Physical therapists (PTs), Occupational Therapists (OTs) and Speech-Language-Pathologists (SLPs) dedicate their careers to improving patients’ lives through tailored treatment plans and personalized care. The explosion of research in understanding activity dependent neuroplasticity and key elements for effective rehabilitation have elevated the potential for PT, OT, and SLPs to positively impact human behavior post-injury or disease.
However, the realities of clinical practice often introduce challenges that can interfere with the ideal therapeutic process and limit the professional autonomy of therapists and the patients they serve. One such challenge is when management mandates rigid 45-minute appointments across the board, potentially compromising patient care and ethical practice when patients require a longer or shorter session.
If you find yourself in this situation, here are some strategies to navigate this complex terrain while still prioritizing patients’ outcomes, evidence-based practice, and your code of ethical practice.
The time constraints that currently exist in rehabilitation practice are not optimal for achieving the full impact of repetitive task practice on motor recovery and neuroplasticity. The length of inpatient stays have grown shorter and shorter, and limitations on outpatient rehabilitation result in more time spent teaching compensatory techniques that may not promote brain and behavioral recovery.
Beth Fisher, Journal of Neurologic Physical Therapy 35(3):p 148-149, September 2011.
1. Understand the Rationale Behind the Change
Before taking any action, seek to understand why management has implemented 45-minute sessions. These changes are often driven by financial pressures, the need to increase patient volume, manage productivity, or insurance constraints. By understanding the underlying reasons, you can better frame your concerns and propose solutions that align with management’s goals while advocating for your patients and yourself as a professional.
2. Communicate Effectively with Management
Clear and open communication with your supervisor is crucial. Schedule a meeting to discuss your concerns and present evidence-based arguments about the benefits of longer appointments for certain cases. Highlight how adjusting length of sessions can lead to better patient outcomes and improved patient satisfaction, which will ultimately benefit the clinic’s reputation and finances.
In the case of LSVT BIG® and LSVT LOUD®, over 30 years of research with level one evidence demonstrate the efficacy of this treatment protocol, specifically at the dosage of 60-minute sessions. There is no evidence to support that a 25 percent or greater reduction in treatment session duration would yield equivalent results. Additionally, such a reduction could lead to a decline in referrals, as physicians, patients and families expect gold-standard care from LSVT BIG and LSVT LOUD treatment.
Through this step alone, many therapists have been able to successfully offer 60-minute sessions for specific types of patients.
3. Advocate for Flexible Scheduling
Propose a flexible scheduling model that allows for longer or shorter appointments when medically necessary. For example, consider advocating for:
- Complex Cases: In addition to LSVT patients, those with more complex needs might also require the full 60 minutes, while others can be adequately treated in 30 or 45 minutes.
- A blocked schedule: Many therapists have had success keeping a consistent slot open for a 60-minute session at the same time every day. This is most often the first or last appointment of the morning or afternoon. Other therapists choose to use four 45-minute appointment slots to serve three patients for 60 minutes each, or two 45-minute slots to serve one patient needing 60 minutes and another needing 30 minutes.
- Working with scheduling staff: In large health care organizations, make time to educate and communicate with scheduling staff about “why” and “when” varied appointment lengths are needed by therapists. Changing an established process may take time and continued communication between departments, but the result will be positive for clinicians and patients alike.
4. Foster a Team-Based Approach
Collaborate with your colleagues to share strategies and tips for managing flexible scheduling effectively. A united team approach can lead to innovative solutions and create a stronger case for advocating for changes when needed. With support from your supervisor and from the physicians who refer patients for LSVT BIG and LSVT LOUD treatment or patients with complex needs, you can make changes that meet their needs and consider business needs.
For LSVT BIG Certified Clinicians specifically, the LSVT BIG treatment can be a collaborative interprofessional approach between PTs, PTAs, OTs and OTAs. During an LSVT BIG session, the patient first completes large-amplitude exercises, which, along with gait training, could be provided by the LSVT BIG Certified Physical Therapist for a 30-to-45-minute session. Immediately following this, the LSVT BIG Certified Occupational Therapist could complete the Functional Component Tasks and Hierarchy Tasks with the patient for a 30-to-45-minute session, which are often related to activities of daily living, in line with the OT scope of practice. While this does require PT and OT to schedule back-to-back sessions, it may be a feasible option when the health care organization is not able to offer flexible scheduling for one-hour sessions.
5. Know your Code of Ethics and State Practice Acts
While reading your Code of Ethics or State Practice Act is not exactly light reading, it is imperative for every licensed PT, OT and SLP to do so you can advocate for yourself and your patients when necessary. Here are some links we’d encourage you to read and share:
American Physical Therapy Association’s Position on Autonomous Practice
American Physical Therapy Association Code of Ethics (See 3A, 3B)
American Occupational Therapy Association Code of Ethics
American Speech-Language-Hearing Association Code of Ethics (See II-F, IV)
State Practice Act example on who can/cannot make changes to the PT Plan of Care
For SLPs, a recent article from ASHA speaks directly to the issue of advocating for patients and the treatments and dosage they need under the Code of Ethics: Patient Needs—Not Administrative Mandates—Are Critical to Patient and Payer Outcomes This statement from the article is especially relevant and would be helpful to share with administration:
The Code of Ethics specifically addresses administrative interference in Principle IV, Rule B: “Individuals shall exercise independent professional judgment in recommending and providing professional services when an administrative mandate, referral source, or prescription prevents keeping the welfare of persons served paramount.”
Monica Sampson, Sarah Warren, ASHA LeaderLive
6. Document Thoroughly
If concerns about lost productivity are a management concern, keep track of cancellation and no-show rates for patients who you are seeing for sessions which are 60 minutes or longer, along with their outcomes. Evidence-based treatments, such as LSVT LOUD and LSVT BIG, with predictable and successful outcomes often foster high compliance rates with treatment schedules. This documentation can provide valuable data to support future discussions with management in support of one-hour sessions.
Conclusion
While 45-minute appointments pose a challenge, you do not have to compromise the quality of care you provide, your professional autonomy, patient outcomes or evidence-based practice. By understanding the reasons behind the change, communicating effectively, advocating for flexibility, fostering a team-based approach, advocating for professional ethics, and documenting thoroughly, you can navigate this challenge successfully. Always remember, your primary goal is to provide the best possible care for your patients, and these strategies can help you achieve that even when challenges present themselves.
Resources:
For further information, here are some additional resources.
Practical solutions for delivering LSVT LOUD® or LSVT BIG® treatment per protocol
You’ve got questions, we’ve got answers! Top 10 questions related to LSVT treatments