personally, I want to congratulate you. Even without saying anything, you've done an amazing job. And we've been working together on this presentation for several months. So Alex Miller-Williams is a fourth year medical student at Vanderbilt University School of Medicine, applying into PM&R this cycle. If anyone is looking for someone, don't look further. Currently undecided on a subspecialty, which is fair enough. In medical school, she's focused on research and other extracurricular activities on PM&R consults, health equity, mentorship, and into professional health care. I asked everyone for sort of a fun fact. And Alex enjoys fishing. I do, too. So it's something we connect on, except I do sea fishing. She does lake fishing. And she's in a competition with her family to see who can get the biggest catch of the year. And still, you're winning? Yeah. Great. Fantastic. So that's Alex. Kelly Mahinchek is also early on in her career. PGY1. Not only a PGY1, but despite the fact that both of our eyes are very much open, you've just come off ICU and nights and flipping and flopping, we remember that, yes? What it's like. So again, to come up here, stand up on a podium, and to present as a PGY1, being so exhausted, again, thank you so much and congratulations for everything you've done just to get here to this point. Great job. Kelly, as I said, a PGY1 and PM&R in the Department of Physical Medicine, Rehabilitation at Vanderbilt University Medical Center, hometown, Baton Rouge, Louisiana, undergraduate, Louisiana State University. There's a theme here, isn't there? A medical school. Louisiana State University Health Sciences Center, New Orleans. As an Englishman, it's hard to say New Orleans. I say New Orleans. But still, I know that's not right. Career plans. Open-minded. Interests include brain injury, cancer, rehabilitation, interventional spinal sports, and maybe if I can influence Kelly, cardiac and pulmonary rehab, which is my world. Fun facts of what she enjoys doing. Watching LSU sports, trying new restaurants and coffee shops, traveling, spending time with my significant other, her significant other, forgive me, not my significant other. And Doc Charlie. And Sarah. Sarah Welsh. If you don't know her, you should know Sarah. Sarah is an up-and-coming physiatrist, very highly thought about, proving herself on many different levels and areas, is currently an assistant professor in the Department of Physical Medicine and Rehabilitation at Vanderbilt University School of Medicine, is an attending physiatrist in the Department of PM&R at Vanderbilt University Medical Center, was a Nashville VA Quality Scholar Fellow, earned her MPH from Vanderbilt University, is a member of the RMSTP program, Rehabilitation Medicine Scientist Training Program. Clinical area, an area of focus include PM&R consults, which is what we're going to talk about today. Health systems researcher at the VAGRECC, if I'm pronouncing that correctly, Tennessee Valley Healthcare System. And her fun fact is she's here for the seafood, which we can understand. We get that. And to be with PM&R friends. And I'm Jonathan Whiteson, I'm one of the professors of Rehabilitation Medicine and Medicine at Rusk Rehabilitation NYU School of Medicine. I'm the Vice Chair for Clinical Operations. I focus a lot on how good a job we're doing in terms of efficiency and how our system works. So this field of potential for physiatry and PM&R is really very important to me. My area of specialty, I'm not sure our slides are projecting. My area of specialty, if I didn't mention already, was cardiac and pulmonary rehabilitation. So I'm a rarity amongst physiatrists. Can we escape from that slideshow? We can. Sorry. It's funny or it's frightening. I had the same issue at my last presentation. Is it me? Jonathan Whiteson. Yeah, that's me. But I'm saying, am I bringing something? No, sir. Okay, good. All right. I apologize for the technical glitch. Hold on. Okay, so we're not going to be able to look at our screens here. Not right now. The next, I'm going to go back to the next, once you go to the next talk, I'll put it back on here. Okay, so, well, I'm just going to show a few slides here, and then we're going to go to Kelly's presentation. Okay, so this, on completion of our session, hopefully you're going to be able to describe the evidence-based value that a physiatrist brings to the acute care hospital setting. We're going to hopefully know how to implement quality improvement tools to enhance the utilization of acute care physiatry consults and demonstrate value to hospital leadership, and then discuss how hospital physiatrist presence broadens the opportunities for health system strategic planning, administrative, and leadership roles. And these are our talks, and you'll see that Sarah is going to partner both with Kelly and Alex as they go through their talks. Kelly's going to kick us off with hospital PM&R consultative care in the United States, where is the data? And then Alex will follow with PM&R consults and elective spine surgeries, a quality improvement project. And then I will conclude with the value of physiatry in acute care and share some experiences from Rusk Rehabilitation. That's where we're going to stop for now. much Dr. Whiteson for those introductions. It's really been an honor to work with you and the rest of the team here, so thank you everyone for joining. What I will be talking about will serve as a background for what these folks will be talking about a little bit later on. I'm going to be laying the foundation as far as what do we have actually already in the literature and how can that be improved. No disclosures. Okay, so overall the medical system, consultative care, it's very expensive. This necessitates us really trying to look at how can we maximize the value of our consultative care. So as far as PM&R in general, we felt, you know, PM&R is pretty well known for our expertise in post-acute care, but there's not too much evidence about PM&R expertise in the hospital setting, and this is actually a really great place for PM&R to affect change in patient outcomes is actually in the hospital setting. So we feel that it's important to look at this. Okay, so we're wondering about what exists about PM&R consults and the literature. We decided that the scoping review would be the best approach. This is an ideal tool. Oh, sorry, thank you. Okay, so the aim of our study was to understand the extent and the type of evidence on PM&R consult services in the U.S. We decided to focus mainly on the U.S. or just upon the U.S. because of the unique, like, healthcare system of the U.S., and so we moved forward with the scoping review because that's an ideal tool to give us an idea of what's out there. Okay, so we worked with a librarian, Sharon Duffy, here at LSU, actually, and she helped us with a couple pilot searches first in PubMed. Sorry, can you guys hear me now? Okay, so we underwent a few preliminary searches that helped us define our search strategy, and Sharon worked with us, and we decided upon some key words that were about the field of study, obviously, PM&R, physiatry, and then the setting we're looking at is inpatient hospital, acute care, and then words that helped us look for, like, papers about consults, so consults, referral, things like that. And then this is just the overall search strategy. So our inclusion-exclusion criteria, we really wanted to focus upon primary peer-reviewed articles that tell us about specifically physiatry in the hospital setting. We excluded papers that were about, had more of, like, a focus on, for example, physical therapy, occupational therapy, anything that was focused on the outpatient setting we excluded. So here's the story of how we went through. We did the search on June 1st of this year across four major databases, which yielded 862 articles, and two of us went through and independently screened by title and abstract. We were able to, most of the papers were excluded from that step alone. Then 46 papers underwent full PDF