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———————————-———-——— expert perspective —————-———————————-—-

Forecasting Health Care Delivery for Older Adults in the Midst of Change: Challenges

and Opportunities for the Physical Therapy Profession in an Evolving Environment

Andrew A. Guccione, PT, PhD, DPT, FAPTA, Jody Frost, PT, DPT, PhD, and John O. Barr, PT, PhD, FAPTA

Vol 28, No 2, 2014 Journal of Physical Therapy Education 7

the third prong, by discussing how poten- tial changes in the delivery and utilization of care to older adults poses both challenges and opportunities for the physical therapy profession, and describing the demographic sociopolitical backdrop for the companion paper by Wong and associates, “Building the Physical Therapy Workforce for an Aging America,”2 that addresses the first 2 compo- nents of the IOM report related to the pro- fession of physical therapy, particularly the education of the workforce.

Leaders in physical therapy education are committed to preparing physical therapists and physical therapist assistants to provide services to older adults in the United States, therefore must prepare students entering the workforce with the abilities to negotiate a drastically altered heath care landscape, es- pecially when working with older adults. The purposes of this paper are to: (1) inform the physical therapy education community about important age-related population factors that deserve emphasis in physical therapy education curricula; (2) describe the evolving nature of health care financing and service utilization that will effect changes in health care delivery; and (3) identify the challenges and opportunities in the clinical practice of physical therapy that may arise in the profes- sion’s efforts to meet societal needs related to our aging population more effectively and efficiently.

POSITION AND RATIONALE It is our position that the profession of physi- cal therapy in the United States (US) needs to be nimble in an evolving environment that will change health care financing and deliv- ery over the next decade. The profession must also continue to exercise sure-footed steps forward in clinical practice and education that can maximize the contributions that the

Andrew Guccione is professor and chair of the Department of Rehabilitation Science, College of Health and Human Services, George Mason University. Jody Frost is a lead academic affairs specialist at the American Physical Therapy Association. John Barr is a professor in the Physical Thera- py Department, College of Health and Human Services, St. Ambrose University, 518 W Locust, Davenport, IA 52803 ([email protected]). Please address all correspondence to John Barr. The authors declare no conflicts of interest. Received July 13, 2013, and accepted November 25, 2013.

and must continue to exercise sure-footed steps forward in clinical practice and edu- cation to maximize the contributions that the profession can make to the growing population of older adults. Our rationale includes: the changing landscape of aging in the US; the changing pattern of health care services utilization; changing models of health care delivery for older adults; and current and potential innovations in organization and delivery of services. Discussion and Conclusion. In working with older adults, patient/client instruc- tion and performance of functional activi- ties in the environment of the home and community will become more impor- tant in coming years. Physical therapists must position themselves for a leadership role among health professions, master- ing a broad skill set, and adapting to fit the evolving organizational structure of health care financing for older adults. Keywords. Entry-level education, Faculty development, Geriatrics.

Background and Purpose. Providing a backdrop for the companion article in this issue by Wong et al, “Building the Physical Therapy Workforce for an Aging Ameri- ca,” this paper focuses on how potential changes in the utilization and delivery of care to older adults pose challenges and opportunities for the physical therapy profession. The purposes of this paper are to: (1) inform the physical therapy education community about age-related population factors that deserve emphasis in physical therapy education curricula; (2) describe the evolving nature of health care financing and service utilization that will effect changes in health care delivery; and (3) identify the challenges and oppor- tunities in the clinical practice of physical therapy that may arise in the profession’s efforts to meet societal needs related to our aging population more effectively and efficiently. Position and Rationale. The profession of physical therapy in the United States (US) needs to be nimble in an evolving envi- ronment that will change health care fi- nancing and delivery over the next decade

BACKGROUND AND PURPOSE In 2008, the Institute of Medicine’s (IOM) Committee on the Future Health Care Work- force for Older Americans released its report “Retooling for an Aging America: Build- ing the Health Care Workforce.”¹ As a call for fundamental reform in the way that the workforce is both trained and utilized in the care of older adults, this report advocated a 3-pronged approach to an aging America: enhancing the geriatric competence of the entire workforce; increasing recruitment and retention of geriatric specialists and caregiv- ers; and improving the way care is delivered to this population. This paper focuses on

profession can make to our growing popula- tion of older adults.

