Systems Thinking

According to Peter Senge, systems thinking is the practice of seeing wholes. It is a framework for identifying significant relationships between the influences of macrocosmic forces and structures rather than within them. It is seeing patterns of change, rather than static snapshots. It is a focus on “circles of causality” and interrelationships rather than linear cause-and-effect chains and underscores the maxim that “every influence is both cause and effect. Nothing is ever influenced in just one direction” (7).

As mentioned earlier, health care organizations are made up of small and large microsystems, with an interdependence defined by relationships between policies, procedures, regulations, and staff. Each of these microsystems affects others around it and in turn is affected by other microsystems. They are individual parts of a larger whole. As a systems thinker, the physiatrist needs to understand the role of rehabilitation medicine in his or her own health care system, his or her own role within that system, and look for patterns of interdependencies. This is important, because in application of systems thinking, all individuals and their microsystems share in the responsibility for the success and failures generated by their interdependent health care system. Senge also writes that mastering systems thinking “lies in seeing patterns where others only see events and forces to react to” (7). Systems thinkers realize that health care systems have a dual complexity—detail and dynamic complexity.

Detail complexity refers to the various variables that need to be considered, whereas dynamic complexity refers to the subtle causes and effects that are not linear, yet connected in time and space in such a way that their impact is not necessarily obvious.

Dynamic complexity is at work when an action has both local consequences in the health care system and also distant consequences somewhere else in that system. Situations wherein an action with ostensibly localized consequences can grow and have more significant consequences are also illustrative of dynamic complexity. For example, a bedbound diabetic patient whose disease is aggressively treated on an acute medical service in one part of the health care organization may experience hypoglycemia once the patient starts his or her rehabilitation program on an acute inpatient rehabilitation unit in another part of the organization.

Systems thinkers also recognize that they cannot always see the long-term consequences of their actions because of the limited time frame from which the provider must form an analysis. For example, a physiatrist administering a trigger point injection to a patient with myofascial pain may inadvertently cause a pneumothorax; however, the physiatrist may not know this if the patient is not readily available for follow-up and receives treatment for this complication at a hospital in a distant setting.

A systems thinker might, in addition to temporal constraints, meet with organizational limitations on their analyses. They cannot always see the impact of their actions on more removed parts of the institution. For example, a policy decision to address increased length of stay on a medical ward by earlier discharges to an inpatient rehabilitation ward in the same institution may lead to more acute discharges, higher costs of care, and decreased functional outcomes from provision of rehabilitation services due to increased medical acuity of the admitted patients earlier than they might otherwise be considered fit to undergo 3 hours of therapy per day.

Still, systems thinkers become experts at looking for delays and bottlenecks in the health care system as well as workarounds. These can be indicators of system-wide issues.

To be an effective systems thinker, a physiatrist needs to:

To become a systems thinker, one must learn to practice effective reflection, inquiry, and dialogue. Senge commented that “reflective openness leads to looking inward, allowing our conversations to make us more aware of the biases and limitations in our own thinking, and how our thinking and actions contribute to problems” (7). This should be done at the individual level as well as collectively at the group level.

Through thorough and consistent inquiry, we can challenge our mental models for how things work and should work in a health care organization. Senge asserts that mental models are often flawed because they focus on only readily visible variables, miss critical feedback relationships, misjudge time delays, see the system in overly simplistic terms, and are dominated by linear thinking.

Through effective inquiry, the systems thinker develops a collective understanding of the health care system—warts and all—from different perspectives and thus creates a collective mental model.

Dialogue refers to the collective review of the system among the key stakeholders in that system, especially after an unexpected event or outcome has occurred. Some points to consider include (39):

THE PHYSIATRIST AS SYSTEMS CONSULTANT IN REHABILITATION HEALTH CARE DELIVERY SYSTEMS

Following acute hospitalizations for illness or injury, individuals are often referred for postacute care (PAC). This care is usually provided in inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home-based care. The goal of PAC is to improve the level of function to the highest level possible and to assist with the transition from hospital to the community (8).

Inpatient Rehabilitation Services

It has been reported that Medicare is the payer in approximately 70% of patients admitted to IRFs. In 2006, there were 404,000 Medicare discharges from IRFs (9).

Section 1886(j) of the Social Security Act authorized the prospective payment system (PPS) for the payment of inpatient rehabilitation services. The Centers for Medicare and Medicaid Services has described IRFs as “free standing rehabilitation hospitals and rehabilitation units in acute care hospitals. They provide an intensive rehabilitation program and patients who are admitted must be able to tolerate 3 hours of intense rehabilitation services per day” (10).