article review. We had some, some papers that required a tiebreaker, so a third reviewer helped us with that, and ultimately we went, we moved forward with data extraction of 13 articles. And so of those 13 articles, we wanted to map out for you this visual depicting the year of the publication, and over the number of years, you can see the trend is increasing, and we wanted to highlight that the first inpatient rehab unit was opened in 1929, and you can see that there's a lot of time in between where there's not a lot of publications there, and we recognize that this could be due to, you know, some papers may have been missed, you know, maybe some of our databases don't go back quite as far, but this is just an interesting visual representing that there is an increasing interest in this area of research, slightly over time. Okay, so moving forward with data extraction from our 13 articles, we decided that the best way to depict the information we got, because it was very heterogeneous, the, the papers that we selected, and so to organize our thoughts, and Dr. Whiteson really helped us here as far as what should we be looking at here, so there's three main areas of interest here, so service line metrics, these are metrics that are telling you about, just about the console service itself, so things like time to consult, reason for consult, consult follow-up, and then patient measures, where variables such as comorbidities, pain score, patient disposition, you can also think about patient complexity, and then quality indicators, which are things that hospital systems really care about, so readmission rate, health care costs, length of stay, and then you can also put, like, complications of the hospitalization in that category, like pressure injury, DVT, and then we also, we recognize that there is a lot of overlap here, this is just the way that we chose to categorize our data extraction from these articles, so what we did was, from the 13 articles, did these articles look at these variables, yes or no, so from our 13 articles, we also were interested in what subspecialties were represented, so here we have the majority of the articles were about general PM&R consults, and TBI, and stroke, there was one about spinal cord injury, and one about cancer rehab, and then we also looked at study design, most of the articles were retrospective cohorts, and then a few were about prospective cohorts, or the study designs were prospective cohorts, descriptive, and survey, so it was really interesting for us to think about these 13 articles, organizing our thoughts, and what we came up with is that they tended to exist on a spectrum between service-oriented and patient outcomes, and so I just wanted to highlight, and there's a lot of words here for, we can put them up at the end as well for your review, but I just wanted to highlight some of the aims of these papers, so some of them, for example, understand the utilization of, and operational efficiency of the PM&R service, to implement a stroke consult service interventions, huddle rounds, a virtual rounding tool, determine the utility of PM&R-led stroke consult service, all the way over to more of like the patient outcomes, investigate the impacts of their consult service on acute care length of stay, so those are just some of the examples I wanted to highlight, and by the same nature of that, I wanted to highlight some of the key findings, again, existing on the spectrum between just talking about description of their service, so for example, utilization of an inpatient consult service appears to be dependent upon service delivery format, the visiting consultation program has been established, all the way over to more patient outcomes focused, so things like physiatrists are integral members of the trauma care team, patients receiving PM&R consult had more severe injuries, lower acute discharge PIM score, longer lengths of stay, so going back to, and I'll actually go back and show the Venn diagram we showed of the variables for our data extraction, just to remind you of them, and taking into account the colors, and we can move forward to the results table again, and so what we did was we mapped the papers that we selected along the bottom, based upon their year of publication, and then we have the categories of the variables along the y-axis, and the darker the color, the more variables they took into account, and so as you can tell, in general, over time, some of the more recently published papers are tending to move, at least in this good direction we feel, of like taking into account some more of these variables over time. While we were going through the articles, we also wanted to just highlight some of the interesting variables that were, maybe it was just one article that looked at it, things like complication reduction would be interesting to look at, just description of the service model, because what we're seeing is that there's a wide variety of different ways that these console services operate, and then one or two of the papers specifically listed recommendations made by PM&R. These are just variables to talk about, and so in conclusion, there is a heterogeneity of data that exists that makes it hard to really come up with like strong, hard conclusions. However, we can conclude that there just isn't much data there, but what we think is that the data likely exists, it's just not being analyzed or organized in such a way that it can inform practice. All right, and so future directions, we just wanted to throw these up kind of as like talking points and discussion points for the end of the talk, and then of course I wanted to show the actual papers that were chosen for this project. Okay, and that is me exploring a park in Georgia, and so now Dr. Welch and Alex have a very interesting project to share that's like QI related about our console service at Vanderbilt. Can everybody hear me okay? All right. So I'm Sarah Welch. I had the pleasure of mentoring two medical students who are fourth-year medical students applying for PM&R on their quality improvement project, which Vanderbilt Medical Center has quite a course that I've been able to kind of mentor students on in this. And those two students are Alex Williams and Trevor Inessi. And in this project we worked with our spine surgical team at Vanderbilt to kind of look more closely at our consult service. And so that's what we're going to be talking about today. We have nothing to disclose. And I'll just give you a little bit of a background on our consult service currently to kind of lay the stage. So our PM&R consult team consists of two attending physicians who staff patients in the afternoons. We have one PGY-3 or PGY-4 resident that switches monthly. They are the frontline responder during the day on our consult service. This is somewhat similar to many of the other consult services that exist at Vanderbilt. So we kind of fit into the culture in that way. And as we've been working and growing as an academic department at Vanderbilt and trying to kind of look at our consult service more closely, we've developed this perception that we're consulted too late during the hospital stay to make an impact. And so I pulled data on this to kind of validate my own feelings about this. And we found that our time to PM&R consult in days from April through July in the hospital had a median of seven days. And many of you may experience similar. We'll be interested to talk about that later. But because of this, we felt like we had something that we could move forward on. And we decided we would focus in on just one team. That way we could, you know, do some quality improvement work that would hopefully be more effective and learn from it. So the team that we decided to work with is the surgical spine team. We feel that they're really good stakeholders. They actually approached us mentioning that they value us for our disposition efficiency and they feel that they are able to get insurance authorization faster if they have their PM&R consult note