A Transformative Leadership Journey: Experiences of Graduates of the American Physical Therapy Association Fellowship in Education Leadership.

INTRODUCTION: Physical therapy education has an acute need for effective leaders due to multiple factors, including increasing numbers of programs and retirement of experienced leaders. Recognizing the need for formal leadership education, the American Physical Therapy Association (APTA) developed a fellowship in physical therapy educational leadership in 2011. This study aimed to understand participants' perceptions of their leadership experience and the role of the APTA fellowship. LITERATURE REVIEW: A commonly reported approach to evaluating leadership education programs was designed by Kirkpatrick. PARTICIPANTS: Twenty-five fellowship graduates from 2012 to 2019 participated. METHODS: We used a qualitative methodological approach incorporating a heuristic technique to gain an understanding of fellowship graduates' long-term perspectives. Semi-structured interviews were conducted via Zoom. Data were analyzed using thematic analysis. RESULTS: Three themes were constructed using a journey metaphor: embarking on the journey, engaging in the journey, and realizing the effects of the journey. 1) Embarking on the journey included 2 subthemes: a) participants' personal aspirations as career planners, reluctant leaders, or explorers; and b) institutions' goals for a change in leadership or intentional succession planning. 2) Engaging in the journey included 3 subthemes: a) the fellowship learning environment builds a sense of community; b) consideration of leadership frames influences participants' thinking about leadership; and c) participants' institutional environment influences their learning. 3) Effects of the journey included 3 subthemes: a) personal growth as a leader including personal awareness and confidence; b) institutions' benefits from participants' leadership projects and increased engagement in institutional leadership; and c) physical therapy professions' gains from participants' seeking leadership positions in professional organizations. DISCUSSION/CONCLUSIONS: The APTA Fellowship in Educational Leadership results in transformative change of participants as leaders. Findings offer guidance to individuals considering embarking on a leadership journey and institutions considering how to prepare and support emerging leaders in physical therapy education.

Competency-Based Education and Practice in Physical Therapy: It's Time to Act!

Competency-based education (CBE) is a concept, a philosophy, and an approach to educational design where learner progression occurs when competency is demonstrated. It assumes a set of standard defined performance outcomes for any level of professional practice-students, residents, or practicing physical therapists. Those outcomes are based on the health needs of society and guide the curricular design, implementation, and evaluation of health professions education programs. Lack of a CBE framework-with no required demonstration of competence throughout one's career-has the potential to lead to variation in physical therapists' skills and to unwarranted variation in practice, potentially hindering delivery of the highest quality of patient care. CBE requires a framework that includes a commonly understood language; standardized, defined performance outcomes at various stages of learner development; and a process to assess whether competence has been demonstrated. The purpose of this perspective article is to (1) highlight the need for a shared language, (2) provide an overview of CBE and the impetus for the change, (3) propose a shift toward CBE in physical therapy, and (4) discuss the need for the profession to adopt a mindset requiring purposeful practice across one's career to safely and most efficiently practice in a given area. Utilizing a CBE philosophy throughout one's career should ensure high-quality and safe patient care to all-patient care that can adapt to the changing scope of physical therapist practice as well as the health care needs of society. The physical therapy profession is at a point at which we must step up the transition to a competency-based system of physical therapist education.

Frailty and Function in Heart Failure: Predictors of 30-Day Hospital Readmission?