The Changing Landscape of Aging in the United States

In the past decade alone, the number of per- sons whose age is 65 years or older in the US grew faster than the rest of the population.3 In 2010, 40.3 million people counted in the US Census were 65 and older, representing 13% of the entire population.3 By 2030, it is estimated that the number of people 65 and older will reach to 72 million.4 By 2050 the number of individuals who are 65 years of age and older should reach 88.5 million, with about 19 million over the age of 85 who will account for over 4% of the population.4

With aging comes increased risk of man- aging one or more chronic diseases, often associated with disabilities. In the United States, over 45% of adults age 65 or over have 2-3 chronic conditions.5 Arthritis, hyperten- sion, diabetes, coronary heart disease, cancer, and chronic obstructive pulmonary disease appear most frequently as various dyads or triads of multiple chronic conditions among men and women in this age group.5 For non- institutionalized Americans, ambulatory disability (ie, serious difficulty in walking or climbing stairs) affects the highest pro- portion of the population. Stratified by age, 16% of 65-74-year-olds and 33% of those 75 years of age and older have an ambulatory disability.6 This segment of the population with multiple chronic conditions that impede daily function offers a critical opportunity for the profession, as many of these individuals are living and still working in the community and are not the typical geriatric patients seen in acute care, home care, or nursing home settings.7

There is a dynamic tension in the political landscape between government entitlements and individual responsibility, specifically with respect to which side of this equation should shrink and which should grow. If, for example, the Medicare cap on physical therapy were lifted, then presumably services to older adults would increase to cover needs that went unmet because of the cost to the in- dividual. If government entitlements shrink and individual responsibility grows, poten- tially there could be a shift in the number of older adults who choose to receive physical therapist services as out-of-pocket paid ex- penses after the defined benefits of Medicare or a private insurance plan are exhausted. Fur- thermore, with particular respect to federally funded benefits, disproportionate spending at the end of the life span could leave far less to distribute across the health status continu- um of older adults, including those function-

8 Journal of Physical Therapy Education Vol 28, No 2, 2014

ally limited, chronically ill older adults who rely solely on Medicare. Ultimately, physical therapist services will become a value propo- sition, paid for only when value is evident, re- gardless of whether the federal government, the private insurer, or the individual pays the proportionately largest amount.

In addition, trends in labor force growth rates show that the individuals born in the United States between 1946 and 1964, known as the Baby Boomers, continue to participate in the labor force as they approach and pass the typical retirement age and are expected to continue this pattern for at least the next decade.8 Even with this extended participa- tion in the labor force among older adults, the shift from defined-benefit employee health and retirement plans to increased employee health premiums and defined-contribution retirement plans that began in the 1990s plac- es more responsibility on the employee for health insurance premiums, diminishing the financial resources for working older adults as well as retirees who can be concerned that their resources will not be sufficient to sup- port them over the long run. Thus, some older adults must make a deliberate decision to pay for any health services that may be capped as a benefit, entail large copayments with each treatment received, or pose substantial out- of-pocket expenses for the episode of care. This will further complicate the decisions that older people need to make about their health care purchases and force them to determine whether the value of a given service makes it essential or optional.