in. So this is their team structure. We worked most directly with the seven spine APPs. They're really the frontline workers on the team and they're the ones who put in the consults. So we felt it was good to work with them. But we also do have support from the surgeons on the team. They approached us wanting to look more into a PROMIS physical function measure, which is a measure that they were already getting in their preoperative outpatient clinic. So to look a little bit more at the PROMIS measure, it's a patient reported outcome and the team feels that patients who have a PROMIS score less than 30, so over on the right in that severe category, are likely to need post-acute care following their discharge. We did our own literature search on this and we did find evidence suggesting that there is a correlation between low PROMIS score and post-acute care discharge. Though we did note that most of the available studies are on patients who are undergoing very large spine surgeries. So we took the feedback from the spine team about the PROMIS physical function score and we pulled some baseline data. So we pulled six weeks of patients with elective spine surgeries who'd had a low PROMIS score and we found that in those six weeks there had been 17 patients. Out of those 17 patients, six were discharged to post-acute care. There were no differences in characteristics between those who discharged to post-acute care and those who did not, not statistically significant anyway, except for the AMPAC functional score measured by PT and OT post-operatively. Out of those six who discharged to post-acute care, one PM&R consult was placed. The time to consult was seven days and we counted up medically ready days, avoidable days, and there were eight in this cohort. So I'm going to tell you a little bit more about that. So this is kind of a just new measure that we created almost as like a surrogate for length of stay. So essentially this is a physiatrist doing a chart review retrospectively identifying when the patient was medically ready to discharge by reviewing notes and you know from teams and case management etc. We felt this might be a better marker instead of trying to actually change length of stay. Maybe this is something that a physiatrist could impact. So we set out our aims for this initial part of our quality improvement study to be increasing the percent of screened patients who got a PM&R consult. Longer term objectives were to decrease the time to PM&R consult and decrease the number of those avoidable days. Secondary aim was to develop and refine our screening criteria for PM&R consults among those post-operative spine patients. And so for this project we use the Institute for Healthcare Improvements model for improvement and that includes PDSA cycles. For our workflow, that's here, we had we used a manual screener who would log on to our EMR and access the patient lists every weekday morning and they would screen patients. For every patient that screened positive they would text us by an APP team phone. The APP was then able to decide whether they wanted to consult PM&R for that patient or not and then for the patients that were consulted we were able to retroactively collect our outcome and balance measures via chart review. So outcome measures, those are the measures looking at the aims that we just mentioned and then balance measures are variables assessing for any unintended consequences of our intervention. And so to look at PDSA 1 more specifically, our screening criteria. One, it needed to be an elective spine surgery. So we defined elective as non-urgent, the patient did not come in through the ED and then the surgery was not for an infection clearing or any tumor removal. Promise score needed to be below 30 and then the post-op initial PTOT recommendation was for post-acute care. The balance measure that we collected for PDSA 1 was time spent screening patients by our manual screener and then our outcome measure was the percent of positively screened patients who actually received a PM&R consult. So let's see what we found. For time spent screening patients overall, we averaged between 15 and 20 minutes spent per day by that screener. And then for our outcome measures, we plotted this using a p-chart because we wanted to show the proportion of positively screened patients who received a PM&R consult. So that upper red line, that's if a value is there, a hundred percent of the positively screened patients received a consult. And then if a value is down at zero, then none of the positively screened patients received a consult. That middle line you see there, that central line, that's the average. So in the gold box we see PDSA 1 and we had one patient who screened positive and they did not receive a PM&R consult. So because of the low number, we decided to rethink our screening criteria for PDSA 2. Okay, so we kind of went back to the drawing board after that and you might remember me saying that we looked at our baseline patients and the only thing that they differed in was their ANPAC functional score. And if you're not familiar with ANPAC, it's a, you know, a great measure that's been shown to be predictive of discharge disposition, destination. So based on a first therapy evaluation from PT and OT in the hospital. And so we kind of just went back to this and said, well, we'll pull, you know, PT does basic mobility domains, six clicks, you can see kind of the domains that they look at there, and then OT does, you know, our ADLs. Six clicks scores fall on a 6 to 24 range points. Typically if you're like below 17, you're probably going to need post-acute care. And this is a great, reliable, valid measure many hospitals are using now. So we kind of trashed the promise for this cycle and instead our screen was elective spine surgery and a post-op initial ANPAC scoring of less than or equal to 16 for both PT and OT. Our balance measure did change as well, so we were hoping we were going to get higher numbers this time and so we decided we would actually get feedback from the PM&R consult team on the consults that would hopefully come in. And so you can see this worked. We had 16 patients screened in and 14 of them were consulted on. Here's our balance measure, our survey feedback from the physicians. The physicians were PGY-3, a PGY-4, and an attending physician. On 14 of those patient encounters, they helped with both medical management and disposition planning. They felt that the amount of time that the consults took them was about normal to very little. And then they felt that those consults that came in were appropriate, that they added value to the hospital stay, the majority did, and they felt like they did not collaborate with the primary team in caring for this patient. So that was helpful feedback for us to take to think through what we were going to do in PDSA-3. And so for PDSA-3, we kept most of our measures the same. What we did change were our balance measures. So we added on getting some feedback from the primary team, APPs, and the case manager that works with all of those patients. So for PDSA-3, it's actually still ongoing. We're in our final week of screening right now, but this is what we have so far. So 16 patients have screened in and 11 have been consulted on. So not quite as good as PDSA-2. And then for our balance measures, I actually interviewed the residents, spine APPs, and case manager. The residents gave us feedback that was very similar to the feedback they provided us in PDSA-2. For my interviews with the spine APPs, they also felt that the consults were very appropriate and that they felt that they were useful for both medical management and disposition placement. Like the consult residents, they did note a lack of collaboration between the two teams, and they noted that that caused some confusion in our QI process for them. And then speaking with the case manager, she really stressed the importance of getting our consult notes in as early as possible. She felt that even before the PT and OT