Acute Care Physical Therapist Practice and Discharges Home:
The Work of One Learning Community
At Cleveland Clinic, we have prioritized the development of collaborative learning communities. A learning community (LC) is a group of individuals with distinct roles, knowledge, experience, and a shared resolve to address a clinical problem. In this case example, we highlight how one LC is working through each phase of the learning health system cycle to illuminate the value associated with acute care physical therapist practice. 1) “Identify the “problem of interest”: In 2021, Cleveland Clinic leaders identified as a priority the need to help more patients discharge home from the hospital. Since physical therapists play a central role in progressing a patient towards that goal, senior-level rehabilitation leaders sought to contribute, deciding to study relationships between the provision of physical therapist services and discharging to home. Their stated goals were to understand current practice and engage clinicians in practice changes capable of increasing discharges to home. 2) “Assemble a Learning Community”: Rehabilitation directors partnered with our research team to assemble a LC to achieve these goals. The research team was led by Dr. Joshua Johnson and included a biostatistician and research coordinator. In his role as a clinician scientist, Dr. Johnson collaborated with the rehabilitation directors to articulate scientific aims that could guide the work of the LC. Those aims were to 1) Describe physical therapy utilization patterns and patient outcomes thought to be affected by those patterns, 2) Test whether physical therapy utilization patterns are independently associated with patient outcomes of interest, and 3) Develop a clinician-facing data visualization tool and test the effect of providing this tool to physical therapists. For participation in the LC, a group of six physical therapists were identified due to their commitment to improving patient outcomes, work treating varied patient populations, and varying levels of experience. The LC also included the study team, three hospital rehabilitation managers, and technical experts (to facilitate data access and dashboard development). 3) “Practice to data”: In this phase of the cycle, the LC sought to determine the relevant variables to include in the descriptive analysis of physical therapy utilization and patient outcomes (Aim 1). This required several data extractions by the study team, with regular reviews by the full LC so that both clinicians and managers could iteratively conduct a critical appraisal of the data to ensure it was reflective of daily practice. The resulting dataset included patient-level variables (e.g., diagnostic category and functional status), practice-level variables (e.g., physical therapist visit frequency), and outcomes (e.g. function and discharge disposition). 4) “Data to knowledge”: From the descriptive analysis, the LC selected visit frequency as the most relevant variable of physical therapy provision and discharge to home as the most relevant outcome. This decision informed the analysis for Aim 2, which was conducted by our study team. Progress was discussed on occasion with the LC to ensure that findings would be clinically relevant. We found that visit frequency was associated with discharge to home, including within each broad diagnostic category (e.g., general medical, orthopedics, etc.) suggesting that some patients (but not all) in each diagnostic group may benefit from a high frequency of visits. 5) “Knowledge to practice”: Considering these findings, the LC met over several months to design together a clinician-facing data visualization tool that could inform practice (Aim 3). This tool, now known as the “Value Dashboard”, tracks the physical therapist visit frequency for each patient and the proportion of patients discharged home, aggregating data at the level of the therapy department, each therapy team, and each therapist. It is updated weekly, enabling regular discussion about how to improve and sustain practice patterns that lead to better outcomes. The LC is now in the process of assessing how access to the Value Dashboard influences therapists’ perceptions and patterns of practice, while considering how it should evolve to optimally inform practice.
Applied LeaRRning Case
Josh Johnson, PT, DPT, PhD is the PM&R Director of Outcomes Research at Cleveland Clinic. This case is a description of work Dr. Johnson completed as a LeaRRn Scholar, in which he, in partnership with rehabilitation directors and clinicians, examined associations between acute care physical therapy visit frequencies and patients’ likelihood of discharging home. In his presentation, Dr. Johnson highlights how their collaborative learning community progressed through the key phases of a learning health system cycle to address an organizational problem of interest.
“As rehabilitation leaders, clinicians, researchers, and other relevant partners have collaborated at each phase of a learning health system cycle, we are making progress toward understanding how we can help more patients to discharge home from the hospital.”
Josh Johnson, PT, DPT, PhD