The Changing Pattern of Health Care Services Utilization

Until recently, the US health care system was primarily an episodic medical care sys- tem, built around segmented networks of hospitals and primarily fee-for-service com- munity-based providers, including physical therapists. Access and availability have been largely dependent on one’s insurance benefits and locality. Services tended to be fragment- ed because the system lent itself toward frag- mentation by episodic “start and stop” service provision with little contact among providers and little opportunity for coordination of care to maximize health outcomes. Patients fell through the organizational cracks because these flaws were systemically part of health care delivery. However, market response to the Patient Protection and Affordable Care Act (PPACA),9 as well as some provisions of the law itself, may force some of these organizational faults to shift. The emphasis on identifying the drivers of increasing and unsustainable health care expenditures, as well as changes in the vertical and horizontal

integration of health care services under the auspices of accountable care organizations (ACOs), have placed increased attention on well-managed care transitions that are ex- pected to decrease costs and improve quality by promoting early problem detection and preventing costly hospitalizations and read- missions.

One of the primary roles for physical therapists has been the diagnosis and treat- ment of functional deficits in the context of remediating impairments, lessening the functional burden of disease, and improving quality of life. However, the knowledge and skills that physical therapists have contrib- uted to the general well-being of older adults, particularly community-based frail individu- als, has now been placed in the context of the financial sustainability of health care delivery systems. Physical therapists who can prevent problems before or as they arise, and dimin- ish the need for inpatient hospitalization, are more likely to be seen as valued collaborators if the profession can empirically demonstrate that physical therapist services can reduce costs to the system. While the previous re- habilitation paradigm focused on individual patients returning to the community after receiving high-quality care, the new para- digm of rehabilitation will center on patient populations remaining in the community and using fewer system resources. The quality of the service is assumed to stay the same. How- ever, it is not enough that the physical thera- pist service be cost-effective in and of itself. The reach of cost-effectiveness as an outcome variable of health care has been extended be- yond individual service provision to include the value of the service to reducing costs of the whole system.

Changing Models of Health Care Delivery for Older Adults

The PPACA,9 signed into law on March 30, 2010, is seen by many as having the poten- tial to transform the health care system. In actuality, there is still a great deal of uncer- tainty as to exactly how the new law will be implemented or changed as many of its pro- visions will take effect in 2014 and later. Key provisions removed many barriers to health insurance such as preexisting conditions and life-time limits, linked Medicare payments to quality measures, expanded coverage op- tions for Medicare beneficiaries, opened the door to preventive services under Medicare, and offered the possibility of innovation in community-based wellness programs.

Although there are some who are con- vinced that the long-term savings realized from improving the quality of health care while reducing the need for more costly

Vol 28, No 2, 2014 Journal of Physical Therapy Education 9

medical intervention will be sufficient to pay for an expanded array of services, there are equally as many who doubt that all of the pro- visions of PPACA will roll out as originally intended if spiraling health care costs are not controlled in the short term. Furthermore, despite earlier indications that disability among adults was on the decline, more recent analyses suggest a more troubling picture. It appears that there is increased disability among the first waves of Baby Boomers en- tering older adulthood compared to previous generations, particularly among non-white, obese, and socioeconomically disadvantaged subgroups, all factors which independently increase the risk of disability as well.10 While these facts could herald an opportunity for the profession, there is no certainty that the emerging description of an aging America is also the final word on the first decades of the 21st century. In actuality, the only certainties on which most nearly everyone can agree is that third-party payment for health care ser- vices is likely to decrease and reporting re- quirements are likely to increase. Therefore, physical therapists must expect that they will be asked to do more with less to provide the right service to the right people at the right time. High quality, evidence-based service provision is assumed; cost-effectiveness with both short- and long-term savings to the sys- tem is expected.

Innovations in Organization and Delivery

Although the PPACA9 is regarded as a major breakthrough in moving away from a proce- dure-focused medical care system towards a wellness-oriented health care system, there have been small scale attempts over the past 40 years to demonstrate the clinical effective- ness and cost utility of organizing an array of physical, psychological, and social health services to older adults living in the commu- nity. Many of the most innovative programs emphasize care coordination and the impor- tance of interprofessional team practice. The Eldercare Workforce Alliance, of which the American Physical Therapy Association is a member, partnered with the National Coali- tion on Care Coordination to produce an is- sue brief that reviews the critical elements of care coordination, as well as emerging mod- els.11 However, it is critical to note that many of these emerging models imply that physi- cal therapists are part of the team, yet fail to explicitly name our profession as part of the team.

