Christiana Care Physical Therapy

Background Information

Christiana Care Rehabilitation Services provides outpatient rehabilitation at 9 sites
throughout northern Delaware. This analysis looks at the Middletown location, which
provides both outpatient orthopedic physical therapy and outpatient rehabilitation
services. Outpatient Orthopedics deals with any musculoskeletal injuries and schedules
patients every 25 minutes, with 50 minutes provided for an initial evaluation.
Outpatient rehabilitation consists of three disciplines; Physical therapy, Occupational
therapy, and Speech Therapy, with patients are scheduled every 45 minutes for both
treatments and initial evaluations. Orthopedic patients are seen 5 days a week Monday
Friday, and Rehab patients are seen at this location 2 days a week, Tuesdays and
Thursdays. Christiana Care also offers aquatic therapy, which is primarily used with the
orthopedic patients and is the only therapy facility in Middletown that offers aquatic
therapy.

Current Staff Includes:
2 Full Time Orthopedic PTs (40 hours per week)
1 Full Time PT/Manager (20 hours per week rehab/20 hours per week
Orthopedics)
1 Part Time OT (16 hours per week)
1 Part Time ST (16 hours per week)
1 Full Time Front office manager
Exercise Technicians



Christiana Care Mission Statement The Christiana Care Way

T


The Christiana Care Way is our promise to youand to each other:
"We serve our neighbors as respectful, expert, caring partners in their health. We do
this by creating innovative, effective, affordable systems of care that our neighbors
value."
As a not-for-profit health system, our mission is one of service. We believe that the key
to providing truly great health care is to partner with our patients and their families,
building a system of care that is effective, affordable and valuable to everyone who is
touched by it.

How do we know what is valuable to our patients. We ask. And we listen. We
understand that medical expertise is fully effective only when it is paired with respect
and compassion. And we understand that the way to help our neighbors to get well and
stay that way requires that we take the time to learn about who they are, what they
want and what they need. (www.christianacare.org)

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The Problem

The current scheduling system used for orthopedic patients results in difficulty
scheduling new patients and aquatic patients and creates disturbances in work flow,
which creates bottlenecks, increasing patient waiting times and decreasing quality of
care provided.

There are 3 different appointment types used, each with different processes and
process times that are being merged into one single schedule. (See process maps and
example of current schedule attached). The schedule currently used is based on 25-
minute appointments times.

There are 3 types of appointments used:

1. Treatments
o All treatments are scheduled for 25 minutes
o A typical treatment session lasts approximately 45 60 minutes

o


Check-in
(2 min)
Exercise
(15-30 mins)
Manual
Treatment
(15-30 min)
Modalities
(0-15 mins)
Documentation
(5 mins)
Check-out/Schedule
(1-5 mins)











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2. Evaluations
o Evaluations are scheduled for 50 minutes (2 back to back 25 minute
appointment slots)
o Evaluations typically take 30-45 minutes with the therapist
o Patients have consent forms and paperwork to fill out before being
evaluated this typically takes 10-20 minutes
Patients are asked to come in 15 minutes early if their paperwork
has not already been completed but this does not always happen.



Check-in
(2 min)
Patient fills
paperwork
(15-20 mins)
Evaluation by
Therapist
(30-45 mins)
Treatment
(10-15 mins)
(Time Permitting)
Schedule Future
Treatments
(10-15 mins)
Check-out
(2 min)
Documentation
(15-20 mins)
Check-in
(2 min)
Patient fills
paperwork
(15-20 mins)
Evaluation by
Therapist
(30-45 mins)
Treatment
(10-15 mins)
(Time Permitting)
Schedule Future
Treatments
(10-15 mins)
Check-out
(2 min)
Documentation
(15-20 mins)



2.3. Aquatic Treatments
oa. Patients are scheduled for 50 minutes in the pool, followed by a 25
minute appointment on the therapists schedule
ob. Patients are typically in the pool for 30 minutes followed by 5-20 minutes
of changing time (depending on the patient). This is followed by 10-15
minutes of treatment with the therapist
oc. The pool schedule is separate from the therapists schedule and patients
pool time is usually scheduled concurrently with 2 treatments on the
therapists schedule
od. Pool availability is currently limited because an exercise technician is
needed to supervise the patient while they are in the pool based on how
they are currently scheduled.
i. Currently limited to MWF 9:00-3:00
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Patients are often scheduled based on pool availability and may
be put randomly on the therapists schedule, which means that
they may actually be ready to be treated by the therapist when
another patient is scheduled.
ii.

