Making a Team Work: Assembling a Rehabilitation Team in O&P Private Practices

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Most healthcare professionals agree that teamwork provides comprehensive patient care and better functional outcomes for patients. But unless you work for the military, a Department of Veterans Affairs (VA) medical center, or a university-affiliated hospital, where team rehabilitation is an established practice, assembling such a team can seem a daunting task. Can O&P private practices take a page from these models and become a part of, or establish, a rehabilitation team network, or are the logistics involved too complicated?

Challenges of a Team Approach

Private practices find the team approach to patient care more challenging for several reasons. For starters, hospitals have team leadership established--people who can gather team members and organize patient care. "A team leader requires a particular type of personality to bring everyone together," says Alexander Lyons, CPO, Lyons Prosthetics & Orthotics Inc., Conway, South Carolina.

Top Row from left: Scott Cummings, PT, CPO Next Step O&P Inc., Manchester, New Hampshire; Charles Levy, MD Physical Medicine & Rehabilitation Service, North Florida/South Georgia Veterans Health System, Gainesville, Florida; Bambi Lombardi, OTR/L Professional and Clinical Services, Otto Bock HealthCare, Minneapolis, Minnesota.
Bottom Row: Alexander Lyons, CPO Lyons Prosthetics & Orthotics Inc., Conway, South Carolina; Michael Oros, CPO Scheck & Siress Orthotic & Prosthetic Inc., Oakbrook Terrace, Illinois; Shawn Swanson, OTR/L Professional and Clinical Services, Otto Bock HealthCare, Minneapolis, Minnesota.

Geography adds to this challenge. "We have ten locations, two of those are in hospitals, and we have seen a difference in how those two are able to assemble a team," says Michael Oros, CPO, Scheck & Siress Orthotic & Prosthetic Inc., Oakbrook Terrace, Illinois. "In a hospital, all the resources are under one roof. There's no barrier in getting people together, which makes it much easier." With various specialties on-site, communication and collaborative efforts are often a matter of just walking down the hall. O&P professionals in private practice often must travel great distances to consult with others.

Breaking Down Barriers

While it does take extra effort on the part of the practitioner to assemble and work with a team of varied professionals, several O&P practitioners have established a successful multidisciplinary approach to patient care in their private practices and can provide valuable insight into how other practitioners can apply the model to their own practices. Lyons, for example, uses technology to help break the distance barrier.

Although there are times when face-to-face communication between healthcare professionals is essential, it is now easier for practitioners to consult with rehab team members, regardless of location. "I view my job as a facilitator," says Lyons. "Because we're not all in close proximity, I rely on phone and e-mail communications, which have made this type of collaboration easier." Lyons has successfully assembled an advisory board comprising top healthcare providers including surgeons, nurses, physicians of various specialties, and physical therapists that meets twice annually. "[My goal] is to have a forum to share ideas among different professionals with equal participation," he says. "As healthcare professionals, we can get caught up in our own area of medicine. We welcome an opportunity to see other areas of medicine so we're knowledgeable about them."

Benefits of a Team Approach

"In the long run, spending time upfront to work with a team is a good approach that will benefit our patients and our practices," says Scott Cummings, PT, CPO, Next Step O&P Inc., Manchester, New Hampshire. "It's beneficial to have more than one person's input and patient knowledge, including history and prognosis, when designing a device." An added benefit of working toward a team approach, says Cummings, is increased referrals. "When we invest time to run across town to evaluate a hospital outpatient, and the patient isn't a good candidate for an orthotic or prosthetic device, that time isn't necessarily wasted," he says. "The therapist appreciates our efforts, we build trust, and it can work to our advantage when the therapist refers patients to us in the future."

Oros, who has also adopted a team model for his practice, says that the patient benefits the most from the approach. "Everybody brings a unique perspective, different discipline, and different personality to the table, which results in comprehensive care." Oros remarks that how a patient responds to a healthcare professional can be impacted by personal dynamics, so having a variety of personality types contribute to patient care is ideal. "Sometimes you might have a patient who is more aggressive in nature paired with a conservative physician," he says. "An aggressive therapist, orthotist, or prosthetist can convince the physician to try new concepts. This team approach also helps us as practitioners to think more globally in terms of outcomes and [be] less device-specific. This helps our profession to be viewed less as deliverers of a device and more as valuable members of a team. It becomes more about what we can intellectually bring to the table and not just what we can make with our hands."