In this system, payment is based on information collected from patient assessment instruments (PAIs). This information includes data about the patient’s clinical diagnosis, comorbidities, impairment group, swallowing status, level of function (based on the Function of Independence Measure) at admission and discharge, interruptions to their rehabilitation program, discharge destination, complications encountered during the course of a rehabilitation program, and quality indicators about pressure ulcers and catheter-associated urinary tract infections (11).

Patients are grouped into rehabilitation impairment categories and mixed-case groups, then subsequently into four tiers within each mixed-case group where the costs associated with the patient’s comorbidities are factored in to determine a higher or lower level of payment. The payment level is also adjusted if the patient had a length of stay less than 3 days or one that was shortened due to a transfer. Other factors that are considered in the payment include (a) geographic differences in labor costs, (b) whether the facility is located in a rural area, (c) whether the facility treats a high proportion of low-income patients, and (d) whether the facility has a residency training program.

In order for an IRF to be payed under the PPS instead of the acute care hospital inpatient PPS, the facility must treat patients with one of 13 medical conditions for a minimum of 60% of its total inpatient population. This compliance threshold is known as the “60 percent rule.” These medical conditions are stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, hip fracture, brain injury, and neurological disorders (multiple sclerosis, motor neuron disease, polyneuropathy, muscular dystrophy, Parkinson’s disease, and burns).

To substantiate the need for admission to an IRF, complexity of the condition can be taken into consideration in some clinical scenarios such as (a) severe arthritic conditions in which less intensive rehabilitation programs were not successful, (b) the patient underwent bilateral knee or hip joint replacement surgery just before the admission to the IRF and was obese (body mass index of at least 50 at the time of admission to IRF) or is 85 years or older at the time of admission to the IRF. The patient must be medically stable to participate in the rehabilitation program and have a need to be medically supervised during the rehabilitation stay (12). Quality indicators must be reported for catheter-associated urinary tract infections and pressure ulcers by the IRF facility. Failure to report leads to a two-percentage point penalty in payment effective in 2014 (13).

Conditions for payment under PPS also stipulate that patients directly admitted from the community to the IRF following a first illness are responsible for a deductible, whereas those admitted from an acute care hospital to the IRF are not. The patients would also be responsible for copay for the 61st to 90th day according to Medpac (14).

Outpatient Rehabilitation Services

A course of outpatient rehabilitation commonly includes services provided by physical therapists, occupational therapists, speech pathologists, and physiatrists. Medicare pays for services provided by “skilled professionals that is appropriate, effective for a patient’s condition and are reasonable in terms of frequency and duration. The beneficiary must be under the care of a physician, have a treatable condition, and be improving.” “Medicare does not cover maintenance-level outpatient therapy services.” Speech pathologists may bill Medicare directly. Certain services provided by physical and occupational therapy assistants are also covered if performed under the supervision of a qualified therapist who bills for these services. For most services, Medicare pays the provider 80% of the fee schedule amount and the patient pays a 20% copayment. Medicare has therapy caps for outpatient rehabilitative therapy services provided by physical therapists, occupational therapists, and speech and language pathologists, unless they are provided in a hospital outpatient therapy department (15).

Skilled Nursing Facilities

Medicare covers costs of an admission in a skilled nursing facility for patients following a hospital stay of at least 3 days that requires specialized nursing and/or rehabilitative care. Medicare pays the SNF on a predetermined per diem rate for up to 100 days through a PPS. The base payment rate takes into account geographic differences in labor costs and case mix. Case mixes enable the Resource Utilization Groups (RUGs), which have nursing and rehabilitative therapy weights that are applied to the base payment rate (16). Patients are assigned to an RUG based on the following: (a) number of minutes of therapy that the patient will need (e.g., need more or less than 45 minutes of therapy per week), (b) need for specialized services such as respiratory therapy, (c) presence of certain conditions, and (d) patient’s level of function for eating, toileting, bed mobility, and ability to transfer (16).

Home Services

Home health agency (HHA) personnel provide care in the patient’s home. This typically includes skilled nursing, physical therapy, occupational therapy, speech pathology, social work, and home health attendants. The Center for Medicare and Medicaid Services (CMS) pays HHAs for these services for 60-day episodes based on a PPS. Patients are assigned to 1 of 153 home health resource groups (HHRGs) based on their level of function and required need of services using the Outcome and Assessment Information Set (OASIS). The HHRGs range from those comprised of uncomplicated cases to very complicated patients in need of extensive rehabilitative resources. The base rate for the HHRGs takes into account geographic differences in labor and administrative costs, and whether the patient needs more or less than five visits, and whether the payment is subject to a high cost or short stay outlier, respectively. The PPS also pays for nonroutine medical supplies (17).