notes are in would be best so that they can be included in that initial round of insurance authorization requests. She did feel that as we have them now coming in after that they are typically very helpful for the second round. And then we also wanted to compare the patients in the study that the APPs did decide to consult us on versus the ones that the APPs did not decide to consult us on to see if those populations are different. For the most part, they're pretty similar in demographics, but some differences that we did note were the PROMIS scores were different, the discharge to post acute care more likely in those that we did receive a consult in, and then the avoidable days was different as well. Not statistically significant, but we did note that the hospital length of stay was higher in the patients that we were consulted on. So now it's time that we revisit the aims that we set out in the beginning and kind of review our results and future directions. So our primary aim that you guys keep seeing this p-chart on, our primary aim was to increase the percent of screened patients who got a PM&R consult, and we have done that. There's still a lot of work to do, but this is kind of where things are at at this very moment. And when we look at our aim two and three, as I mentioned in the beginning, these are our longer-term aims that we already know are going to take some time. And so this is just kind of a trend in PDSA cycle two and three in terms of our time to consult, so time between admission and consult order. The table at the bottom is showing that initial data pull we did on the entire hospital. We were not able to tease out the spine team specifically for that, and so that's just important that I mention that the median of seven days for all consults might differ a little bit from the spine team. But when we look at PDSA two and three specific to our spine team, it was about the same. We had a median of three days and time to consult. And then for our measure of number of avoidable days, you know, we're hopeful that again with time this will improve, but specifically we're hopeful that maybe this will improve if we continue to work on our time to consult. Many of the patients, one of the things we're going to be looking at is that many of the patients who had, you know, time to consult of four days also happened to have three or four days that were avoidable days. So it might be kind of interesting to look at that in the future. So in conclusion, avoidable days may be a useful new measure that, you know, we can think about and talk about at the end to use as like a surrogate for length of stay to use in our consultative work. And overall our consults from both teams were felt to be helpful with medical management and discharge planning. But of course there is a selection bias. Our PM&R patients do tend to be harder discharges, have longer lengths of stay, you know, more avoidable days. So always have to take that into account. So we do want to, so we do want to acknowledge some of the limitations of our study. First, like we just mentioned, it's a small bias sample. Second, we use human screeners, so there's a possibility of human error with that. And then thirdly, the feedback for our balance measures for PDSA 2 and 3 was not anonymous, so there is the possibility that some of those answers were kind of filtered. So some learning points that we wanted to highlight. First, for screening, we do feel that the AMPAC is a more useful measure for our purposes than the PROMIS score. And then collaborations. Both the primary team and our consult team noted lack of collaboration and some confusion about the process. So we think by increasing our transparency and working on that, we can improve our buy-in in the future. Some other things that we want to work on in the future. One, we want to continue to collect data. We want to do more PDSA cycles. We also want to focus on education, both on, both for the primary team and for our consult team on the utility of these consults. And then we want to also focus on getting earlier consults in. So two things we're thinking about for that are the possibility of automated alerts in our EMR and then also considering taking the AMPAC score preoperatively. So thank you for listening to us. This is Trevor and I. Trevor is hiking in Gatlinburg and I'm hiking up Mount Kenya. Now I feel bad. I don't have a photograph of me hiking anywhere. Sorry. All right, I'm double multitasking here, but here we go. So I'm going to—I'll try, if I'm messing up, I'm going to pass it to you, I promise you. But, you know, we've heard about a literature review, which really didn't show very much data and tells us that there's a lot of work, potential work, that we can do. And we've heard about some QI improvement projects, which really, you know, try to quantify what we are all experiencing and produce something that can be publishable, that can fill that gap in the literature. And I'm going to present sort of, I guess, a real-world experience, what we've been experiencing at Rusk, not having done a literature review, not having done any research, but feeling this potential, but also the consequences of not having a coordinated consult service. So hopefully this will resonate and bring all that we've discussed into some focus. I have nothing to disclose. My overview, we're going to highlight the value of physiatrists in the hospital system. We know it. We hear it from Steve at the plenary, but we've got to really highlight that. We want to review opportunities to build collaboration. As you heard, when there's no collaboration, when there's no communication, there's an issue there, there's a breakdown. How do we formalize hospital consultative processes and programs? And how does the presence of physiatry broaden the opportunities for health system strategic planning, administrative, and leadership roles? What's in it for us as physiatrists in our day-to-day practice, and what's in it for our departments in the field of PM&R? So I think we need to just go back to this term that you hear about, that's talked about, and that we're getting more and more familiar with, which is value-based care, this sort of triple aim of healthcare, although at the plenary we heard the fourth aim, which is taking care of us, the docs. I get that, and I don't mean to overlook that at all, but I didn't have time to change my slides. Triple aim, so we want to improve outcomes, we want to improve the outcomes for our patients, and that's sort of somewhat, you know, we look at that through metrics. We want the improved patient experience. We know they report out and they get sent surveys on how they've experienced the system and they rank us in terms of all elements of the care that we provide. And we want to do a better job in less time, and somewhat for the same or even less money. How can we save the health system money or avoid unnecessary expenditure? So that's the triple aim of healthcare, and we as physiatrists are essential to that through the continuum of care, right from the ER or the ICU through acute care setting, post-acute setting, into the outpatient setting or home care, and then outpatient setting, the community. We are essential in that process. We can't just say it. We have to show it. We have to prove it. But this is what value-based care is all about. So what about that continuum of care? And I've used this before because I love The Wizard of Oz. I wish I had a pair of ruby red slippers and I would click my heels because there is no place like home. So forgive the film detour. But we do want to get our patients from the hospital system, from the acute care setting, out into the community, into the outpatient setting, into the community setting. We need to find our own ruby red slippers so we can click and make sure our patients are getting just what they want. So when we think about it, what are the opportunities? What is the role that the physiatrist can take in the acute care setting? Well, think of it not just as an