The Community Rehabilitation Team (CRT) provides intermediate care and rehabilitation to individuals unable to leave their homes or who do not meet referral criteria for specialist services. Therapists are generalists whose specialism is managing complexity.
Current practice required all clinical staff (B4 and above) to triage referrals for suitability, and to assign appropriate referrals to immediate action (within 5 days) or a waiting list (up to 18 weeks), according to clinical need. This decision was commonly made directly from information contained within the referral.
Staff expressed anxiety and frustration with the process, and an inability to affect change or provide support to colleagues. Referrals from traditionally hierarchical superiors could be challenging, especially when declining inappropriate referrals, with concern that this may affect future commissioning.
This audit of physiotherapy referrals, aimed to classify our caseload through collection of quantitative data, and to trial an alternative triage process.
A 'Plan, Do, Study Act' (PDSA) project was registered with the locality manager and referral audit registered with the local information governance team.
A three-month prospective audit was undertaken of all referrals to the CRT. Anonymised data were collected, including:
- Referral source (including local primary care hub).
- Primary referral reason, including whether the referral was to support a hospital discharge.
- Relevant comorbidities (to help guide future training needs).
- Referral outcome: Accept, decline or re-route.
Trial of new triage process:
The triage process was adapted to include a guided telephone conversation between a band 7 physiotherapist and potential patients, or if appropriate their representative, to explore their expectations. This facilitated early discussions regarding aims of intervention, motivation and readiness to change. Referrals where intervention was not indicated were declined and if needs were better met elsewhere, re-routed.
161 physiotherapy referrals were received from 30 different referral sources. 1 in 4 to support hospital discharge. High referral generators were identified and referral reasons classified. The highest number of referrals was received for:
- Falls and frailty rehabilitation (including fragility fractures) 28%
- Mobility rehabilitation 20%
- Stroke and neurological rehabilitation 19%
24 referrals were declined; 15 by the individual or their representative. 17 referrals were re-routed to specialist therapy services.
Navigating community therapy services is challenging for referrers: There are 14 different NHS therapy services locally, operated by 2 different NHS trusts. 13 of those are specialist teams.
The addition of the guided telephone conversation with a B7 contributed to decisive action on referrals and appears to have contributed to a 54% reduction in caseload. Additionally, the new triage process has ensured that individuals placed on the waiting list (if able) had voiced engagement and readiness to change. Triaging therapists identified an increased need to debrief from emotionally challenging conversations.
Cost and savings
The work presented at PUK 19, was a halfway report of a 6 month audit. Below are figures relating to the completed project:
- A significant number of referrals were based on an outdated, therapeutic model, in which physiotherapy was considered something which can be done to you, regardless of your engagement or consent, to make you better.
- In the instances where the referrer was unsure, the CRT was used as a central point of access for referrals to wheelchair services, orthotics, to request major environmental adaptations and specialist therapy services. Referrals were received from 44 different teams.
- Point 1 and 2 contributed to 25% of referrals received. Triaging referrals of individuals who did not wish to be seen or whose referral required re-routing costs £3528 pa (mid pay scale B7).
B7s completing 100% of triage cost an additional £743 pa, when compared to all staff B4-B7 completing triage. This was achieved by the B7s reducing their clinical caseload.
On completion of the 6 month audit: triaging by B7s demonstrated a reduction of 25% in initial home visits and offered a cost saving of £4623 pa plus travel expenses and travel time.
On completion of the project triage was returned to the whole team. Further study shows that with all grades triaging, 17% of referrals are declined or re-routed. Reports of fatigue in decision making were often given in accepting referrals where we were not in a position to influence outcomes or support change.
Top three learning points
This work is unfunded.
This work was presented at Physiotherapy UK 2019
Please see the attached Innovations poster below.
For further information about this work please contact Vicky Farrell.