BACKGROUND AND PURPOSE: Although there have been decreases noted in 30-day readmission rates for persons with heart failure since enactment of the Hospital Readmissions Reduction Program, costs related to heart failure readmissions remain high. Consequently, there is a need to better identify persons with heart failure who are at risk for 30-day hospital readmission. Therefore, this study aimed to compare the ability of measures of function and frailty to predict 30-day hospital readmissions for adults 65 years and older with heart failure. METHODS: Secondary data analysis using the 2011 National Health and Aging Trends Study analysis merged with Medicare claims data. Logistic regression modeling was used to compare the ability of function (Short Physical Performance Battery) and frailty (Fried's Physical Frailty Phenotype) to predict 30-day readmission. Receiver operating characteristic curves were constructed to examine the ability of function and frailty to identify those who were readmitted. RESULTS AND DISCUSSION: Frailty and function demonstrated comparable ability to predict 30-day readmissions (R2 = 0.087 and R2 = 0.087, respectively). Neither measure identified persons at risk for readmission (AUCSPPB = 0.608; AUCPFP = 0.587). CONCLUSIONS: Functional assessment demonstrated comparable ability to predict 30-day readmissions in persons with heart failure compared with frailty. However, neither measure was able to identify persons at high risk for readmission. Although frailty status is emphasized in research for older adults with heart failure, functional status is an important patient-level factor associated with readmission.

Physical Therapist Management of Total Knee Arthroplasty.

A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of physical therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches to management of total knee arthroplasty.

Functional Trajectories of Persons with Cardiovascular Disease in Late Life.

OBJECTIVES: Physical function declines with aging and is accelerated for persons with cardiovascular disease (CVD). While CVD increases the risk of functional decline in late life, little is known about differences in trajectories of functional decline. To determine whether there is more than 1 trajectory of functional decline in Americans with cardiovascular disease (CVD) who are functionally independent. DESIGN: Secondary analysis of National Health and Aging Trends Study (NHATS). Latent class growth modeling was used to estimate trajectories of function over 4 years of follow-up. SETTING: Annual structured in-home interviews. PARTICIPANTS: Americans aged 65 and older with CVD who were functionally independent at baseline (N = 392). MEASUREMENTS: We compared trajectories of function in individuals with CVD with trajectories of those without and examined the association between risk factors (sex, age at baseline, education level, comorbidity) and trajectory group membership. Function was measured using the Short Physical Performance Battery. RESULTS: Three functional trajectories emerged: rapid functional decline (23.8%), gradual functional decline (44.2%), and stable function (32.0%). Similar trajectories were seen for those without CVD, with a smaller proportion in the rapid functional decline group (16.2%). Women, older participants, and those with less education and greater comorbidity were less likely to be in the stable function group than the rapid functional decline group. CONCLUSION: Although function declines in late life for independently functioning persons with CVD, some individuals remain stable, and others decline gradually or rapidly. Persons with CVD were more likely to experience rapid functional decline than those without, suggesting that CVD increases the risk of rapid functional decline. Risk factors predicted functional trajectory group membership, not just overall decline. J Am Geriatr Soc 67:37-42, 2019.

Therapists' Perceptions of Application and Implementation of AM-PAC "6-Clicks" Functional Measures in Acute Care: Qualitative Study.

BACKGROUND: Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" tools are functional measures used in acute care. No studies have identified reactions and perceptions of therapists in implementing these measures. OBJECTIVES: The purpose of this study was to explore therapists' perceptions regarding the application and implementation of AM-PAC "6-Clicks" tools. DESIGN: This study used a qualitative design with thematic analysis. METHODS: A convenience sample of 13 physical therapists and occupational therapists participated in semistructured telephone interviews. Interviews were recorded, transcribed, and coded, after which thematic analysis was used to determine common themes. RESULTS: Five themes were identified: (1) unclear purpose, (2) lack of confidence in scoring, (3) too simple for decision making or generalizing patient function, (4) no effect on clinical routine, and (5) potential for communicating patient function across disciplines. LIMITATIONS: Participants came from one health care system. A relatively small percentage of staff agreed to participate in this study, and additional interviews might have revealed new themes. CONCLUSIONS: As participants in this study implemented the AM-PAC "6-Clicks" tools, they considered the role of the measures, how they fit within the context of practice, and their value. They also were concerned with the accuracy and feasibility of the tools. The tools were accepted as potentially valuable to assist administrative decisions and research; however, they were not perceived as particularly useful for routine patient care. Participants lacked complete confidence in the reliability of their scoring and expressed concern that the scores might be substituted for their clinical decision making. They also felt that the tools were too simple to fully reflect patients' overall function and were not useful alone for discharge planning. Participants believed the tools had the potential to be used for communication among colleagues about patients' physical function.