individual, but think of it as a service, that we're going representing the continuum of care and all the expertise that there is. And we take many, many skills to the acute care setting. Many of the patients that we see are going to have pain, and who better to manage pain than physiatrists? Spasticity is another example. Who best to prescribe that therapy and to guide the therapist? And I so agree that, you know, with the case manager who said it would be great if we had the physiatrist consult before the therapists were there. Of course. Why? Because you can put in an order, please see and treat, which is what a lot of our acute care teams do, but you cannot nuance that if you don't understand the field of physical medicine rehabilitation as physiatrists are trained to do. So we need to take that under our care, and we need to prescribe those therapies and guide those therapies. And we also recognize that we are excellent in care of these special populations, brain injury patients, patients with spinal cord injury, the patients with oncologic disease, trauma, musculoskeletal disorders, cardiac and pulmonary disease, which is what I take care of. So we really do play a role in managing the care of the patient at the bedside. What about disposition planning? Acute care teams, and I'm being a little cynical and a little unfair because it's less crude than this, they want the patient out. Of course they want the patient off their service. They don't care where the patient goes. Of course they do, but we are great at disposition planning. We see the whole picture. We see the psychosocial issue, the family issue, the home care issue, the functional issue, the safety issue, the medical issue. We take it all into account. The wound hasn't the hiss to get the patient out of here. No. We know better than that. And so disposition planning is something that we can be really engaged with and should take that on. Why not? Our consultative physiatrists should be able to take that on. I will take care of the disposition. I'll help your patient get out of here quickly, wherever they go to. And then we can discover or discuss and develop special programs. And at Rusk we've worked on this in many different areas, but one of them specifically, which we'll talk about in a little bit, is our ICU early mobilization program. But why shouldn't physiatry be there in the acute care setting, standing back, looking at the 10,000-foot view and say, this is what we can do. This is what we can bring to the efficiency of the system here. If you get on with your medical management, your surgical management, we will manage the throughput of these patients. So let's go to our experience at Rusk, and I'm going to talk from our own personal experience here. So we recognized when we looked at our data that we had, for our patients, a long length of stay for those patients who were coming to Rusk. And it was a complaint of all of our acute care services. It takes too long for our patients to get into inpatient rehab. And so we had to try and understand what that was, what were the causal factors. We understood by talking to ourselves and talking to our colleagues that there was limited understanding by our acute care providers of what we did as physiatrists. Like Steve said at the plenary, we were the best-kept secret in some places, and sometimes we're still the best-kept secret. And we need to do our best to let our acute care colleagues know what we can do, help them understand our scope of practice, what we can take on. We also realized that we had an underdeveloped physiatric consult process. There were many ways to call a consult, by tugging on the elbow, by sending a carrier pigeon, by texting, by phone call, I bumped into you in the elevator, multiple different ways. So nobody quite knew how best to call a consult. When we looked at the content of the consult note, all the physiatrists, everyone who did consultations, they all said something different. What they wanted to say, some of it had great relevance. There were a lot of tests and investigations that took a long time to scroll through, but we had no standardization. We also didn't know how long it took for our physiatrists to complete their consults. And they may see a patient in the morning, but not until the following day would they actually finish the note and put it so everyone else could read it. So it was delayed. We were delayed in being called, just like has been experienced at Vanderbilt, and we were guilty of delays in completion. And we didn't know what was going on. We weren't collecting data, we weren't collecting metrics, we had no idea how long this was taking or what the pain points were as we broke down the process. So what about our solutions? Education, communication. Of course, we had to educate ourselves, but we also had to educate the acute care teams. And as one of my colleagues says, we went on a dog and pony show. We went around and around and around. Have you ever painted the Brooklyn Bridge, which I haven't? Once you finish, you go back and start again, and when you finish, you start again. And that's what we have to do, and that's what we continue to do. Why? Because a lot of the nurses or nurse practitioners or residents, they turn over. The attending physicians, they don't turn over, hopefully. The surgeons, they're in the OR. So we need to go back and back and back and back again to continue the education and ongoing education. We need to establish some goals of our consult service, so our physiatrists who were doing consultations, we needed to educate them and set some goals that they needed to achieve. Timeliness was really important. You get a consult, you need to complete that consult. We set a time, and it wasn't arbitrary, it had some relevance, of 16 hours. From the time of consult, from the time of order, should I say, complete the consult within 16 hours. You know, our physicians weren't always present on the floor. If a consult came in at 5 o'clock in the evening, did we expect them to go back and do the consult if they were now in office hours or out of the hospital? So we gave them a little bit of wiggle room, but 16 hours, that was the time we set. When we refined the physiatric consult service, we've actually developed what we call a career path. This is a career job. This is not just something I dabble in or something I have to do because I'm on service this week or whatever. This is something that we looked to create as a pivotal position and hire someone into it. You will do consults, you will be that pivot person from the acute care team to our inpatient team or to discharge home. And so we created that career, that job description, I'll show you that in a moment. And we also worked on developing our note templates so we had consistency in terms of what we were asking our physiatrists to look for, to ask for, and to document. And we developed tools as well to track. So this is the process. This is the process of our consultation. And we had to break this down because otherwise we couldn't measure where the block or sticking points were. So the acute care team identifies patients early. And we kept on saying early, don't wait, please don't wait, get our physiatrists in there early, early, early. We'll see them in the ER, we'll see them in the ICU, we don't care if they're on ventilators or sedated, we'll come back, but get us involved early. And you may not need to know if they're going to go home or not go home, doesn't matter. We want to be involved early. So it was changing a culture. We wanted the order to be placed in the electronic medical record. Why? That started the time clock for that 16 hours. And we also wanted it to be placed by service or by category because we have different physiatrists who are expert in different areas. So a neurologic physiatrist or a physiatrist expert in neurologic disease may not have the same skill or technicality when it comes to seeing a patient who's had a lung transplant or a heart transplant and vice versa. So we sort