MODULE 2
Coordination and Communication
Case management requires therapists to be able to communicate effectively with all members of the
rehabilitation team, directly or indirectly. For example, the therapist communicates directly with other
professionals at case conferences, team meetings, or rounds or indirectly through documentation in the
medical record. Effective communication enhances collaboration and understanding.
Therapists are also responsible for coordinating care at many different levels. The therapist delegates
appropriate aspects of treatment to physical therapy assistants and oversees the responsibilities of physical
therapy aides. The therapist coordinates care with other professionals, family, or caregivers regarding a
specific treatment approach or intervention. For example, for early transfer training to be effective,
consistency in how everyone transfers the patient is important. The therapist also coordinates discharge
planning with the patient and family and other interested persons. Therapists may be involved in providing
POC recommendations to other facilities such as restorative nursing facilities.
Patient/Client-Related Instruction
In an era of managed care and shorter time allocations for an episode of care, effective patient/client-
related instruction is critical to ensuring optimal care and successful rehabilitation. Communication strategies
are developed within the context of the patient/client’s age, cultural backgrounds, language skills, and
educational level, and the presence of specific communication or cognition impairments.
Figure 1.4 The three components of physical therapy intervention. (From APTA Guide to Physical Therapist
Practice, p. 98 with permission.)
Therapists may provide direct one-on-one instruction to a variety of individuals, including patients,
clients, families, caregivers, and other interested persons. Additional strategies can include group discussions
or classes, or instruction through printed or audiovisual materials. Educational interventions are directed
toward ensuring an understanding of the patient’s condition, training in specific activities and exercises,
determining the relevance of interventions to improve function, and achieving an expected course. In addition,
educational interventions are directed toward ensuring a successful transition to the home environment
(instruction in home exercise programs [HEP]), returning to work (ergonomic instruction), or resuming social
activities in the community (environmental access). It is important to document what was taught, who
participated, when the instruction occurred, and overall effectiveness. The need for repetition and
reinforcement of educational content should also be documented in the medical record.
Procedural Interventions
Skilled physical therapy includes a wide variety of procedural interventions, which can be broadly
classified into three main groups.
1.) Restorative interventions
are directed toward remediating or improving the patient’s status in terms of impairments,
activity limitations, participation restrictions, and recovery of function. The involved segments
are targeted for intervention. This approach assumes an existing potential for change (e.g.,
neuroplasticity of brain and spinal cord function; potential for muscle strengthening or
improving aerobic endurance). For example, the patient with incomplete spinal cord injury
(SCI) undergoes locomotor training using body weight support and a treadmill (BWSTT).
Patients with chronic progressive pathology (e.g., the patient with Parkinson’s disease) may
not respond to restorative interventions aimed at resolving direct impairments; interventions
aimed at restoring or optimizing function and modifying indirect impairments can, however,
have a positive outcome.
2.) Compensatory interventions
are directed toward promoting optimal function using residual abilities. The activity (task) is
adapted (changed) in order to achieve function. The uninvolved or less involved segments are
targeted for intervention. For example, the patient with left hemiplegia learns to dress using
the right upper extremity (UE); the patient with complete T1 paraplegia learns to roll using
upper extremities (UEs) and momentum. Environmental adaptations are also used to facilitate
relearning of functional skills and optimal performance. For example, the patient with TBI is
able to dress by selecting clothing from color-coded drawers. Compensatory interventions can
be used in conjunction with restorative interventions to maximize function or when restorative
interventions are unrealistic or unsuccessful.
3.) Preventative interventions
are directed toward minimizing potential problems (e.g., anticipated indirect impairments,
activity limitations, and participation restrictions) and maintaining health. For example, early
resumption of upright standing using a tilt table minimizes the risk of pneumonia, bone loss,
and renal calculi in the patient with SCI. A successful educational program for frequent skin
inspection can prevent the development of pressure ulcers in that same patient with SCI.
