Direct access and #patient self-referral

WCPT supports the principle that people should have access to physical therapists without referral by a medical practitioner. Emma Stokes and Jonathan Kruger explore the issues. What is direct access? The terms direct access and patient self-referral refer to physical therapy services being available to patients/ clients without need for a referral by a third-party, usually a physician. Normally, direct access occurs when a patient/client self-refers to a physical therapist as an out-patient or in a primary care setting. However, it is also relevant to in-patient services, which can be provided without referral. In a growing number of countries, physical therapists have this "first contact status". The development of direct access in PT The requirement for a patient/client to be referred by a medical or dental practitioner began to be questioned in the 1970s in Australia and the United Kingdom1-3. Was there an ethical justification for this, physical therapists asked? Supporting the move away from this model of dependency was the profession's growing knowledge base and emerging research culture4. In addition, professional bodies were developing codes of practice, professional insurance and other means of accountability to ensure public safety when self-referring. Thereafter, changes in practice occurred in many countries. For example, in the United States, a successful model for direct access to physical therapy services was developed in the military to optimise access by injured personnel5,6. Why is it important now? There are many factors driving change towards direct access and self-referral. Demographic changes will result in more users of health services. They will be increasingly informed about the choices available to them and have higher expections of health services. Given financial constraints, services and interventions increasingly need to demonstrate both clinical and cost effectiveness. Health policies throughout the world are stating the need for patients/ clients to be able to selfrefer directly to the health care profession of choice. With health care moving increasingly into primary care settings, the removal of barriers to direct access to physical therapy provides a number of key advantages for patients/clients, including more choice. For physical therapists,direct access may result in increased autonomy and responsibility in the prevention and management of lifestyle related impairments and activity limitations. WCPT and direct access WCPT supports direct access and patient self-referral and the concept of physical therapists as first contact practitioners. A new policy on direct access and patient self-referral was adopted at the WCPT General Meeting in June 2011. It is available at Messages from research Research has mainly focused on direct access in primary care – for example, patients visiting physical therapists in the community or as out-patients7-12. Research has looked at two concerns. The first is that users of physical therapy services may be placed at risk if they do not have a physician referral. The second is that introducing direct access to physical therapy services will result in significantly more users of physical therapy services. The research has shown no evidence to support either concern. Not all patients/clients will self-refer, even if it is available. In Scotland and the Netherlands, following the introduction of patient/client selfreferral to physical therapists, 22-28% of patients/clients chose to self-refer while 18% attended at the suggestion of a primary care physician, but in the absence of a referral. In Australia, where self-referral has been possible for over 30 years, approximately 65% of patients use it. Some research suggests that when considering introducing direct access, some thought should be given to how its availability will be communicated to patients/clients and entry points such as health centres and health care personnel13. Age, education and socioeconomic status may all influence the extent to which patients/clients self-refer. It is possible that older patients/clients or those with lower levels of education will be less likely to self-refer. Patients/clients with symptoms of Direct access and patient self-referral WCPT Keynotes | Direct access short duration and those who have previous experience of attending a physical therapist are more likely to self-refer. Patients/clients who self-refer to physical therapy services are more likely to complete their course of treatment. One study noted that treatment goals were more often fully achieved. Research has also shown that there are significant cost savings when patient/client self-referral is introduced7-12,14. What do patients think? Research has shown that patients/ clients support direct access and self-referral when they are informed of its availability. However, it should not be assumed that patients who attend physical therapy know that self-referral is possible. Patients/clients who selfrefer to physical therapy report similar levels of satisfaction with their interventions to those referred by a physician. The availability of direct access and patient/client self-referral may result in patients/clients taking more responsibility for the management of their health problems. What do other health professionals think? In countries where the profession has attained or attempted to obtain primary contact status there have been tensions with the medical profession, who have said that physical therapists do not have the diagnostic skills to act as primary contact professionals. Opponents of direct access argue that physical therapists may overlook serious medical conditions. However, when the diagnostic accuracy of physical therapists has been directly compared to orthopaedic surgeons in prospective clinical trials, physical therapists have been found to be as diagnostically accurate15-17. Studies have also shown that the risk to the patient from physical therapy diagnosis is extraordinarily low. In a retrospective analysis of 472,000 patient visits at 25 military healthcare sites, 45% of visits were determined to be patients with direct access and without physician referral. No adverse events were reported from physical therapy diagnosis or management6. Competency to accept direct access patients A recent survey suggests that graduates of entry level programmes in most of WCPT member organisations have the required competencies to accept patient/client self-referral on graduation. Where it is not expected that graduates of entry level programmes will have the competencies to accept patient/client self-referral, a number of options are available: a period of supervised practice; the completion of Master’s level education; a period of continuing professional development. WCPT's guideline for physical therapist entry level education recognise that there is significant diversity between the environments where such programmes are delivered. Nonetheless, they recommend that graduates of entrylevel programmes are prepared as first contact autonomous practitioners. Barriers and facilitators In countries where legislation places limits on the extent and nature of the services provided by physical therapists, this can be a major barrier to advancing direct access/patient self-referral. In some parts of the world, reimbursement funding systems, requiring that a patient/ client is referred for physical therapy by a medical doctor, are also a barrier. Opposition from the medical profession can also be a problem. However, when there is support from the medical profession, this is a major facilitator for advancing direct access/patient self-referral. Waiting lists and service demand have also been reported as being notable facilitators for enabling direct access/ patient self-referral. There are also professionalspecific facilitators such as the quality of entry-level education, the development of professional autonomy and scope of practice and key individuals within the professional organisation acting as leaders to drive this development. Regulation Direct access/patient self-referral brings with it a set of responsibilities and it is best provided in the context of appropriate regulation of the profession. This ensures standards of education and ongoing practice as well as mechanisms to protect the public should the services provided by a physical therapist be a cause for concern. Reading list Galley P (1976) Patient referral and the physiotherapist. Aust J Physiother XXII (3):117-120 Holdsworth LK, Webster VS, McFadyen AK, The Scottish Physiotherapy Self Referral Study Group (2007) What are the costs to NHS Scotland of self-referral to physiotherapy? Results of a national trial. Physiotherapy 93:3-11. Holdsworth LK, Webster VS, McFadyen AK, The Scottish Physiotherapy Self Referral Study Group (2007) Self-referral, access and physiotherapy: patients’ knowledge and attitudes Kruger J (2010) Patient referral and the physiotherapist: three decades later Aust J Physiother 56:218-219. LeemrijseCJ, Swinkels ICS, Veenhof C (2008) Direct access In physiotherapy in the Netherlands: results from the first-year In community-based physical therapy. Phys Ther 88(8):936- 946. References References for this article can be found at Keynotes is a series of occasional papers dealing with important professional, practice and policy issues relevant to physical therapists across the world, and to the development of physical therapy internationally. Keynotes are written by independent authors and do not necessarily represent WCPT’s opinion. For further information contact: WCPT, Victoria Charity Centre, 11 Belgrave Road, London SW1V 1RB E-mail: عنوان البريد الإلكتروني هذا محمي من روبوتات السبام. يجب عليك تفعيل الجافاسكربت لرؤيته. The World Confederation for Physical Therapy is a registered charity in the UK, no 234307 © WCPT 2011 Emma Stokes is Associate Professor in Physiotherapy at Trinity College, Dublin, Ireland. Jonathon Kruger is General Manager, Advocacy and International Relations Division, Australian Physiotherapy Association

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