of broke down into these sort of different categories of neurologic, orthopedic, cardiac and pulmonary pain, oncologic, et cetera. But that was the way that the orders were placed into the electronic system. And it was also tagged to an early warning to our admitting department. They didn't act on it, but when a consult went into a physiatrist, our admitting department was notified, this patient may be coming your way. They just kept the list. They were made aware. The consult physiatrist, we said to our consult physiatrist, keep refreshing your list. Every 10 minutes, every hour, you know, three or four times a day, check your list, check your list, check your list. As soon as that consult hits your list, we want you to go and see that patient as soon as you can. And so the consult physiatrist would check and they would add that patient to their list. They would take the consult under their wing. They had the 16 hours to complete. And complete meant from the time of order until the time they sign off on their note. Everything has to be in. The orders have to be in. Everything has to be done within 16 hours. We set a target of 80% within 16 hours. And that note had to use the template that we designed and had to be directive. And directive, essentially, this patient is a candidate for post-acute care, skilled nursing facility, or IRF, or this patient's a candidate for home. And it's okay. We may not get it right and we didn't get it right all the time and we did change our minds, you know, as the patient either progressed or regressed. But we wanted that note to be directive so that acute care teams knew what they needed to do. If the patient was not slated for going home and we didn't have to know exactly, then we completed that electronic order to our admitting department. That triggered the insurance authorization. That triggered the review by our admitting team to make sure all the I's were dotted and the T's were crossed. We had all the information we needed. A discussion with family members and started to think about disposition to home so that we could get our patients home and what may be the potential barriers. The consult physiatrist started an electronic medical record chat. The chat was important because it solidified the discussions that were going on, but we also encouraged them to speak face-to-face with the acute care teams. But that communication, that collaboration that's already been mentioned, was really very essential. And we told our physiatrist, you've got to follow up and you've got to follow up as needed. But two, three times a week is not overkill. And if you need to follow up with the patient every day because things are changing quickly, follow up with the patient. It's justifiable. So we needed the data. And so we developed and designed tracking tools and metrics that we could look at and we could watch over the course of time. So just going through this quickly, that's the number of consults, that's the notes completed on time, that's the average time it took to complete the consult, and the median time to complete the consult. As I said, you can see from the targets here, if it's pointing, there we go, that's 80% within 16 hours. And this was 12 hours in terms of the average time and 12 hours in terms of the median time as well. So we're sort of lucky because we're a program in evolution and growth. And we took over a new hospital. And so we were able to collect data from that system, that acute care system, where we didn't have a dedicated consult physiatrist. And we compared it to data when we did have a consult physiatrist, so a dedicated consult physiatrist. So you can see here that the percentage of notes completed on time, 47%. The average hour is close to 20 hours, and the median hour is close to 16 hours. So not doing a very good job without a dedicated consult physiatrist. It means we had a consult physiatrist, but they weren't dedicated. They were doing other things as well, inpatient work, outpatient work, skilled nursing facility work. So they weren't their dedicated job. But look at the difference when you have a dedicated consult physiatrist who goes to work, whatever time it is, 7, 8 o'clock in the morning, they live in the acute care system, they stay there all day, and they leave there in the evening. That's their home, 70%. So not quite at 80%. We're moving in that direction. We're not perfect, far from it. But we're learning, and we're doing better still. So up to 80%. Average hours down to 9 hours. Median time, 4 hours. A significant difference when you have a dedicated consult physiatrist. We're also able to look at our data by service, and we're also able, but I blocked this out, just mentioning no names, we're also able to look at it by physician as well. So each physician can be a each physiatrist who is involved with the consult service Can be accountable for their own data and this comes up in their annual reviews This is important metrics to the department and to the institution So this was the more data from that new service that we created you can see here starting in 2019 We had very few consults all the way through to to the the fiscal year up to 590 consults In an annual basis, so our consult service is vibrant and is growing and this is some of the data that I'll just read off to you because it really rings true and shows the Value that we provide 16% decrease in 30-day unplanned readmissions on the neuro neuro surge patients Who had a physiatry consult versus those who did not 16% decrease in 30-day unplanned readmission. That's great More than 13 readmissions may have been prevented if a physiatry consult have been called significant dollar savings patients who went to An inpatient rehabilitation facility if they had a physio physiatric consult close to four days four days reduction in length of stay that incredible Could have yielded a hundred and ninety seven incremental discharges and admissions by creating those extra beds 36% increase in admissions to our rehabilitation facility Okay, as opposed to other rehabilitation facilities our physiatrist said Listen come go to Rusk. That's where you should be as opposed to us losing them to other health systems Without a dedicated physiatrist on the consult service you saw 16 close to 17 hours the median time to consult with the dedicated consult physiatrist for hours and change And this results in a faster transition to a post-acute care 40% of the readmissions on the neurosurge service related to falls Who knows about falls if it's not physiatry and who knows how to prevent falls if it's not us? And patients seen by the physiatrist on the consult service are more likely to thought be followed up by an NY Physiatrist in the outpatient clinic. So all this really does make sense So this is the data another way of looking at the data and this is how we sort of broke down that consult service So this is the time that it takes from hospital admission to the physiatry consult and we want to turn our You know our our color scheme here from sort of red and orange, which is slow to yellow and green Which is obviously moving in a quicker Direction so, you know again still work to be done for us This is still an evolution But these are the kinds of things that we're looking at how long does it take for that? consult order to go in how long does it take from that physiatrist consult order to go in for for the for the For the consult to be signed What about the discordance between the acute care team when they say the patient is medically ready? Versus our rehab team when they say it's medically ready, you know again the surgeon says the wound is is not draining the patient's fine and We say well that fever is 102 and the white count is 17 and going up, you know There's this this discord and so and again understanding the scope of practice understanding what we can do having that conversation Changing that culture is really important to bring that time down and then the the pre-admission encounter to financial clearance again The earlier