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Fast-Tracking Physical Therapy Can Save Time, Money – and Pain

Military health personnel checking out an injury Army 1st Lt. Nicholas Wankum, a physical therapist at Madigan Army Medical Center, evaluated the progress Marine Staff Sgt. Dalton Everhart made in his range of motion since the recruiter came to the emergency department after an injury nearly a month before this September 2019 visit (U.S. Army photo).

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If you've ever twisted your ankle and seen it swell up size of a softball, you know that having it examined quickly by an experienced professional is important to prevent further injury.

But that doesn't necessarily mean seeing a medical doctor in the emergency room.

Getting service members back in mission-ready shape quickly and efficiently can help save time and money, reduce the need for medication, and minimize the time lost at work or for training. That's why a project at the Madigan Army Medical Center, located at Joint Base Lewis-McChord, Washington, employing an algorithm aimed at speeding up the process of soldiers needing to see a physical therapist, has won an inaugural innovation award through a program at the Defense Health Agency.

The award-winning algorithm is like a checklist that helps hospitals and local clinics sort through its potential patients and identify those individuals with ailments or injuries that will benefit most from immediate access to medical care.

The Clinical Quality Improvement (CQI) Leading Practices Program (LPP) is a new awards program that aims to improve care across the Military Health System (MHS). The DHA's LPP initiative has a goal of finding local innovative practices and supporting their spread and scale to other facilities. The winning leading practice, called "Implementation of Direct Access Physical Therapy Within the Military Medical System," along with the other top 10 finalists, was selected at the end of April.

"We wanted to make sure our patients could get in to see us sooner," explained Army Maj. Eliza Szymanek, a physical therapist (PT) who led the winning team at Madigan. Her team implemented the performance improvement project to provide timelier care for acute musculoskeletal conditions in the active-duty population.

"Typically for a specialty care clinic, the referral process can be up to 28 days," she said. "Creating that availability in our schedules was important to us - to see somebody with an acute ankle pain on the same day versus four to six weeks later is super important."

Szymanek and her team at Madigan presented their project along with an algorithm used to identify service members for "direct access" physical therapy sick calls. Results show a host of tangible benefits, including a decreased long-term disability and placement on permanent profile; as well as a reduction in imaging, medications prescribed, and number of physical therapy visits scheduled. A Soldier with a permanent profile is limited on the amount of physical activities that they can do.

The spread and scale of the winning Madigan practice will also be supported by Irwin Army Community Hospital at Fort Riley, Kansas. Irwin's own submission took second place with a musculoskeletal triage decision tool called the "Military Orthopedic Tracking Injuries and Outcomes Network (MOTION)," to monitor the improvement of readiness outcomes.

"Out of 76 total submissions this year, various subject matter experts selected these practices as having the greatest potential to make a critical impact on health care delivery and patient outcomes while maximizing value across the MHS," the DHA announced.

Every PT at Joint Base Lewis-McChord's five clinics is a provider with a doctoral level degree and both diagnostic and prescriptive capabilities.

The submission "went through a multi-phase, multi-faceted, rigorous evaluation process," said Dr. Chin Hee Kim, chief of the Clinical Quality Improvement Program at DHA, who is responsible for the development and execution of a sustainable program to identify and implement locally led leading practices (CQI LPP).

"Maj. Szymanek's submission contained strong pilot data to support the impact, and was feasibly replicable and scalable," Kim said.

Picture of Army Maj. Eliza Szymanek
Army Maj. Eliza Szymanek, a physical therapist, at Madigan Army Medical Center in Washington (Army courtesy photo).

Madigan's winning submission also strongly aligns with three of four DHA campaign plan lines of effort: medically ready force, provider readiness, and satisfied patients.

"By providing direct access to the physical therapists, you're subverting the traditional referral process for service members and veterans with acute MSK injuries who would most benefit from that immediate care," Kim said.

"The savings in healthcare utilization costs arise in part from treating service members early to maximize their outcomes and quickly address their duty-limiting condition, as compared with waiting up to 28 days for a PT referral process through their PCM (primary care manager)."

Other benefits include a likely reduction in medications prescribed; likewise, a reduction in imaging needs saves money and wear-and-tear on equipment.

"Direct access to PT enables a more efficient use of provider time, skill and expertise," Kim said. "You free up the PCM and provide the capability for the injured service member to be treated rapidly by an MSK specialist."

Szymanek says that direct access to military PTs has been around for years, but that it hasn't always been in the military treatment facility (MTF) model to have sick-call hours or walk-in hours.

"When I first got here to Madigan (late 2017), that was the case for our main clinic and for our outlying clinics," she recalled. "We didn't have any dedicated sick-call time. We created a working group that included myself and some of our physical therapists at our multiple clinics. We asked: 'What does implementing direct-access or sick call look like at each of those clinics and how would it work best?'"

"We put our minds together and (decided) which patients would be best for that kind of setting. The algorithm that we put together is what we started with, and modified it as we needed."

The program at Madigan has been successfully in place for three years now, with proven results in decreased long-term disability and a reduction in medications prescribed. Waiting up to 28 days to be seen not only means the loss of a soldiers' service, but it adds significantly to the risk of further injury, though typically an injured person would see a primary care physician at sick-call well before a couple of weeks go by. But the referral and scheduling processes to see a PT meant perhaps even more time elapsed.

Now, service members at Madigan can just hobble in and be seen by PTs, same-day.

"Readiness has been the Army's number one priority, and a piece of readiness is the ability of that soldier to be medically ready to do their job," Szymanek said. "It's important that we're able to provide them that care as soon as possible. It's really thinking about the physical therapist as part of that primary care team, that first-line care provider. Our initiative was really just making our availability easier."

The algorithm is akin to a checklist, she said. Szymanek added that she was inspired to implement direct access because she arrived at Madigan after an 18-month sports PT fellowship at the United States Military Academy.

"The culture of West Point is: If you are sick, you see your primary care doctor, and if you hurt your ankle or your knee, you go to physical therapy," she said. "That's really established from Day One for West Point cadets. I really think this is changing the culture of musculoskeletal injuries and making sure they can be seen by a PT sooner rather than later. In some places that's already the case."

For more on Health Innovation during July, please visit: www.health.mil/HealthInnovation.

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