Established models of rehabilitation for frail older adults. The following programs are recognized as exemplary models for orga- nization and delivery of care to older adults.

They also include elements of interprofes- sional practice. On Lok is considered by many to be the first program of its kind to of- fer comprehensive health and social services in a single point of care to community-based frail older adults who were eligible for nursing home placement.12 Shortly after its inception, On Lok was eligible for Medicaid reimburse- ment, taking on the challenge of providing coordinated comprehensive services to low income and impoverished older adults. Sub- sequently, On Lok became the model for mul- tiple replication projects across the country in which the organization assumed the financial risk for providing care to enrollees for a fixed capitated payment. Over the past 25 years, On Lok evolved to become the entity now known as the Program of All-Inclusive Care for the Elderly (PACE). PACE was recognized by Medicare as a financially viable alterna- tive to traditional Medicare plans, known as special needs plans (SNPs), along with other Medicare Advantage plans.12

Physical therapists are extensively in- volved in PACE programs due to the health and functional status of individuals enrolled in this type of program. A key admission re- quirement is that the person be eligible for nursing home placement. Therefore, only frail older adults with substantial limitations in performing activities of daily living are served by the clinical team of providers across the professional spectrum. Although the point of care and the highly coordinated team approach may be innovative, the goals of care and the methods of one-on-one service deliv- ery, dictated by the needs of the patient, are similar to what one would expect for physical therapists working in other geriatric settings.

Some SNPs such as Evercare, operated un- der the auspices of United Healthcare, have targeted specific market segments, such as chronically ill individuals, who experience or are at great risk for functional decline, as well as palliative and hospice care.13 Evercare provides services at home, in assisted living residences, and in nursing homes. A major emphasis of Evercare’s approach is care coor- dination and problem surveillance by nurse practitioners. Again, due to the health and functional status of the individuals enrolled in this type of health insurance plan, physi- cal therapists play a major role in providing services to remediate impairments, improve function and support quality of life, such as they perform under other insurance models.

Models of rehabilitation for community- based older adults. Fifteen years ago, Rim- mer14 presented a model of health promotion for adults with chronic illness and disability that described a major community-based role for physical therapists in secondary preven-

tion. Secondary prevention, intervening early in disease progression to limit its effects on morbidity, is a role that unfortunately re- mains largely marginalized in contemporary physical therapist practice.15 Rimmer’s model distinguishes between clinically supervised health promotion, which a small but increas- ing number of physical therapists routinely provide as an extension of rehabilitation, and community-based health promotion programs, typically run by fitness profes- sionals who are not licensed as health care providers.16 Specifically, Rimmer notes that implementing a therapist-to-trainer model strengthens these sorts of programs by bring- ing the physical therapist’s clinical expertise in treating this population to bear on the de- sign of post-rehabilitation fitness programs as they are implemented in the communi- ty.17 Reintegrating older adults back into the community by facilitating their transition to non-health care, community-based fitness facilities promotes the full inclusion of in- dividuals with disabilities in environments intended for the general population. Further- more, these programs can diminish some of the accessibility and affordability barriers to maintaining a healthy lifestyle while living with a chronic condition.18 Actively embrac- ing emerging models of service provision such as these offers an unparalleled opportu- nity for innovative leadership in community- based health promotion. Participation of PT educators and clinicians in community-based exercise and fitness programs has the poten- tial to extend the success of a rehabilitation program by promoting behavioral change and adherence to prescribed exercise and physical activity recommendations that are critical to the health status of older adults, particularly those living with chronic illnesses.19