that our admitting department could know about the patient and know that they had to start working on financial clearance The quicker things moved so what about outcomes in terms of some key metrics? Well length of stay is one of those key metrics There's a more important one which I'll come to in a moment but length of stay is something that that we look at and again when we looked at length of stay by implementing this Physiatric consult service we see that the length of stay in acute care is heading south which is good shorter lengths of stay But this is the this is the metric that is really really very very key and one that a lot of health care Executives and CEOs are looking at and it's the observed to expected length of stay Observed is how long people are staying the expected is a calculation that's based on their diagnosis and comorbidities And it's a calculation that's done even after the patient's been discharged But it does rely on a lot of documentation of these comorbidities Which we're very good at by the way and acute care teams often gloss over so that's another value that you bring which is Your documentation your thorough documentation increases that expected length of stay but when we started this initiative back in fiscal year 2020 The observed to expected length of stay of patients who are coming over to to our rehab facilities was close to two but four years later Hovering around one and dipping now below one So that's a significant change in the observed to expected length of stay the lower the number that we see for ODE LOS The better it is and we've managed to do that by implementing this physiatric consult service. So what does it look like? What do you say you say? Okay, I'm convinced. I want to do this. I want to get this into my health system Well, this is what we said. It's a full-time position Okay, this is where you live. You're embedded in the acute care setting you attend those acute care teams You're part of the morning huddles. You're part of the discharge planning You're part of or leading the patient and family meetings You see all new consults within 16 hours you follow up with all patients two three times a week as needed You communicate communicate communicate collaborate collaborate collaborate. That's what we do with the physicians with the social workers and case managers Who's better? To do that appeal to the insurance companies than physiatrists We're the best why because we understand the medical issues and we know the rehab issues like the back of our hands and none of The other acute care physicians know this so we said we'll take it on We have taken on all the denials all the peer-to-peer reviews Oops, excuse me We talked with our acute care therapists. We talked with our inpatient Rehabilitation physicians and we talked to all of our physiatrists across our Continuum of care as we're helping move people through the system And and then as I said the physiatrist has to guide the rehabilitative care And the functional disposition needs it's their role. It's their world. It's their responsibility So this is I think one of my last slides, but Recognizing that we are not an island to ourselves as physiatrists. We're not an island to ourselves as As departments and we need to be strategic and we need to integrate and we need to collaborate so If this has stimulated you and you say well, this is maybe something I can take back to my department Take it back there go and talk with your chair with your administration And start to plan about implementing a an acute care rehabilitation service Talk to your partners in the acute care system. Talk to the surgeons the surgeons As I said if you can fix their problem They don't really mind how you do it. Just fix it Same for the hospitalists same for you know all the acute care teams they want us or they're happy for us to come in and Know that we can fix their problems talk to the case managers and the social workers They will love partners that we the partnership that we can provide talk to our community care providers Which includes our skilled nursing facilities outside of maybe our immediate system also our home care agencies as well Be bold talk to the c-suite go and tell them. Hey, we can reduce your length of stay We can reduce your observed to expected length of stay. We can reduce readmissions. We can reduce complications We can improve your bottom line and they know what that means money They're gonna make more money or lose less money from our interaction and our intervention Talk to the insurance companies develop relationships with the insurance companies. They're open to that. They want to serve their clients as well I know we hear denial after denial after denial and you may tell them, you know The patient needs it and they you know, we feel they have quotas, you know There's a certain kill if you develop a relationship with the insurance companies. It makes a difference Develop that dialogue know your medical directors have your administration have your leadership have your social worker in case managers Get on a call with you with the insurance companies. It makes a difference We've done that with several of our largest insurance companies and they have really worked with us to improve the throughput of their patients Who have their insurance? build partnerships with your Inpatient rehabilitation facilities around you forgive me and the skilled nursing facilities and the LTAC's etc develop relationships build that trust and of course for first and foremost is that we're working with patients and families and Build the relationship with them as well and that helps with Forgive me brand loyalty as well. They've had a good experience. They want to come back to that health system They want to come back to that hospital because you've taken the time you've made the difference for them So again, this is value-based care. This is strategy. This is thinking it can be done. We're doing it I don't think any of us can ever say we've done it because the knot is a tough nut to crack But as we talk about it as we share ideas as we look at the literature that's published as we do Research to really understand where our weak points are where our opportunities are when we're bold and we implement systems We can truly make a difference. So I thank you for listening and we are all open to any questions And If you're gonna ask questions, please do come up to the mic it's being recorded. Hi Ed Hurwitz from Michigan Medicine Thank you for this presentation. It's very interesting So I want to ask you about the service line model Our stroke physiatrist is really part of the stroke team goes to the stroke huddles Our TBI physiatrist works with the neurosurgeon who does the TBI? This model takes that apart because you know, it puts the stroke physiatrist on the inpatient ward and he has a console physiatrist Do we lose some value and and when the patients aren't being seen by the specialist in that particular area? Do we lose some value there? I Think you make a great point. I'm not saying that this model is the only model not at all I think there are lots of different models and I think what it comes down to Is what Sarah can do with her mind and her thinking and her models in terms of how do we evaluate these systems? How do we look at the data? How do we do the research to see which works best and it may not be and we know that I mean There's there's so much Variety and variability and how we practice but this is one method it worked for us in an academic center It may not work elsewhere in terms of our the expertise of our Physiatrists, so we have essentially now to full-time consult physiatrists on one of our settings and One is in the neurologic side So they will do the stroke the brain injury the spinal cord injury the spine surgery The other non-surgical neurologic like Parkinson's disease and MS and those kinds of things and then on the other side We have the medically complex the transplant the oncologic actually forgive me. We have What I'm saying