Check-in
(2 min)
Aquatic
Treatment
(25-35 mins)
Change/Shower
(5-20 mins)
Manual
Treatment
(10-15 mins)
Modalities
(0-15 mins)
Check-in
(2 min)
Documentatio
n
(5 mins)






Because these 3 types of appointments have various lengths and the actual
appointment times generally overlap each other, the schedule creates backups for the
therapists, which can result in increased waiting times for the patients, backlog of
documentation for the therapists, and decreased quality of care and patient satisfaction
(See Example Schedule Flow. Often times, patients come to Christiana Care because of
their reputation for more personalized care and attention from the therapists that they
do not get at other therapy locations. This results in improved outcomes and greater
patient satisfaction. However, this current scheduling system can create situations that
decrease the therapists ability to provide one to one treatment to the patients.

As seen in the example provided, there is often significant overlap of treatment
between patients, and the mixing of appointment types feeds into this (See example
schedule flow). In addition, because the schedule is based on 25-minute appointment
slots, it can be difficult for the front office to effectively schedule new patient
evaluations that require 50 minutes of time blocked out in the schedule. Also, the
current schedule requires patients to be scheduled for aquatic treatment while the
therapist has other patients on their schedule. This provides little to no opportunity for
the therapist to provide any supervision of the patient while they are in the pool.

To improve this process, we propose changing the schedule so that all appointments
types are scheduled as 40 minutes in length.

This new scheduling system would provide several advantages.
Improve ease and efficiency of scheduling and help to eliminate scheduling
errors
o All appointment types would be equal in length on the schedule., Thisit
would allow the person scheduling to only have to look for open
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appointments on the schedule and not have to worry about needing to
find two slots for an evaluation, or to coordinate between scheduling an
aquatic patient on both the pool schedule and then a therapists schedule.
Eliminate the need for a separate pool schedule because the patient could be
scheduled right onto the treating therapists schedule
Allow therapists to provide appropriate supervision of aquatic patients while
they are in the pool because the therapist would not have other patients
scheduled simultaneously
Eliminate the need to restrict pool hours based on Exercise Technician
availability
Allow for increased supervision and more one to one interaction with patients
during treatments
Allow therapists to bill for 3 units of supervised therapy codes during treatments
and aquatic therapy sessions vs. ability to only bill for 2 codes under the current
25 minutes appointment system
Billing for aquatic therapy would be more ethical as the therapist would be
providing direct supervision to the patient that is in the pool and not
concurrently treating other patients
Eliminate the need to block out documentation time
Help to decrease patient wait times
Eliminate therapist backlogs with documentation and billing
Serve as a market tool to referring physicians that their patients are getting
individualized, one-on-one treatments with their therapist for 40 minutes at
Christiana Care

Disadvantages of changing to the proposed schedule would include
Decrease the total volume of patient that could be seen by the existing staff,
which may mean that hiring additional therapists may be necessary
o If it is necessary to add additional therapists, that cost would be offset by
a decreased need for exercise technician hours and increased revenue
through increased billable units per patient under the proposed schedule
change

Schedules

CURRENT SCHEDULE PROPOSED SCHEDULE
6:55

7:00
7:20

7:40
7:45

8:20
8:10

9:00
8:35 BLOCK

9:40
9:00

10:20
9:25

11:00
9:50

11:40
10:15

12:20
10:40

1:00
11:05

1:40
11:30 BLOCK

2:20
11:55
12:20
12:45
1:10
1:35
2:00

Current Proposed
Appointments Available (8 Hour Shift) 16 12
Billing Units Per Treatment 2 3
Billing Units Per Therapist (8 Hour Shift) 32 36


Effects of Changes Patient Volume (July 2013 March 2014)

Clinic Volume ( July 2013 March 2014)
Month Treatments Evaluations Cancel
No
Show
#
Days
Total
Seen
Total
scheduled
Jul13 635 53 78 93 22 688 859
Aug13 644 65 93 22 22 709 824
Sep13 583 43 69 22 20 626 717
Oct13 629 48 86 16 23 677 779
Nov13 450 44 56 23 20 494 573
Dec13 454 49 105 29 21 503 637
Jan14 587 56 150 20 22 643 813
Feb14 506 51 146 17 20 557 720
Mar14 563 56 130 24 21 619 773