Establishing Relationships

Rehabilitation teams most often consist of a physician, therapist, and O&P practitioner. In a hospital setting, the team leader is most likely the primary care physician, but some say the most suitable rehabilitation team leader is the PM&R (physical medicine and rehabilitation) physician. PM&R physicians focus on restoring function to people with disabilities by evaluating and addressing a patient's needs as a whole. As a team leader, he or she coordinates medical care, prescribing therapy and monitoring the patient's progress with the primary care physician and other team members.

Other team members may include a case manager, nurse, social worker, podiatrist, and vascular and orthopedic surgeons.

Establishing and maintaining good relationships with these team members is critical for O&P practitioners who want to follow a team rehab approach. "We attend clinics [with other healthcare professionals] provided by local hospitals or doctors," says Cummings. "However, when it's our initiative, the group is smaller, [and] we might ask to meet with a particular therapist or doctor one-on-one. When I meet with doctors, it's usually at their request because they have time constraints and less flexibility. My best relationships are with physical therapists, but it's important to have good communication with the physician. When a patient arrives at our doorstep, we get a brief snapshot in time with which to make critical decisions. But a physician has usually seen the patient multiple times, and he or she has a broader picture of the patient's condition."

Case managers serve as patient advocates who help clients make informed healthcare decisions and connect members of the healthcare team with the patient. "Case managers often orchestrate the care," Cummings explains. "They will contact us for an evaluation or fitting of a prosthesis, and they work with the physician and insurance companies to make care decisions."

Manufacturers as Models

Professional and Clinical Services team at Otto Bock. From left: Byron Backus, CP; Shawn Swanson, OTR/L; Pat Prigge, CP; Julie Schick, CP; and Bambi Lombardi, OTR/L.
Professional and Clinical Services team at Otto Bock. From left: Byron Backus, CP; Shawn Swanson, OTR/L; Pat Prigge, CP; Julie Schick, CP; and Bambi Lombardi, OTR/L.

Companies that manufacture and engineer healthcare products can also be valuable members of the rehabilitation team. For example, Otto Bock, Minneapolis, Minnesota, has a team of prosthetists, orthotists, occupational therapists, and rehabilitation technology specialists on staff to help educate O&P professionals on the proper use of their products. "Teamwork, based on close communication between the prosthetist and therapist, is key to ensuring a successful outcome," comments Bambi Lombardi, OTR/L, one of two occupational therapists on staff in the Professional and Clinical Services department at Otto Bock. "The team approach in treating the upper-extremity limb loss patient is a rare occurrence, and Otto Bock acknowledges the need to facilitate communication and improve education across the two disciplines--therapy and prosthetics."

In addition to providing a number of online resources at , Lombardi and Shawn Swanson, OTR/L, act as liaisons between the prosthetist and the therapist, and they provide educational seminars to professionals involved in treating upper-extremity limb loss and consult with individual clients and clinicians as needed. "Prosthetists don't necessarily have the time to teach patients how to use high-tech devices, so some patients end up rejecting their prosthesis," says Swanson. "We try to help improve patient outcomes by providing training in advanced myoelectric technology by teaching OTs, PTs, and O&Ps what they need to know when using our devices, as well as how to prepare their patient's limb through range of motion (ROM), scar massage, strengthening, and desensitization."

Lyons and Oros both add that the focus is always on the patient and the best possible outcome. "We let patients direct where they'd like to go for their rehab," says Oros. "They're the most important team member."

Drawbacks to Team Care

Team rehab care is not without its drawbacks, though, and one of the biggest for O&P practitioners is inadequate compensation for their time. "Sometimes we get calls from a case manager who asks us to educate a patient considering elective amputation on what life will be like," Oros says. "I can spend an hour educating a patient, who is appreciative, but it doesn't necessarily do anything for the bottom line."

Cummings adds, "Some companies frown on attending clinics because those are non-billable hours."