we also have an oncology Rehab physician and she does all of her own consults on the oncology service. So I Have not found I have not felt that we have lost Expertise I Think it's a very valid question Sarah. What are your thoughts in terms of evaluating different systems from the research model? You know There's opportunity there I think you obviously could I Would imagine build more trust if you are, you know, if you've got your brain injury physiatrist working with you know Those surgeons and that team on trauma specifically But no one has no one has evaluated these different models, right? So You know, there were one or two papers I think that kind of looked at you know, the differences between specialists versus general physiatrists But Really a lot more work is needed if we're gonna look at it from a research and like value perspective, I would think yeah I mean No one can criticize any model that we have because any model that we have is better than no model But as we collect data, I think we do need to examine it and understand it And I'll also say that our consult physiatrists do reach out to us as specialists So again, I'm in cardiopulmonary and sometimes the physiatrist if they've seen a patient in cardiopulmonary, that's not their expertise They reach out to me and ask me they reach out to our brain injury specialists. They ask him or her so again Communication within the team helps. That's a great question Hello, I'm Stacy Hoffman practicing at Mercy Health in Ohio and I had a question On our system-wide acute rehab call with our medical directors last week Some of us are starting to get pushback from insurance companies about the physiatrist doing the quote peer-to-peer Because it's never actually a physiatrist on the other end of the phone. So I'm using air quotes But they're saying that there's a potential conflict of interest for the physiatrist because in some way we may Benefit from that patient coming to our acute rehab in our system We do them for the patient regardless of their disposition Location so I was just wondering if any of you are experiencing that or have any rebuttal to it So in in our at Vanderbilt I'm not doing the peer-to-peer says, you know As I as we kind of reviewed with our quality improvement work our case managers are doing them and then they're pulling our notes to do them Yeah, I'll go back and say there's no one who's better than doing a Peer-to-peer We have a vested interest. Yeah. Sure. We do not because we're gonna make money But because we're gonna take care of patients tell the cardiologist to refer to someone else for the calf I mean, where's the line exactly exactly an insurance company and I think this is why there's value in developing relationships with insurance companies So you don't have to have these conversations in the heat of the moment Where you're pulling out your hair because the physician at the other end of the line who's not a physiatrist is just either You know adding up how many patients they've approved or it doesn't get it. So developing that relationship I think really goes a long way, but it's true I mean, I still would maintain that we're the best to do the peer-to-peer denial reviews UT Southwestern question about using virtual rounding tools. First of all, thank you for citing our 2022 paper We're happy that the lab was appreciated for that Have there been any discussions about using virtual rounding tools that allow you to integrate information from the physical therapist the care coordinators social work So basically having an epic build That's what we did in Dallas that kind of populates everything for the consultant in one screen So you don't have to scan through the charts And then my second question was we have a huddle round so that we get all of our consoles automatically checked off on every stroke Patient so we're consulted for everyone. Have there been any discussions about doing that across y'all's health system? so For the first question we've done similar but we've actually built it into the note So the note will auto populate a lot of that information that you just mentioned It's so it's not like a workbench or anything that we're interacting with but it's all kind of there in our note to help us And we have not used any virtual otherwise I'm less able to comment on your second Yeah in terms of you know off our template formulates pulls in the information that we need in the functional data and Social and disposition data. So a lot of it pre populates so We use the mr from that perspective The only experience we've had in terms of and I'm maybe I'm missing the question But if I am correct me, but during the pandemic when office artists were not going bedside They were doing the consults remotely by doing chart reviews and by doing some phone calls, etc Etc and we're making decisions based on what they were seeing Only from a remote review using sort of the the chart and sort of a telehealth perspective I love that. I love that. I think that that you know someone going through the ER You know when they when they discharge the patient to the acute floor should be a consult to physiatry or that's fantastic That's great. We also do not have that. I truthfully have mixed feelings about that just because I want the team to consult us for our input and to be paying attention to our input But at the same time I do There's no there's no correct model right? Yeah it's an excellent point of what you're saying if it's automatic they're not even thinking about and that may not be such a good thing in terms of the consult and I will say that that my perspective is I'd rather be called on everyone than no one and I'd rather be called sooner than later so what you're saying allows us to be called on everyone soon rather than no one late. Yeah no absolutely it's certainly something to consider. By the way we are at 332 and I will take one last question real quick and then I know we have to move on sorry. Lisa Lombard I'm from Ohio Health Rehabilitation Hospital and we're trying to develop some consultative services in facilities that have not previously had much or if any rehabilitation consults so one of the problems I run into is do the primary services even know what makes for a good patient for us to see and so this is somewhat affiliated to the last discussion point and again I'm opening up a Pandora's box at the time this lecture is supposed to be done but some things that can some objective things that could automatically trigger rehabilitation consultation impact score certain diagnoses or something like that and I'd love providing them resources? I mean, I think my opinion is what you're doing, where you guys go through and educate and re-educate, is probably... Yeah. Yeah, I mean, again, we know a certain number of these patients are gonna be going on to post-acute care. And a lot of these teams have a gestalt when the patients come in, that this patient's not gonna go home. To me, and I know I'm being very vague, but that's enough of a reason to say, okay, let's get the physiatric team in there to do a consult. And then, the physiatric team can work back with them in terms of, this is the function, this is the home situation, this is the gap. So I think there's, I don't think we have the hard triggers, other than to say that, we know many patients aren't gonna go home. We know many patients are gonna need some kind of post-acute care, getting the physiatrist in there early, getting them to optimize the care in the acute care setting, getting them to work through all the disposition issues is gonna enhance the efficiency of throughput. So it is a great question and something that I think we all need to work on. For the next lecture. Yeah. Well, listen, I wanna thank everyone for coming, for listening, and for participating. Take this home to your place, too.

physiatry

acute care

patient throughput

continuum of care

bedside care

pain management

spasticity management

special populations

physiatric consult service

collaboration

communication