Are CMS G-Code Functional Limitation Severity Modifiers Responsive to Change Across an Episode of Outpatient Rehabilitation?

BACKGROUND: The Centers for Medicare & Medicaid Services has mandated rehabilitation professionals to document patients' impairment levels. There is no evidence of responsiveness to change of functional limitation severity modifier codes. OBJECTIVE: The purpose of this study was to assess the validity of G-code functional limitation severity modifier codes in determining change in function. DESIGN: This was a retrospective observational study. METHODS: Patients completed the Activity Measure for Post-Acute Care (AM-PAC) and were assigned G-codes, with severity modifiers based on AM-PAC scores at initial and follow-up visits. Patients were classified as having AM-PAC scores in the upper or lower range for each severity modifier, and sensitivity, specificity, and positive and negative predictive values for change in severity modifier level and odds of changing by one severity modifier level using a change in AM-PAC score of at least 1 minimal detectable change at the 95% confidence interval (MDC95) as the standard were determined. RESULTS: Sensitivity and specificity of change in severity modifier in determining change in function were dependent on patients' initial AM-PAC scores. Improvement in severity modifier level was 2.2 to 4.5 times more likely with scores at the higher end of the range within a severity modifier level than with scores in the lower end of the range. Decline in severity modifier level was 2.7 to 4.8 times more likely with scores at the lower end of the range within a severity modifier than with scores in the higher end of the range. LIMITATIONS: Data were from one health care system, and most patients had orthopedic conditions. The MDC95 for AM-PAC tool may not be the best standard for defining functional change. CONCLUSIONS: The G-code functional limitation severity modifier system may not be valid for determining change in function and is not recommended for determining if patients have changed over the course of outpatient therapy.

Interrater Reliability of AM-PAC "6-Clicks" Basic Mobility and Daily Activity Short Forms.

BACKGROUND: The interrater reliability of 2 new inpatient functional short-form measures, Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" basic mobility and daily activity scores, has yet to be established. OBJECTIVE: The purpose of this study was to examine the interrater reliability of AM-PAC "6-Clicks" measures. DESIGN: A prospective observational study was conducted. METHODS: Four pairs of physical therapists rated basic mobility and 4 pairs of occupational therapists rated daily activity of patients in 1 of 4 hospital services. One therapist in a pair was the primary therapist directing the assessment while the other therapist observed. Each therapist was unaware of the other's AM-PAC "6-Clicks" scores. Reliability was assessed with intraclass correlation coefficients (ICCs), Bland-Altman plots, and weighted kappa. RESULTS: The ICCs for the overall reliability of basic mobility and daily activity were .849 (95% confidence interval [CI]=.784, .895) and .783 (95% CI=.696, .847), respectively. The ICCs for the reliability of each pair of raters ranged from .581 (95% CI=.260, .789) to .960 (95% CI=.897, .983) for basic mobility and .316 (95% CI=-.061, .611) to .907 (95% CI=.801, .958) for daily activity. The weighted kappa values for item agreement ranged from .492 (95% CI=.382, .601) to .712 (95% CI=.607, .816) for basic mobility and .251 (95% CI=.057, .445) to .751 (95% CI=.653, .848) for daily activity. Mean differences between raters' scores were near zero. LIMITATIONS: Raters were from one health system. Each pair of raters assessed different patients in different services. CONCLUSIONS: The ICCs for AM-PAC "6-Clicks" total scores were very high. Levels of agreement varied across pairs of raters, from large to nearly perfect for physical therapists and from moderate to nearly perfect for occupational therapists. Levels of agreement for individual item scores ranged from small to very large.

AM-PAC "6-Clicks" functional assessment scores predict acute care hospital discharge destination.