Interventions are chosen based on the medical diagnosis, the evaluation of examination, the physical
therapy diagnosis, the prognosis, and the anticipated goals and expected outcomes. The therapist relies on
knowledge of foundational science and interventions (e.g., principles of motor learning, motor control, muscle
performance, task-specific training, and cardiovascular conditioning) in order to determine those interventions
that are likely to achieve successful outcomes. It is important to identify all possible interventions early in the
process, to carefully weigh those alternatives, and then to decide on the interventions that have the best
probability of success. Narrowly adhering to one treatment approach reduces the available options and may
limit or preclude successful outcomes. Use of a protocol (e.g., predetermined exercises for the patient with hip
fracture) standardizes some aspects of care but may not meet the individual needs of the patient. Protocols
can foster a separation of examination/evaluation findings from the selection of treatments.
Watts suggests that clinical judgment is clearly an elegant mixture of art and science. Professional
consultation with expert clinicians and mentors is an effective means of helping the novice sort through the
complex issues involved in decision making, especially when complicating factors intervene. For example, a
consultation would be beneficial for the inexperienced therapist who is treating a patient that is chronically ill,
has multiple co-morbidities or complications, impaired cognition, inadequate social supports, and severe
activity limitations.
A general outline of the POC is constructed. Schema can be used to present a framework for
approaching a specific aspect of treatment and assist the therapist in organizing essential intervention
elements of the plan. One such commonly used schema for exercise intervention is the FITT equation
(frequency-intensity-time-type), presented in Box 1.5.
Box 1.5 The FITT Equation for Exercise Intervention
Frequency: How often will the patient receive skilled care?
This is typically defined in terms of the number of times per week treatment will be given (e.g., daily or three
times per week), or the number of visits before a specific date.
Intensity: What is the prescribed intensity of exercises or activity training?
For example, the POC includes sit-to-stand repetitions, 3 sets of 5 reps each, progressing from high seat to low.
Time (duration): How long will the patient receive skilled care?
This is typically defined in terms of days or weeks (e.g., three times per week for 6 weeks). The duration of an
anticipated individual treatment session should also be defined (e.g., 30- or 60-minute sessions).
Type of intervention: What are the specific exercise strategies or procedural interventions used?
The therapist should ideally choose interventions that accomplish more than one goal and are linked
to the expected outcomes. The interventions should be effectively sequenced to address key impairments first
and to achieve optimum motivational effect, interspacing the more difficult or uncomfortable procedures with
easier ones. The therapist should include tasks that ensure success during the treatment session and,
whenever possible, should end each session on a positive note. This helps the patient retain a positive feeling
of success and look forward to the next treatment.
Discharge Planning
Discharge planning is initiated early in the rehabilitation process during the data collection phase and
intensifies as goals and expected outcomes are close to being reached. Discharge planning may also be
initiated if the patient refuses further treatment or becomes medically or psychologically unstable. If the
patient is discharged before outcomes are reached, the reasons for discontinuation of services must be
carefully documented. Elements of an effective discharge plan are included in Box 1.6.
The therapist should also include the discharge prognosis, typically a one-word response such as
excellent, good, fair, or poor. It reflects the therapist’s judgment of the patient’s ability to maintain the level of
function achieved at the end of rehabilitation without continued skilled intervention.
Box 1.6 Elements of the Discharge Plan
Patient, family, or caregiver education: instruction includes information regarding the following:
• Current condition (pathology), impairments, activity limitations, and participation restrictions
• Ways to reduce risk factors for recurrence of condition and developing complications, indirect
impairments, activity limitations, and participation restrictions
• Ways to maintain/enhance performance and functional independence
• Ways to foster healthy habits, wellness, and prevention
• Ways to assist in transition to a new setting (e.g., home, skilled nursing facility)
• Ways to assist in transition to new roles
Plans for follow-up care or referral to another agency: patient/caregiver is provided with the following:
• Information regarding follow-up visit to rehabilitation center or referral to another agency (e.g., home
care agency, outpatient facility) as needed
• Information regarding community support group and community fitness center as appropriate
Instruction in a home exercise plan (HEP): patient/caregiver instruction regarding the following:
• Home exercises, activity training, ADL training
• Use of adaptive equipment (e.g., assistive devices, orthoses, wheelchairs)
Evaluation/modification of the home environment:
• Planning regarding the home environment and modifications needed to assist the patient in the home
(e.g., installation of ramps and rails, bathroom equipment such as tub seats, raised toilet seats,
bathroom rails, furniture rearrangement or removal to ease functional mobility)
• All essential equipment and renovations should be in place before discharge