Evolving payment priorities. At one time, it was assumed that an increased number of older adults would translate to more physi- cal therapy (and thus, more physical thera- pists and physical therapist assistants). Such growth is not likely to occur in an environ- ment where sustainability is the overriding financial concern. While the specifics of re- imbursement and payment policy are uncer- tain at the moment, the move begun in the 1990s toward managed care and away from procedure-oriented fee-for-service will con- tinue.20 Moreover, it is reasonable to antici- pate that government programs will seriously consider capitation for complete episodes of care, including rehabilitation services, as a potential strategy in devising an alterna- tive payment system mandated by Congress and that private insurers would follow suit if such an alternative payment system were implemented. A high value has already been placed on services that decrease overall costs

10 Journal of Physical Therapy Education Vol 28, No 2, 2014

as capitated systems are incentivized toward savings. Although physical therapists and pa- tients tend to recognize the intrinsic value of physical therapy as it reduces impairments, increases function, and promotes quality of life, the profession should expect increased emphasis on its extrinsic financial value to save money. Physical therapist services that increase the costs of care without reducing or eliminating other health care costs will not be seen as valuable by health care systems, whatever their intrinsic value to patients. This value will be easiest to ascertain in closed sys- tems, such as self-insured hospital groups or employer-based insurance programs.

The emerging market shift does not nec- essarily entail a complete end to outpatient fee-for-service private practices, or even sound the death knell for self-pay practices. The number of older adults with potentially disabling conditions is clearly increasing, and the relevance of physical therapy to the func- tion and health of this population is generally accepted. Older adults with financial means will continue to seek out services they find beneficial. However, given the real and rela- tively high costs of providing physical thera- pist services, there are limits as to what the market will bear. The older adult patients with the most health care needs are likely to have lesser economic means to pay for them. Therefore services that are relatively infre- quent, produce long-term results, and make best use of personnel mix to lower costs are likely to benefit from changing demograph- ics and economic incentives. However, the profession also needs to consider that simi- lar services from less educated (and therefore less costly) providers are likely to increase at the same time, and the quality/cost ratio will remain in delicate balance for consumers and payers. Simply put, our profession will have to provide the right service to the right pa- tient using the right personnel at the right time in the right way for the right outcome at the right price.

DISCUSSION AND CONCLUSION There are 3 components to physical therapist practice as described in the Guide to Physical Therapist Practice21: documentation and care coordination, patient/client-related instruc- tion, and procedural interventions. The last of these, treatment for the older adult patient, is not the major challenge for the profession, presuming adequate academic education and clinical training in geriatric physical therapy as described by Wong and associates.2 Physi- cal therapists experienced in working with older adults know how to diagnose and treat those with multiple comorbidities and return them to the highest level of function. Howev-

er, the teaching component of physical thera- pist intervention could change drastically in an evolved health care delivery system in the decades ahead, particularly given the em- phasis placed on patient self-management, use of technology, and incentivizing to limit utilization. The patient in this system of the future is likely to be ethnically and racially more diverse, sicker with multiple chronic conditions, and generally less well-educated, which also means likely to have less economic means. English may not be the first language, and cultural preferences in diet, attitudes to- ward exercise and physical activity (outside of paid labor), and living conditions such as neighborhood amenities may not support be- havioral changes necessary to living well as an older adult at risk for deterioration of health and functional status. These individuals may not be well-integrated into traditional chan- nels of health care or have designated health care providers.

Evidence-based practice is more critical than ever, clinically and economically. The profession cannot meet the challenges ahead unless it sets aside a disposition to do what has always been done, commits to providing only those services whose efficacy is estab- lished, and promotes interventions whose effectiveness has been tested. Furthermore, goal-setting must fully incorporate the pa- tient’s perspective. While movement dysfunc- tion is central to diagnosis and intervention by physical therapists, developing the ca- pacity for movement (ie, movement under controlled clinical conditions) is not patient- centric. Physical therapists and physical ther- apist assistants must recognize that patients regard performance of functional activities in the natural environment of the home and the community as the standard for function- ing. Moreover, such a shift in perspective will increase the attention given to the patient’s physical and social environment as factors that influence disability.