BACKGROUND: Physical therapists and occupational therapists practicing in acute care hospitals play a crucial role in discharge planning. A standardized assessment of patients' function could be useful for discharge recommendations. OBJECTIVES: The study objective was to determine the accuracy of "6-Clicks" basic mobility and daily activity measures for predicting discharge from an acute care hospital to a home or institutional setting. DESIGN: The study was retrospective and observational. METHODS: "6-Clicks" scores obtained at initial visits by physical therapists or occupational therapists and patients' discharge destinations were used to develop and validate receiver operating characteristic curves for predicting discharge destination. Positive predictive values (PPV), negative predictive values (NPV), and likelihood ratios were calculated. RESULTS: Areas under the receiver operating characteristic curves for basic mobility scores were 0.857 (95% confidence interval [CI]=0.852, 0.862) and 0.855 (95% CI=0.850, 0.860) in development and validation samples, respectively. Areas under the curves for daily activity scores were 0.846 (95% CI=0.841, 0.851) and 0.845 (95% CI=0.840, 0.850) in development and validation samples, respectively. Cutoff scores providing the best accuracy for determining discharge destination were 42.9 for basic mobility and 39.4 for daily activity. For basic mobility, the PPV was 0.748 and the NPV was 0.801 in both development and validation samples. For daily activity, the PPVs were 0.787 and 0.784 and the NPVs were 0.748 and 0.746 in development and validation samples, respectively. LIMITATIONS: Limitations included lack of information on the rater reliability of "6-Clicks" instruments, use of surrogate data for some discharge designations, and use of a clinical database for research purposes. CONCLUSIONS: This study provides evidence of the accuracy of "6-Clicks" scores for predicting destination after discharge from an acute care hospital.

Validity of the AM-PAC "6-Clicks" inpatient daily activity and basic mobility short forms.

BACKGROUND: Standardized assessment of patients' activity limitations in acute care settings can provide valuable information. Existing measures have not been widely implemented. OBJECTIVES: The aim of this study was to provide evidence for validity of scores on Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" measures of basic mobility and daily activity in acute care. DESIGN: A retrospective measurement study was conducted. METHODS: The study used a database from one health system containing "6-Clicks" scores from first and last physical therapist and occupational therapist visits for 84,446 patients. Validity was analyzed by examining differences in "6-Clicks" scores across categories of patient characteristics; the ability of "6-Clicks" scores to predict patients' having more than one therapy visit; correlation of "6-Clicks" scores with Functional Independence Measure (FIM) scores; and internal responsiveness over the episode of care. Internal consistency reliability also was determined. RESULTS: The "6-Clicks" scores differed across patients' age, preadmission living situation, and number of therapy visits. The areas under receiver operating characteristic curves derived using "6-Clicks" scores at the first visit to predict patients receiving more than one visit were 0.703 and 0.652 using basic mobility and daily activity scores, respectively. The "6-Clicks" scores at the final visit were correlated with scores on subscales of the FIM completed on admission to inpatient rehabilitation facilities (r=.65 and .69). Standardized response means were 1.06 and 0.95 and minimal detectable changes with 90% confidence level (MDC90) were 4.72 and 5.49 for basic mobility and daily activity scores, respectively. Internal consistency reliability of basic mobility and daily activity scores was .96 and .91, respectively. LIMITATIONS: Using clinical databases for research purposes has limitations, including missing data, misclassifications, and selection bias. Rater reliability is not known. CONCLUSIONS: This study provides evidence for the validity of "6-Clicks" scores for assessing patients' activity limitations in acute care settings.

Use of quality indicators in physical therapist practice: an observational study.

