Indian Health Service (IHS) and Public Health Service (PHS)

Cherokee Nation Health Services

Cherokee Nation Health Services (CNHS) has implemented a primary care PT program with the following model:

• A roving DPT is co-located in the Primary Care department and screens patients referred to PT from various primary care providers (MD/DO, NP, pediatrics, podiatry). Those patients referred to PT are scheduled in a 20-minute slot on the PT Same Day schedule by the check-out nurse and/or primary care clerk 
• If the patient presentation is low complexity, the screen becomes a low complexity evaluation and the patient is given a home exercise program along with the DPT's contact information for follow-up as needed or is scheduled back in the appropriate timeframe
• If the patient presentation is more complex and is not appropriate for the 20-minute time slot, the patient is then scheduled in the PT department for a moderate/high complexity evaluation time slot
• If the PT Same Day schedule is full, the patient is then scheduled within a week. This is not ideal as the no-show rate increases significantly if the patient is not seen the same day as their primary care appointment

Obstacles: it took ~1 year to work out all the kinks as this had never been done before within the Cherokee Nation.  It took time to transition from a warm hand-off from the PCP to a same day schedule, time to train check-out nurses/primary care clerks and time to find a roving schedule for all DPTs that still allowed adequate follow up slots in the PT department.

Southcentral Foundation Integrated Physical Therapy

Southcentral Foundation (SCF) in Anchorage, Alaska has been praised nationally for their integrative approach to Primary Care. The “Nuka” model emphasizes same day appointments being available, if needed, to the Alaska Native/American Indian patients who are called “Customer-Owners” (CO’s). Additionally, the Nuka model prioritizes the use and availability of integrated providers who are available to assess CO’s when they come in to see their primary provider. These integrated providers represent various disciplines such as behavioral health, pharmacy, psychiatry, pediatrics, and physical therapy. At times, there is an integrated Internal Medicine physician as well. The integrated providers are embedded in the 9 primary care units that make up primary care. 

For example, SCF employs 13 Behavioral Health Consultants (mostly LCSW’s), seven integrated pharmacists, four integrated psychiatrists, six integrated pediatricians, one Behavioral Pain Consultant (PhD psychologist) and one physical therapist (PT). As such, the lone physical therapist might be called upon to see CO’s from any of the nine clinics. Each clinic has four to five pods, and each pod consists of a physician, mid-level provider (PA’s/NP’s), Nurse Case Manager, and a Case Management Support person. There are generally four to five physicians on each unit. We currently have 28 primary care physicians and about 42 mid-level providers in primary care.

The Integrated PT works M-F from 8:00-4:30. His schedule, as seen on the Cerner scheduling screen, is divided into six yellow 30-minute slots and seven green 30-minute slots. The yellow slots are CO’s that have been scheduled in advance to come in at that specific time. These CO’s have all been seen previously (usually one to four days previously) by the physician or mid-level provider. At the time that these CO’s initially came in to see their provider, the integrated PT might have been busy with another CO or otherwise unavailable. These individuals will be placed, via the PT’s Case Management Support (CMS) into an available yellow slot on the integrated PT’s schedule for the following day, or later in the week. The green slots are left open so that a primary care provider can contact the PT’s CMS person (either by phone, Tiger Text, Cerner Message) and request the PT come by to assess the CO. The PT is allotted 30 minutes per assessment and treatment. 

In practice, however, there is such a demand, typically by the integrated PT to have CO’s return for two to three visits, that the green slots need to be used to accommodate the daily demand. Therefore, in practice, there might only be three, instead of seven, available green slots on a given day. There is a lot of flexibility built into this system so that CO’s might have to be seen 30-60 minutes later than what they were hoping for with the same day (green slot) appointments. Fortunately, the CO’s understand that there is only one integrated PT and generally are very understanding and willing to wait to be seen.

There are three types of visits/PT encounters that the Integrated PT can do: PT Screening; Curbside; Co-visit. Sometimes, the primary care providers might want to chat about a certain CO to get more clarity or guidance from the integrated PT or other integrated health professional. This 5–15-minute chat would be recorded as a “Curbside” on the integrated PT’s schedule. A Co-visit is where the primary care provider remains in the room with the integrated PT and CO during the PT assessment or “Screen.” This sometimes happens when the medical provider wants to watch and learn how the integrated PT arrives at a given diagnosis, for example, or perhaps wants to observe a certain treatment. Most encounters, however, are PT Screenings (95% or more) which is essentially a 30 minute (often less time due to late arrivals) quick assessment by the integrated PT. 

The COs can be seen either on the 2N unit where the integrated PT is located and has a designated treatment room or can be called to go to any of the other eight primary care units, where the CO will be seen in the same room where they saw the primary care medical provider. Typically, medical providers (physicians, nurse practitioners, physician-assistants) will have two to three rooms that are designated for their specific use (their name on door). This way, if the integrated PT is assessing a CO in one room, one to two other rooms will be available for the medical provider to see other CO’s.

The Primary Care Clinic building does not have a gym. The integrated PT’s treatment room on 2N houses a standard treatment table, cabinet, and sink. The integrated PT has a designated closet where TheraBand is kept, along with lumbar and cervical rolls, Tensogrip compression stockinette’s, basic foot orthotics, heel lifts and shoe wedges, foam half rolls, overhead pulleys, and TENS units. There is another hallway closet that houses durable medical equipment such as crutches, walkers, canes, along with the standard orthopedic braces for ankles, knees, wrists, elbows, etc.

The integrated PT typically sees an average of eight CO’s per day in an 8-hour shift. Most of these visits are one-time only as the CO is happy with a quick assessment and exercises that can be done on their own in the convenience of their home. Some of the CO’s hail from an outside village and have come to the Alaska Native Medical Campus for medical tests and/or interventions. During their brief stay on the campus, their medical provider might suggest one or more visits with the integrated PT. These individuals will often have a follow-up videoconference with the integrated PT one month after returning to their village. Most of the musculoskeletal (MSK) issues seen by the integrated PT are acute in nature and can be treated in one visit or a few follow-up visits. However, some of the CO’s are screened then referred to outpatient PT for conditions requiring longer plans of care such as shoulder adhesive capsulitis, strengthening status post thoracic compression fracture, etc.

As the demand continues to grow, SCF will most certainly hire another PT, or perhaps a few more physical therapists to handle the increased volume. For now, many of the medical providers are content to refer most of the CO’s that come in with MSK complaints to outpatient PT. Others take a more conservative approach and make use of the integrated PT, especially for CO’s that voice their opposition to going to outpatient PT due to time constraints or just wanting to know how to treat the condition on their own. More in-house research needs to be done to determine the satisfaction of CO’s that are treated by the integrated PT and the degree to which those who are treated by the integrated PT do not have to return to their primary care providers for the same ongoing MSK complaint.

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