Some O&P practitioners have expressed an interest in changing current billing procedures to adequately reimburse for time. "Not getting paid for treatment time undermines our professional capacity to offer more than just a device," says Cummings. "Service, such as evaluation, fittings, and follow-up, is a huge component of what we can provide."

"We should be viewed like other healthcare providers," suggests Oros. "We should be reimbursed for consultations and services over and above delivery of a product." A poorly structured fee schedule that contains outdated L-Codes makes it difficult for O&P practitioners to bill for hours. "L-Codes go back 30 years," explains Oros. "Product and service is wrapped together, and back then it made sense to pay that way with the educational requirements for O&P. That model is evolving. With a movement toward more stringent educational requirements and licensure in this field, there will come a time when we will be able to bill for non-product related hours."

In addition to financial deterrents, Oros says there can be political dynamics to juggle when working with other therapy groups. "Supporting therapy groups that support your practice in return can help grow your business," he says. "Our patients come to us with referrals from primary care physicians. Sometimes we have to refer them to other facilities. There are constraints to which groups will become aligned."

Communication Is Key

However, Oros says putting together a team outside the confines of a hospital can be accomplished despite the political or financial barriers. "We try to model what's taking place in rehabilitation settings already," he explains. "We take the core team members--physicians, therapists, and O&P practitioners--and get them all together. We consult other team members by phone or e-mail to make sure we're all on the same page." To enhance communication, Oros has a template to facilitate sending messages between team members. "Surgeons have more demands for their time, and they may not be comfortable in [a round table] setting. They might not want to sit in a clinic once a week for three hours, but we've had busy physicians make themselves available through e-mail," he says. "We communicate about how a patient is doing, components, how a wound is healing, and prescription changes."

Alexander Lyons' advisory board, front row, from left: Martha Lewis, PT; Tammy Priganc, PT; Louise Pearce, PT; and Douglas Sadler, patient advocate. Back row, from left: Jack Richmond, area sales manager, The Fillauer Companies; Cornelius L. Alston, MD; John A. Pienkos II, DC; Alexander L. Lyons, CPO (chairman); and Charles Myers, DPM.
Alexander Lyons' advisory board, front row, from left: Martha Lewis, PT; Tammy Priganc, PT; Louise Pearce, PT; and Douglas Sadler, patient advocate. Back row, from left: Jack Richmond, area sales manager, The Fillauer Companies; Cornelius L. Alston, MD; John A. Pienkos II, DC; Alexander L. Lyons, CPO (chairman); and Charles Myers, DPM.

In describing his advisory board, Lyons explains that the concept was something he'd seen in other businesses, but not O&P. "Patients who come to us are consumers, too," he says. "It's time to take a look at what other industries are doing to attract, keep, and satisfy consumers." To that end, Lyons says that he simply wrote a letter describing his goals and inviting several professionals to join the board. "The thought of putting this type of team together almost seems overwhelming, but I was pleasantly surprised to find a lot of energy and support from others. I was also surprised that people just jumped right in. It wasn't as difficult as I thought to assemble a team. This team empowers different [people] to step up and take a leadership role in the community."

The board recently met at the Marina Inn at Grande Dunes, Myrtle Beach, North Carolina. Sensitive to the number of meetings these professionals are required to attend, Lyons wants his meetings to be entertaining as well as informative. He welcomes his members to invite guests, enlists corporate sponsors to offset the costs of five-star locations and social hours before the meetings, and provides a catered dinner. They discuss a special itinerary of relevant topics such as licensure issues, new technology, and how they can better serve their patients.

With the additional guidance and assistance that case managers, physiatrists, and even some manufacturing companies can provide, rehabilitation teams can closely resemble hospital models. "If we can get more professionals to value this method, with collaborative and collegiate communications between each

other, our outcomes will improve and our practices will do better," Cummings concludes. Despite the added hurdles of assembling a team, practitioners in private practices might find that the benefits of adopting a team approach outweigh the costs.

Sherry Metzger, MS, is a freelance writer with degrees in anatomy and neurobiology. She is based in Westminster, Colorado, and can be reached at

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