A panel of PTs from the Hospital for Special Surgery (HSS) in New York explained how that institution implemented direct access (DA) to physical therapist services during a June 13 session at APTA's 2019 NEXT Conference and Exposition. They then advised attendees how to operationalize DA at their own institutions.

Presenters from HSS were Carol Page, PT, DPT; Mary Murray-Weir, PT, MBA; Robert Turner, PT, DPT; and Jaime Edelstein, PT, DScPT. Also presenting was Aaron Keil, PT, DPT, from the University of Illinois at Chicago.

Keil noted that DA was achieved in all 50 states and the District of Columbia in 2015, but only 18 states have unrestricted access. The others include limiting or restrictive provisions, meaning there still are barriers to DA.

He cited a 2015 APTA survey for which nearly 65% of respondents said the major administrative barrier to DA implementation was "My supervisor/facility requires all patients to have a referral." Keil noted that this is especially true in hospital-based inpatient and outpatient facilities, as hospitals tend to be more risk averse and "may be more restrictive than state law."

Page said that an essential first step to achieving DA was getting buy-in. One key group was physicians—particularly surgeons—who were concerned that their patient levels would drop. Page explained, "We showed that direct access would 'widen the funnel' and actually provide them more patients," while at the same time screening to avoid sending inappropriate patients to the surgeons.

Administrative staff was taught how to screen patients and schedule them with appropriate PTs. They also were made responsible for tracking timing and number of permissible visits for adherence to state provisions, building on an HSS foundation of training and competency programs it conducts for all staff.

The hospital established criteria for DA PTs that were more stringent than required by the state. For example, while New York requires 3 years of clinical experience, HSS required that experience to be at outpatient facilities. It also required CEUs in certain areas, such as spine, manual therapy, and differential diagnosis.

Turner described the development of a written exam for aspiring DA PTs. Questions were developed following the same item-writing guidelines used by the American Board of Physical Therapy Specialties. A score of 80% is required to pass the test.

HSS also developed a practical examination involving an actual patient. The primary question to be answered is: "Can you take this patient and treat him or her? Or do you refer to a physician?"

The program was made voluntary for PTs since some didn't initially feel comfortable with it. "Not everyone fits the mold," Turner said.

Page addressed operationalizing DA, which she divided into 4 categories. The first was resources. She said, "APTA has amazing resources." She advised those in the audience to search APTA's website for "direct access" and browse the resources. The second category is billing, which she made clear "is different in a hospital setting" from a private practice and requires a hospital-wide effort. The team leading the DA program at HSS made a conscious decision not to contact insurance companies in advance and announce their intentions. "We did a soft launch with a small number of patients. We let them know that their interventions might or might not be covered," Page said, but he found that most insurers did cover the services, and HSS now contacts insurers in advance.

The other elements of operationalizing DA were documentation and marketing. These included developing specific policies and procedures, providing notice of advice for patients, identifying common ICD-10 codes, and developing tip sheets for patients and physicians.

The panel listed a series of lessons learned—things to do and things not to do. For example, don't:

• Assume people understand what DA is.
• Give up.
• Be mean, defense, argumentative, or otherwise difficult to deal with.

On the other hand, do:

• Assume some people will think DA is illegal and/or unsafe.
• Highlight improved patient access and patient care.

Ask "How can we?" rather than "Can we?"