PATIENT CARE COORDINATION IN THE PRACTICE OF REHABILITATION MEDICINE

Patient care is often delivered in multiple settings and is provided by multiple different providers. It is not uncommon for patients to be admitted to a medical or surgical ward of a medical center for an acute illness or injury and be cared for by a team of physicians, nurses, and therapists, and then, once stabilized, be transferred to another ward, only to be cared for by another team. Subsequently, admissions to a medical rehabilitation facility and/or a skilled nursing facility and care by other teams often ensue.

Coordination of the patient care across this health care continuum requires a working knowledge of the following: (a) the health care system and its rules, regulations, and policies; (b) health insurance companies—their policies, rules, and regulations as they apply to the patient and his or her diagnosis; (c) community resources; and (d) effective communication and interpersonal skills and an ability to work with a team that consists of different clinicians and administrative staff.

The physiatrist is well suited for this role by virtue of his or her training in the team approach to patient care. The patient’s best interests should remain paramount in the mind of the physiatrist at all times and serve as the primary driver of care and decision making—a concept known as patient-centered care.

In the inpatient setting, interdisciplinary team meetings and interactions are ideal opportunities to coordinate the care of the patient with a coalition that might at any point include therapists, nursing staff, social worker, psychologist, and recreational therapists. In these settings, the team can set goals, discuss medical complications that are affecting the patient’s ability to reach functional goals, and determine length of stay and postdischarge plan of care. The physiatrist can also coordinate clinical care among medical and surgical consultants and communicate information to treating therapists.

Coordination of care is especially important at transition points when attention to detail is paramount. The information passed from one treating team to another should be complete and include key information about the following:

If this information is not complete, the physiatrist should obtain it from the most credible source and subsequently ensure that it is passed along to the next team caring for the patient in the inpatient or outpatient setting.

The time of discharge from an inpatient rehabilitation facility to another facility or to a home setting is another opportunity for ensuring that care coordination is effectively handled. This includes contacting the physicians at the receiving institution or the patient’s primary care physician in the community, and verbally discussing the key aspects of the patient’s care and any concerns or pending test results that need follow-up.

If the patient is to receive home health services, discussing the patient’s care with the nurse or therapist in the home setting can also ensure that the patient’s care is not interrupted and that an appropriate treatment plan is carried out. Telemedicine technology can play a significant role in patient care coordination with monitoring of the patient’s condition in the home setting using monitors for vital signs and periodic phone calls from nurses or physicians.

One should take care to remember that the patient and family members are integral partners to the physiatrist in care coordination. The physiatrist should take the time to educate his or her patient about key aspects of the patient’s diagnosis, potential problems, and how to best manage them as well as how to self-advocate for their needs.

THE PHYSIATRIST AS RESOURCE MANAGER

There is evidence that patients discharged from comprehensive medical rehabilitation facilities gain functional improvement relative to their condition at the time of admission in the context of a variety of conditions, such as hip fractures, stroke, brain injury, medical debility, and lower limb joint replacement. In addition, the vast majority of patients with these conditions are discharged back to the community.

Ottenbacher and Graham described four types of barriers to access for rehabilitation services: financial, personal, structural, and attitudinal.

Financial barriers include insurance coverage and out-of-pocket expenses for treatments. Personal barriers include lack of understanding of rehabilitative resources available, lack of knowledge about how to access these services by patients, and socioeconomic factors. Examples of structural barriers include referral patterns restricted to specific providers and institutions, and the 3-hour rule, which limits access to certain types of rehabilitation facilities. Attitudinal barriers are based on individual beliefs and preferences about rehabilitation services and their outcomes (24).

Chan discusses the impact that changes in the payment systems for PAC have on quality, outcomes, and access to rehabilitation services. He raises concerns that while the changes in the payment systems carry financial incentives for different providers of rehabilitative services, there is conspicuous lack of information about where the incentives should be placed to ensure the most effective and efficacious treatments for different types of patients to achieve the best outcomes. There is also a lack of knowledge about the future impact of these payment system changes on the care of individuals with conditions such as traumatic brain injury and spinal cord injury, as well as the potential for racial, ethnic, or sociodemographic barriers to receiving adequate PAC (25).

Financial factors can be powerful motivators for facilities and HHAs providing PAC. Different payment structures can lead to different utilization patterns and differences in PAC sites that provide care. These in turn can affect patient outcomes. Buntin provides an example in which SNFs are incentivized to keep daily costs down since they are payed a per diem rate, even as incentives for decreasing length of stay are considerably less robust. Buntin also raised concerns with respect to access to PAC rehabilitation, specifically for severely ill patients who are at higher risk for the following: