Only 35% of physical therapy patients fully adhere to their plans of care
We have all been “there”. We spend an hour doing a comprehensive evaluation on a patient. We educate the patient on what the diagnosis is and what treatment will be. We schedule the patient for visits. We feel confident that everything went well and set a plan of care for the next few weeks. When it’s time for the next session the patient doesn’t show or cancels. We place a follow-up call that isn’t returned. After a few weeks we discharge the case for non-compliance and wonder what went wrong.
Physical therapists spend an average of 6.5 to 7 years learning how to evaluate and treat patients. They attend educational courses each year to improve and expand their skills. Yet with all of this effort, education, and thought Only 35% of physical therapy patients fully adhere to their plans of care.1
There are many pieces of a physical therapy evaluation. According to the APTA Physical Therapist Guide To Practice, “Physical therapists engage in an examination process that includes taking the individual’s history, conducting a standardized systems review, and performing selected tests and measures to identify potential and existing movement-related disorders. The data gathered during history taking, including answers to review of systems questions, enables the physical therapist to generate diagnostic hypotheses and select specific tests and measures to identify and characterize signs, symptoms, and risk of movement dysfunctions. To establish the individual’s specific diagnosis, prognosis, and plan of care through the evaluation process, physical therapists synthesize the collected examination data and determine whether the potential or existing disorders to be managed are within the scope of physical therapist practice. Based on their subsequent judgments about diagnoses and prognoses, and considering an individual’s goals, physical therapists manage an individual by making referrals, providing interventions, conducting reexaminations, and, as necessary, modifying interventions to achieve the individual’s goals and outcomes and to determine a conclusion to the plan of care. The detailed physical therapist examination and evaluation process is similar in structure across individuals, but will vary in specific content based on the individual’s needs.”2
We know we have the skills to help patients. We have a strong desire to help patients achieve their goals. The question we have to ask ourselves is “where are we going wrong?”.
We are not alone in the medical community when asking this question. Medical noncompliance has been identified as a major public health problem that imposes a considerable financial burden upon modern health care systems. There is a large research record focusing on the understanding, measurement, and resolution of noncompliance, but it is consistently found that between one third and one half of patients fail to comply with medical advice and prescriptions.3 Studies have shown that in the United States alone, non-adherence to medications causes 125,000 deaths annually and accounts for 10% to 25% of hospital and nursing home admissions.4 Patient non-adherence is not limited to medications alone. It can also take many other forms; these include the failure to keep appointments, to follow recommended dietary or other lifestyle changes, and to follow other aspects of treatment or recommended preventive health practices.5
While patient compliance may be a challenge, there are some things physical therapists can do on the initial evaluation day to increase chances that the patient will comply with the treatment plan.
- Find Out What They Need and What They Want
Prior to introducing yourself, look over the intake form to understand why the patient is coming to see you. Often patients put their time and effort into filling out forms, only to have to re-state what they just wrote. Review the forms and start to get an understanding of why the patient is coming to see you. When the patient is in front of you, acknowledge the findings on the intake form. This may look like “Mr. Jones, I see that you have had back pain for the last 6 months. It hurts when you try to lift anything and when you are walking.” At this point open up the conversation to fully understand what the patient isn’t able do based on having this pain. Most people come to physical therapy not just because they have pain. They usually arrive at our door when this pain is stopping them from doing something they want to do. Getting a full understanding of what it is that the patient wants to be able to do is vital in increasing compliance.
- Ask If The Patient Has Had Physical Therapy In The Past
If patients have had a negative experience in physical therapy in the past they are less likely to be compliant. It is valuable to understand what the patient has felt worked or did not work in the past.
- Ask “How Important Is It For You To Handle This?”
Everyone is busy. Regardless of if you are retired, have children, work full-time or part-time. It is human nature to get overwhelmed with daily schedules. Many patients intend to follow through with treatment, but get distracted with their daily lives. This is a great question to help the patient keep on task with overcoming their problem and to remain true to the treatment plan.
- Test – Treat – Re-Test
You should have a goal on every visit to make a meaningful change on the first (and every) visit. Small steps on every visit add up to big gains overtime. It also allows the patient to see the value of attending physical therapy.
To do this pick an impairment that the patient is showing. For instance, if a patient is able to lift their arm into shoulder flexion to 40 degrees you may decide to perform shoulder mobilizations. Immediately after re-test shoulder flexion. Show the patient that this has increased the range of motion by the number of degrees you find when re-testing. This demonstrates immediate value and motivates a patient to follow their treatment plan towards full range of motion and return to the activity they are unable to do.
Patients who are well informed and understand what their impairment is are more likely to be compliant. It is important to use lay language when discussing exam findings and treatment.
- Agree On and Review The Plan Of Care
Patients should fully understand what the plan is and understand what successful treatment looks like. They should receive an explanation of rationale of frequency and duration.
- Schedule Patients For The Full Plan Of Care
Patients who have needs for specific times and days will have better success in scheduling if they do this at the time of evaluation. They will also create a habit of attending their sessions and be more successful in staying focused on their plan of care.
- Phys Ther. 1993 Nov;73(11):771-82; discussion 783-6.
- American Physical Therapy Association. Guide to Physical Therapist Practice. Second Edition. American Physical Therapy Association. Phys Ther. 2001 Jan;81(1):9-746. PubMed PMID: 11175682.
- Donovan JL. Patient decision making. The missing ingredient in compliance research. Int J Technol Assess Health Care. 1995 Summer;11(3):443-55. Review. PubMed PMID: 7591546.
- Smith DL. Compliance packaging: a patient education tool. Am Pharm. 1989;NS29(2):42–45. 49–53.
- Atreja A, Bellam N, Levy SR. Strategies to enhance patient adherence: making it simple. MedGenMed. 2005;7(1):4. Published 2005 Mar 15.