BACKGROUND: The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 contain provisions specific to health care quality that apply to physical therapists. Published evidence examining gaps in the quality of physical therapy services is limited. OBJECTIVE: The primary purpose of this study was to determine the use of quality indicators in physical therapist practice. DESIGN: This was an observational study. METHODS: All members of the Orthopaedic and Private Practice sections of the American Physical Therapy Association were invited to participate by completing an electronic survey. The survey included 22 brief patient descriptions, each followed by questions regarding the use of examinations and interventions based on the 2009 list of Medicare-approved quality measures. Separate multivariate logistic regression models were used to determine the odds ratios related to the performance of each examination and intervention on more than 90% of patients, given perceptions of its importance to care, the burden of performing it, and the level of evidence supporting its use. RESULTS: Participants (n=2,544) reported a relatively low frequency of performing examinations and interventions supporting primary and secondary prevention (3.6%-51.3%) and use of standardized measures (5.5%-35.8%). Perceptions of high importance and low burden were associated with greater odds of performing an examination or intervention. Importance and burden were more influential factors than the perceived availability of evidence to support use of identified techniques. LIMITATIONS: The survey was not assessed for test-retest reliability. A low response rate was a source of potential bias. CONCLUSION: The study findings suggest that physical therapists may not see themselves as providers of primary or secondary prevention services. Patient management strategies associated with these types of services also may be perceived as relatively unimportant or burdensome.

Physical therapist practice in the acute care setting: a qualitative study.

BACKGROUND: Physical therapist practice in the acute care setting is not thoroughly understood, and it has been argued that skilled care is not required. OBJECTIVES: The objective of this study was to describe the role of physical therapists, the clinical reasoning processes used by physical therapists, and the context for providing physical therapy services in the acute care setting. DESIGN: A convenience sample of 18 physical therapists working in 3 academic medical centers in the United States was included in this qualitative study with grounded-theory methods. METHODS: Semistructured interviews were conducted. Transcripts were coded, and a constant comparative process of analysis was used to determine common themes. A theoretical model was derived. RESULTS: Eight themes were identified: collection and analysis of medical information, application of specialized physical therapy knowledge, communication to gain information, communication to provide information, continual dynamic assessment, professional responsibility, complex environment, and decision making for patient care. Among the limitations of this study were that the sample and method limited the generalizability of the findings, the participants were not observed in their practices, and researchers' preconceived views may have influenced the interpretation and derivation of themes. CONCLUSIONS: Physical therapists in the acute care setting used clinical reasoning that required the ability to integrate medical information with physical therapy knowledge. Clinical reasoning required continual dynamic assessment of patients in a crowded, complex, fast-paced environment and resulted in rapid decision making. Constant communication with many people was critical to the process. The major concerns for physical therapists in the acute care setting, like physical therapists in other settings, were patients' mobility and safety. The goals were an optimal plan of care and an appropriate discharge setting for each patient. The therapists' roles reflected professional core values applied in ways unique to the acute care setting.

Physical therapists' management of patients in the acute care setting: an observational study.

BACKGROUND: Previous literature has not fully described physical therapists' management of patients across diagnoses in the acute care setting or how that management might vary by facility. OBJECTIVE: The purposes of this study were to describe patient management by physical therapists in the acute care setting and to examine variations in patient management across facilities. DESIGN: This was an observational study. METHODS: Fifty clinicians practicing at 3 academic medical centers in the northeastern United States agreed to participate. Over a 2-week period, clinicians completed checklists indicating the details of patient visits. Logistic analyses, controlling for patient age and diagnosis and accounting for clustering of data, were conducted to examine the odds of patients having several categories of examinations, goals, and interventions. RESULTS: Participants provided 2,364 visits to 896 patients. More than 75% of patients in each facility received examinations, goals, and interventions related to functional ability. Median number of visits per patient, duration of visits, and number of visits in which the patient was not treated varied across facilities. Patients with orthopedic conditions were more likely than those with medical/surgical conditions to receive several types of examinations, goals, and interventions. The odds of patients having examinations, goals, and interventions related to functional abilities were greater in facility 2 than in facility 1. LIMITATIONS: Limitations include the convenience sample, use of an untested data collection tool, and use of only age and diagnosis to control for case mix. CONCLUSION: This study of physical therapist practice in 3 acute care facilities suggests that patient management focuses on functional activity. There was no clear pattern of examinations, goals, and interventions related to specific diagnoses. A small degree of variation was found in practice across the facilities.