Effective care management is essential in physical therapy. It helps coordinate treatment, track patient progress, and ensure each patient receives personalized, appropriate, and effective care. As clinical providers, we play a key role in promoting continuity, minimizing complications, and improving the overall patient experience — all of which contribute to better outcomes and more efficient recovery.
This guide is designed to support you in navigating patient care while partnering with Luna. Below, you'll find best practices for handling unique care situations and step-by-step guidance on when and how to reach out for support.
If you have any patient care questions, please message the Clinical team through your Luna app.
Sections
1. Managing a Patient that is “Out of Scope”
2. Clinical Escalation Management
3. Roles in Establishing a New Patient
4. Effective Discharge Planning
1. Managing a Patient that is “Out of Scope”
Patient and therapist safety is our top priority at Luna, and we strive to ensure that our care is clinically appropriate and meets the needs of our patients. This guide aims to provide valuable information on how Luna defines "out of scope" and what to do when a patient requires a higher level of care.
Defining “Out of Scope”
Luna has established clear requirements for clinical appropriateness in outpatient level care. During the intake process, patients are screened for the following factors:
- Need for Additional Services: We assess whether the patient requires nursing, occupational therapy (OT), or speech-language pathology (SLP) services in addition to physical therapy.
- Medical Complexity: We evaluate the patient's medical complexity, considering factors such as multiple comorbidities, ongoing medical treatments, or recent hospitalizations.
- Lower Functional Status: We assess the patient's ability to transfer and ambulate, determining if their functional status requires a higher level of care beyond outpatient therapy.
Patient Requiring Higher Level of Care
If a patient is found to require a higher level of care despite the screening process, it is essential to take the following steps:
- Communicate Clearly: Clearly communicate your clinical findings and recommendations for care with our clinical team and the patient (if appropriate). This ensures that everyone is aware of the situation and can take appropriate action.
- Escalate to Clinical Team: Our clinical team will escalate the findings to the referring physician, ensuring that they are informed about the patient's needs and the recommendation for a higher level of care.
Actions to Avoid
To ensure a smooth and compassionate transition for patients requiring higher level of care, it is important to avoid the following actions:
- Discharging without Notification: Do not discharge the patient without notifying them and the appropriate parties involved. Clear communication is vital to maintaining patient trust and ensuring continuity of care.
- Derogatory Language: Avoid using derogatory language such as "wheelchair bound" or any language that may be perceived as negative or stigmatizing. Maintain a respectful and person-centered approach in all communication.
Contacting the Clinical Team
- To get in touch with our clinical team, the preferred method is to message in the Luna app via chat.
- Please include information about clinical findings, recommendations, rationale, and the patient's response to findings or potential discharge. This allows us to provide the best possible assistance and guidance.
- Continuing Care: If the patient is medically stable and you can safely deliver outpatient level care, you may continue providing therapy within the appropriate scope should you choose.
2. Escalation Management
At Luna, we prioritize prompt and efficient communication, ensuring that medical concerns are addressed effectively. This guide provides comprehensive information on who to contact, when to escalate, the importance of handling emergencies, and communication best practices with non-pathways patients.
Who to contact?
- To escalate medical concerns or the need for physician office communication, it is best to reach out to Luna's clinical team via chat using the Luna app. The clinical team is readily available to provide support and guidance Monday through Friday 8am to 4:30pm PST.
- For Pathway patients, you will be prompted in the app to respond to escalation questions. Simply select “yes” for any area of concern and an automated message will be sent to the clinical team. Luna will promptly reach out to you during our business hours for additional information. If appropriate, please provide relevant pictures for medical escalations.
When to contact?
For any medical concerns, it is essential to escalate immediately. Clear communication is crucial when providing information. The clinical team may ask follow-up questions to ensure accurate and concise sharing of information. Being prepared for our return messaging helps avoid delays in urgent escalations.
Some common escalations include:
- Incident or traumatic event (Falls)
- Medical concerns (Vitals, abnormal response to treatment)
- Signs of DVT or infection
- Need for higher level of care
The purpose of escalation questions?
Our pathways feature incorporates escalation criteria as an essential component. Physicians and surgeons require prompt notification of escalations to address medical concerns swiftly and prevent unnecessary ER visits. Escalations also help ensure home safety, communicate post-op needs, and address progress concerns effectively.
Should I contact 911 or send the patient to ER?
For pathways patients, utilizing the escalation feature prompts allows us to communicate rapidly with the surgeon's office. Our streamlined communication channels with physician and surgeon teams enable quick responses. However, in true medical emergencies where immediate action is required, your clinical judgment is paramount. Contact 911 or refer the patient to emergency care for prompt medical attention. Be sure to alert Luna whenever this occurs.
Escalating Non-Pathways Patients:
For patients not enrolled in the pathways program, you can still communicate directly with the clinical team via message in the Luna app. The clinical team will then escalate concerns to the referring physician on file. Be prepared to answer follow-up questions so that the team can provide a timely and effective escalation.
3. Roles in Establishing a New Patient
Luna schedules all new patient Initial Visits. Follow up visits and continuity of care is typically managed by the treating therapist, and particularly so for Practice Patients.
How does Luna help its therapists prepare for a New Patient Evaluation/Initial Visit?
- Screening for Appropriateness: We assess if the patient is suitable for outpatient PT.
- Special Instructions: We collect any special arrival instructions for the physical therapist, including presence of pets, stairs, gate codes, etc...
- Home Health Services Check: We identify if the patient is currently receiving home health services. Luna services cannot be provided while a patient is receiving HH.
- Insurance Verification: We collect and verify insurance information to determine physical therapy benefits. If a payor requires a referral before starting care, Luna team will only schedule if a referral is on file.