Physical therapists must also position themselves for a leadership role among the array of professions who are attempting to corner the “post-rehabilitation” market, while recognizing that market forces will favor less expensive personnel over more highly edu- cated providers. Thus, physical therapists may need to grow more comfortable design- ing programs that can be implemented by supervising non-licensed personnel. Without uncontestable evidence that more expensive personnel, including physical therapist as- sistants, are safer or more effective than less expensive personnel, economics will prevail over professional provincialism. While it has become fashionable to speak of population- based physical therapy, on a practical level

much of physical therapy is appropriately delivered as a service to individuals. Gen- erally, physical therapist services are not population-based in the same respect as im- munization services are population-based. Innovation by physical therapists in health promotion by leading community-based fitness programs for older adults, especially individuals with chronic illness, will be a critical first step of physical therapy into public health . However, our profession has generally been reluctant to engage in popula- tion-based policy formulation or in planning services that meet the needs of any popula- tion segment, particularly if such policy or planning might engage service providers outside of physical therapy.

The profession is very aware of this im- pending evolution. The American Physical Therapy Association (APTA) has taken steps in recent years to address workforce and service delivery issues related to our aging population. As a member of the Eldercare Workforce Alliance, APTA has worked in a national coalition concerned with both the immediate and future workforce crisis in caring for older adults, by focusing on the workforce shortage, training and compen- sation, and advancing models of care.22 Ad- ditionally, as a member of the Partnership for Health in Aging, APTA was active in the development of Multidisciplinary Competen- cies in the Care of Older Adults at the Com- pletion of the Entry-level Health Professional Degree,23 and has endorsed the Partnership for Health in Aging Statement on Interdis- ciplinary Team Training in Geriatrics.24 In 2010, APTA explored innovative practice models being utilized to deliver physical therapist services in the US and found a di- versity of models being employed in a range of settings, including university-based, many having direct implications for older adults.25 Recently, APTA hosted the Innovation Summit: Collaborative Care Models, which brought together physical therapists, physi- cians, policy makers, and representatives from large health systems to discuss both current and future roles for physical thera- pists in integrated care models.26 In early 2014, APTA intends to initiate Innovation 2.0 to provide both guidance and funding to innovators who are developing or promoting the roles of physical therapists in collabora- tive care models.27

To effectively manage the emerging health care crisis, the workforce engaged in the practice of physical therapy with older adults will need to master a broad skill set. Perhaps most importantly, physical therapists who are ready to value the teaching components of practice as much as, or perhaps even

Vol 28, No 2, 2014 Journal of Physical Therapy Education 11

more than, direct treatment components, are primed to serve older adult populations in the coming decades. Future cohorts of older adults will need to understand how physical activity promotes high-level functioning and health across the lifespan, how exercise can improve balance and decrease falls and frac- tures, and how increasing functional well- being can diminish the impact of clinical and subclinical depression in the aftermath of sudden illness or injury such as stroke, heart attack, or other chronic illness. How- ever, physical therapists who succeed in the coming decades will need to develop a keen appreciation of the theory and practice of be- havioral changes as the system shifts greater responsibility to the individual for managing one’s own health.

There are certainly barriers to the adapta- tion and evolution needed by our profession to thrive in this challenging environment. Physical therapy is deeply embedded in tra- ditional reimbursement models that are rap- idly eroding. Whether physical therapists are prepared to accept a largely capitated system remains uncertain. The profession has typi- cally approached its role in the well-being of older adults through a fee-for-service system focused on treating disease. The profession has simultaneously ignored the underserved market of health promotion services for older adults with chronic illness. There is no doubt that the profession of physical therapy can provide knowledge and skills to support health maintenance and health promotion for older adults as a fundamental component of a restructured health care delivery system. The question is whether our profession is willing to move away from unsustainable economic models of health care delivery and adapt our expertise to fit the evolving organizational structure of health care financing for older adults.

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