Chapter 17: Management Issues in Hospitals and Health Systems

Learning Objectives

Part 1 The Contemporary Setting

Brief Overview of Hospitals and Health Systems

In the past 25 years, the organizational changes that have occurred in hospitals may have had more of an effect on the actual practice of physical therapy than any other factor in any other setting. Rehabilitation services in acute care moved from major revenue-generating centers in the fee-for-service model of reimbursement in the early years of Medicare to a cost center (not direct profit producers) in the current prospective payment system of Medicare. The focus of management has become reducing the cost of care per patient and making physical therapy a value-added service—providing something beyond standard expectations that does not add to costs.

Once the gold standard of physical therapy prac-tice, and often the preferred work setting of many physical therapists, large acute-care hospitals were where new graduates were encouraged to take their first jobs because those hospitals were perceived to be the foundation for all other practice settings. Most physical therapists sought to work in acute care at the beginning of their careers because that was where the majority of patients were cared for when they needed rehabilitation services. The variety of clinical experiences presented by patients with a wide range of diagnoses in acute care settings, opportunities to follow patients for extended periods in the early stages of their recovery, and the availability of experienced mentors were perceived as important to professional development of novice physical therapists.

Many of these factors continue to affect the career choices of physical therapists. The current high patient turnover in hospitals provides therapists with a large variety of patient experiences, many of which are often unique or at least rarely seen. Therapists remain challenged by complex, immediate clinical decision-making and constant communication with other members of the care team required in hospital-based practices.¹ What has changed is that patients no longer reach their optimal rehabilitation goals before discharge to home. Instead, physical therapists set specific, limited functional goals that prepare patients for discharge as soon as possible.

Because of these shorter lengths of stays, therapists have assumed two important roles. First, they are consultants who make discharge recommendations based on their determination of a patient's rehabilitation potential and identification of the safest post-acute care setting. Second, they are educators who, for example, conduct classes to prepare patients for elective surgeries, and training sessions for hospital personnel to develop safe patient handling techniques.

Selected Issues in Inpatient Hospital Care

Freestanding community hospitals may ...