Asset Utilization (Monthly)
Asset Current Proposed Treatment Days
PT1 212 180 20
PT2 320 240 20
PT3 320 240 20
OT 80 96 8
ST 72 88 8

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Total 1004 844
(Monthly) (Monthly)



Current
Schedule
Proposed
Schedule
Appointment Length 25 minutes 40 minutes
Treatments/Week (Maximum) 194 150
Treatments/Month (Maximum) 776 600
Timed Units Billed/Treatment 2 3
Timed Units Billed/Week (Maximum) 388 450
Time Units Billed/Month (Maximum) (20 Days) 1,552 1800
Amount Billed/Treatment (Low) $46.74 $71.79
Amount Billed/Treatment (High) $50.10 $73.47
Amount Billed/Month (Low) $36,270.24 $43,074.00
Amount Billed/Month (High) $38,877.60 $44,082.00



The above charts show the statistics for the clinic over the pervious 6-month period and
the number of available appointments under the current schedule and the proposed
schedule. Although the proposed schedule cuts down the amount of available
appointments per month (based on 20 treatment days), it still provides enough capacity
to handle the current patient loads over the previous 6 months. There is more than
enough capacity in the proposed schedule to handle the amount of patients seen and
there is enough capacity to handle the amount of total appointments scheduled. This
indicates that in this clinic, a change to the proposed scheduling system would not
require additional staff based on the volume over the past 6 month period. Because no
additional staffing is required, the change to the proposed schedule would decrease idle
time of therapists, and would actually result in increased revenue through increased
units billed. and decrease in exercise technician hours.

We also believe that this new proposed schedule will enhance care that is provided in
accordance with the Christiana Care Way and the Focus on Excellence Diamond. Our
proposed schedule would result in increased ease of scheduling for patients and
employees, enhance patient care and clinical excellence by allowing the therapists
increased personal time with each patient, and increased supervision will lead to
increased patient and staff safety. Because of these things, patient satisfaction will be
increased, and will lead to increase in return clients and increase in referrals from
physicians, creating greater financial strength.

Defining Success
Successful implementation of this new scheduled would be defined by
Decrease in scheduling errors
Decrease in patient waiting times to < 5 minutes per patient
Increase in patient satisfaction as measured through month patient satisfaction
surveys
Decrease in therapist backlogs of documentation and billing
Increased employee satisfaction

Due to Physical Therapy being a service, it is difficult to make changes to the
actual process, as therapy is individualized, meaning that the process is never exactly
the same for each patient. As we were examining the general processes involved in
therapy, the way that appointments were scheduled continued to show up a limitation
to these processes. By making these proposed changes, we feel that we would positively
effect patient experience and therefore patient satisfaction, and take stresses off the
therapists, while at the same time actually increasing revenues.

One Additional change that we would also recommend is to make paperwork for
new patients available online, so that patients could fill it out prior to coming in for their
evaluation. This would decrease process time of the initial evaluation, and would
provide more time for the therapist to spend with the patient without going into the
next scheduled appointment time.

Limitations to Proposal

While this proposed scheduling system would be advantageous for the clinic discussed,
currently individual clinics do not have the autonomy to make schedule changes by
themselves. Most other clinics in the system do not have aquatic therapy, and therefore
do not have pool schedules to worry about and have different volumes and different
staffing needs. Most of the advantages of the proposed schedule would remain valid for
all clinics, although some of the scheduling problems of the Middletown clinic may not
be uniform throughout the entire system. The proposed schedule would have to be
further evaluated for each of the 9 locations, to determine if various patient volumes
and staffing needs of all the clinics would be enhanced through this new proposed
schedule. The other solution would be for upper management to allow individual clinics
to make changes based on their own needs and own best interests, in which case it
would seem to be in the best interest of Middletown to adopt our proposed schedule.


Attachments
Physical Therapy Treatment Process Map
Aquatic Treatment Process Map
Initial Evaluation Process Map
Physical Therapy Process Map
Example of Current Schedule vs. Proposed Schedule
Example of Patient Flow using current Schedule
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