The cost benefits of risk identification with subsequent behavioral changes that can minimize or eliminate the risks have significant implications for health cost containment and quality of life. Examples of screening activities that PTs commonly engage in according to the APTA Guide to Practice,2 “include:
identifying lifestyle factors (e.g., amount of exercise, stress, weight) that may lead to increased risk for serious health problems
identifying children who may need an examination for idiopathic scoliosis
identifying elderly individuals in a community center or nursing home who are at risk for slipping, tripping, or falling
identifying risk factors in the workplace
pre-performance testing of individuals who are active in sports
conducting pre-work screening programs.”2
These examples illustrate that screens are performed in multiple venues, from shopping mall health fairs and schools, to hospitals, extended care facilities and other clinical settings across the lifespan.
In the context of health and wellness, screening may be performed in the presence or absence of any pre-identified signs, symptoms or individual concerns. Most of the screens performed by PTs do not require testing equipment that bears significant cost. Generally speaking, if there is cost associated with screening in the short term, it is warranted in the wellness and prevention arena to minimize costs and maximize health and quality of life in the long term. In reality, much of the screening performed by PTs may be performed at no cost to the client as in venues such as health fairs, or as included components of initial examinations and evaluations that include the screens. There is however, the cost of time that should be considered.
Many conditions, benign and/or malignant, may be potentially identified by appropriate screens. With identification of certain “markers,” the need for further evaluation of a potential pathology by the appropriate skilled healthcare professional can be obtained as needed. Although the Guide to Physical Therapist Practice states “Candidates for screening generally are not patients/clients currently receiving physical therapy services,”2 that is not necessarily the case, as a variety of circumstances may exist in which the physical therapist may be performing screening procedures. Circumstances include clients who self-refer in direct consumer access situations, clients referred to PT by physicians or others, and those in the general population who may be participating in screening activities offered to the public or in pre-arranged situations such as pre-employment or pre-performance athletic screens. Depending on the circumstances and venue, there may or may not be information available to the “screener” about the patient or client. In venues such as a skilled nursing facility or extended care facility, information is available in the form of the medical record and from the caretakers; professional and nonprofessional, for example, family. In public venues, where there is no information available, the “screener” must elicit appropriate information by history, interview and or observation and assessment only as appropriate and in accordance with HIPAA. It should be noted that when screens are performed in public venues, such as health fairs, the PT should be careful not to establish a PT/patient relationship in order to prevent potential liability issues. Screens performed should be general and reproducible with essentially objective findings noted and given to the “client” with recommendations for “follow up” if the client chooses to, on a form that expressly states such. Any PT that plans to engage in community screening or screening as a marketing tool in a community, should check with their attorney or liability provider about their risk and coverage. In some instances, if a PT is screening under the auspices of a county public health department, there may be immunity status granted for the screening process, thereby precluding liability concerns. It should be noted that even if a referral with a diagnosis comes from a physician, a physician extender such as a physician assistant (PA), or other practice act acceptable referral source, screening may be needed to determine the accuracy or appropriateness of the diagnosis or referral. In this case, the liability would be consistent, the regular course of PT care. In the educational setting, the types of screening that can be done in public with physical therapy students under the supervision of licensed PTs should be sanctioned by both the legal department and consultants for the college or university as well as the professional liability carrier.
Clients, who self-refer to physical therapy, require screening, examination, and evaluation to determine if their primary complaint is appropriate for physical therapy or is indicative of a medical condition that warrants referral to another health professional. They may have multiple conditions that require the attention of a PT in addition to another health professional such as a physician. Clients referred to physical therapy by physicians, in spite of the referrals, may have conditions that require further medical assessment based on the results of the PT screening, examination, and evaluation. Those individuals in the general population screened in public venues may demonstrate signs and or symptoms or history that warrant referral to a physician or other health care professional, such as identification of a suspicious skin growth. If a client is referred for PT by a physician for a specific problem or diagnosis, areas other than that of the primary problem area, should be screened to determine if they are causal or contributing to the problem, or if other problems co-exist. For example, if a patient is referred with a hand or wrist problem, the PT would screen the cervical and shoulder area to rule out pathology proximal to the regions of primary complaint. The PT should also confirm that it is not a problem related to body system that is not neuromuscular or musculoskeletal in nature that is “referring pain” to the area. “Screening examinations allow the therapist to quickly scan through the data from the body systems, noting areas of deficit. Screening examinations indicate areas where more detailed assessments are warranted. More definitive assessments are then used to provide objective data to accurately determine the degree of specific function and dysfunction, for example, manual muscle tests, range of motion tests, oxygen consumption.”6
In the context of current societal cultural demand, it is assumed that all health care professionals will practice screening, as they do in all interactions, with cultural competence. “Cultural competence initiatives may even help control costs, by making care more efficient and effective.”7 To effectively screen, a PT must be able to communicate effectively with any group of individuals regardless of cultural or ethnic background. It is also imperative to be aware of the healthcare disparities inherent in the US healthcare system, and being aware of the same, emphasize the need for cultural sensitivity and competence for equality of service provision. There are also pathologies that may be more prevalent in some ethnicities than others. In today’s world, many communities are more culturally integrated than in the past, although pockets of ethnic groups may choose to live in enclaves within a larger geographic area. There may also be groups living in more isolated geographic areas that may or not be rural. There are six primary dimensions of culture to be considered in all client encounters: age, ethnicity, gender, physical ability race, and sexual orientation. Socioeconomic status, education, religion, marital status, parental status, personal habits, recreational habits, appearance, and work experience, and work status or student status must also be considered in the context of culture. With the high incidence of unemployment in the current decade, sensitivity to the lack of health insurance should also be considered. Community offered screening may be the only healthcare services an individual has access to.
Therefore, it is in the best interest of the PT or healthcare professional to be able to appropriately solicit information from all cultural groups in a competent manner. As it is impossible to be familiar with the behaviors of all cultural groups and subgroups, it is more practical to become skilled in open-ended culturally sensitive questions. An example of this is in the context of a fall screen: Why are you here today? What is the reason you may have had a steadiness problem? Are you doing anything for the problem you’re having at home?
The LEARN model is applicable in all client encounters to facilitate communication in broad categories.8
|(L) ||Listen to patient |
|(E) ||Elicit patients’ health beliefs |
|(A) ||Assess potential problems that may have impact on health behaviors |
|(R) ||Recommend a treatment plan |
|(N) ||Negotiate a mutually agreed-on treatment plan |
The LEARN model, may be found by the physical therapist to be more contextually relevant in a longer history or initial encounter included in an initial examination and evaluation.