- Notification of Patient Responsibility: We send an email to the patient with the estimated out-of-pocket costs once insurance benefits are confirmed.
- Appointment Reminder: We send a reminder to the patient 48 hours before the Initial Visit, including a prompt to complete intake forms before your arrival.
Top Things for the PT to Do During an Initial Visit:
Set Patient Expectations
- Clearly explain the evaluation process and what the patient can expect during the first session. Address any questions or concerns the patient may have.
- Provide a clear explanation of the patient's diagnosis and the prognosis based on the evaluation, anticipated number of visits & discharge plan.
- Outline what the patient can expect in future sessions, including the types of treatment approaches that will be utilized to reach their goals.
- Emphasize the importance of the patient's active participation in PT for optimal results, and seek to understand the patient’s goals and expectations.
Luna App Navigation
- Ensure the patient completes all necessary intake forms and understands the outcome measures used to track progress.
- Assist the patient with scheduling future appointments to ensure continuity of care. We recommend scheduling out at least 3-4 weeks in advance.
- Establish the Luna app, a HIPAA compliant platform, as the preferred method of communication for scheduling, updates, and questions.
- Help the patient navigate the Luna App, including how to access their schedule, Exercises in the Luna app, and communicate with you and Luna.
By following these steps, Luna physical therapists can set patients up for success on their road to recovery!
4. Effective Discharge Planning
One of the most rewarding, and also challenging things for physical therapists is wrapping up the plan of care! Physical therapists provide tremendous value, and have the unique opportunity to be involved in a patient's healthcare journey for an extended period.
However, there are times when PT’s can be more proactive with goal setting and discharge planning conversations with patients. Below are several strategies to optimize the discharge planning process:
Early Communication and Planning
- Involve the patient in planning their discharge, setting clear goals/expectations. Ensure they understand the role of PT, the plan to achieve goals, and how this aligns with their visit plan.
- E.g. “Based on your evaluation, I anticipate we’ll need 2x/week for 7 weeks to achieve the goals we set together.”
- Identify additional resources needed for a successful discharge, such as family support or unskilled care providers (caregiver, personal trainer, etc...).
Patient Participation and Responsibility of PT
- Educate patients on the distinct roles of skilled PT versus family support or unskilled care providers (caregiver, personal trainer, etc…).
- Clearly highlight the patient’s role in their recovery, particularly the importance of participating in an independent home exercise program.
- Regularly assess progress towards goals and changes in outcome measures to aid in discharge planning conversations.
Discharging Patients - Patient Dashboard for Therapists
- Therapist documentation determines the Visit Plan (Ex: 2x/wk for 7 weeks). When a patient has 4 or less visits remaining, the patient will appear in the “Discharging” section of the Patient Dashboard.
- For patients requiring extended care beyond the initial visit plan, update the Plan in your Chart to update the Visits tracker.
- Be sure to consider potential visit limitations such as authorization or POC signature.
- Utilize the Patient Dashboard for up to 90 days post-discharge for continued communication and support, as needed.
- Patients continue to have access to their Luna Exercises after they have been discharged.
Familiarize yourself with Medicare’s guidelines for Medical Necessity
- Medical Necessity: Clearly document the need for further physical therapy, highlighting the patient’s functional deficits and potential for improvement. It should be clear that without continued therapy, the patient's condition could deteriorate, or their recovery could be compromised.
- Skilled care: Care that requires the judgment, knowledge, and skills of a licensed PT to safely and effectively perform, and cannot be provided by individuals who do not have professional medical training.
- Detailed Treatment Plan: Include updates on goals, specific interventions, and the expected frequency and duration of visits. Interventions should specifically address the patient’s functional deficits and their ability to perform basic ADLs independently.
- Progress Reports: Regularly complete progress reports, detailing response to therapy, improvements made, and any necessary modifications to the treatment plan.
Key Consideration: The risk of Medicare audits increases significantly beyond $3,000 (~ 25 visits). It is crucial to document the medical necessity and skilled care provided to avoid compliance issues.
5. Outcome Measure Exclusions: Why, When, & How?
Why are outcome measure exclusions important?
- Outcome measure exclusions in outpatient physical therapy refer to the specific cases or circumstances that may not be appropriate or applicable for a particular patient. It is important to exclude appropriate patients from using specific outcome measures to ensure accurate and meaningful assessment of their progress.
- Nominating a patient for outcomes exclusion when appropriate allows for a more accurate representation of your patient outcomes at Luna.
When is it appropriate to exclude a patient from outcome measure collection?
The following are acceptable reasons to exclude a patient from outcome measure collection:
- Language Barrier: Patients non-English speaking and translation services are unavailable.
- Mental/Cognitive Impairment: Patients that have a mental or cognitive impairment that compromises their ability accurately complete the patient reported outcome.
- Maintenance Therapy: Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15.
- Extreme medical complexity: Patients with multiple, severe, and interconnected medical conditions or impairments that require highly specialized care and management.
- Referred to another facility: Patient did not finish care their care plan and was referred to another clinic or back to their MD for more appropriate care.
- Life expectancy of 6 months or less
I have a patient appropriate for exclusion, how can I exclude them?
Excluding a patient from outcome measure collection is a two step process.
1. Exclude the patient in your therapist app via the Patient Dashboard.
- Select the “Patients” icon at the bottom of your app.
- Find and select the patient you wish to exclude.
- Go to the Outcomes section and select “Nominate for Outcomes Exclusion.”
- Review, select appropriate exclusion and submit.
2. Ensure your documentation clearly supports the reason selected for exclusion.
