Physiotherapists are aware that they must re-evaluate and monitor their clients throughout their care plan. However, there can be wide variation in when and how this is done. A plan should be in place for each client that is suitable for them as an individual and allows you to safely manage their care. Decisions around things such as treatment plans, frequency of reassessment and monitoring, etc. should be based on your clinical judgement, the nature of the client, their needs, and their goals.
This article will review scenarios in which physiotherapists may or may not be re-assessing and monitoring their clients appropriately or realized after the fact that they missed the mark.
Scenario 1: Long-Term Care
Ali has been working at a long-term care facility for several years. Initially he struggled to figure out how to best manage his clients, his support workers, and his schedule. Ali found it challenging to know how often to reassess his clients because for many, their goal was to maintain their abilities and not to achieve resolution of their symptoms, gain independence or improve function. Below are some lessons he learned.
- Frequency of Reassessment – Ali learned quickly that the variation amongst his clients was challenging. Some would present with conditions that required more frequent reassessment and monitoring. He checked in on these clients weekly while others who were maintaining function and had more stable symptoms only required re-assessment every six to eight weeks.
- Support Workers – Ali became more and more confident in his colleagues as he spent more and more time working with them, discussing clients, reviewing care plans, and assessing their knowledge. He was able to outline more clearly when he needed to be contacted to progress or alter the treatment plan. Ali always assured them that it was best to contact him, even if they thought an issue was minor. As he gained more confidence in his team, he was more confident in his timelines for reassessment and monitoring.
- Refusal to Work with Support Workers – One of the hurdles for Ali was managing the expectations of clients that only wanted to work with him. As Ali was only in the facility once per week, this was not a feasible way for the client to achieve their goals of care. Ali knew he couldn’t provide care one-on-one in his time at the facility and had assessed the skills and competencies of the support workers. He knew they were capable of carrying out the assigned tasks. After he explained the potential negatives of refusing care from the support workers and walked his clients through the skills and benefits of working with them, most of these issues were resolved. For those who were still unconvinced Ali did his best to schedule in treatments when he could and ensured the client was aware of the limitations to this level of care.
Scenario 2: Structured Systems
Ali has just started work at a clinic. The business model is one where physiotherapists are strongly encouraged to assess and then assign exercises and care to the clinic’s support workers. The clinic automatically schedules follow-up treatments twice weekly with the support workers and then with Ali for re-assessment of those clients in four weeks. Although he often monitors and reassesses his long-term care clients with a similar frequency, he doesn’t feel this situation is the same. He feels pressure to follow the clinic’s model of care even though it doesn’t seem to be in his clients’ best interests.
Ben is a client of Ali’s and has been in the gym with Judy, the support worker, doing his exercises for his total knee replacement (TKR) for the past two weeks. Something isn’t quite right with his knee, and he has mentioned it to Judy. Since Ben is still able to complete his exercises, Judy feels it must be something minor. Ben is due for his reassessment in two weeks, so Judy decides to just wait it out. When Ben shows up in Ali’s office, Ali is concerned that Ben has been dealing with an infection that has now been untreated for a few weeks.
Models of care in which a certain number of weeks or sessions are assigned to a support worker before the physiotherapist re-assesses the client can be problematic for many reasons. Let’s take a closer look at what these might be:
- Physiotherapist Autonomy – It is essential that physiotherapists are in control of their own practice and that Ali and Ben are free to create a treatment plan that accomplishes Ben’s goals of care, considers his needs and the physiotherapist’s clinical judgement without influence from outside pressures. Ali needs to be able to re-assess more frequently and be available to follow-up should an issue arise.
- Physiotherapy is not a recipe – Although many protocols provide suggested timelines and phases of exercise programs, there are still significant variations in a client’s pain levels, ability to function, self-efficacy, etc. Due to these variations, physiotherapists are constantly tweaking and shifting their care to meet their client’s current status.
- Support Worker Competencies – Support workers are an integral part of delivering physiotherapy services. However, physiotherapists need to assess the support worker’s competence and knowledge. In this scenario Ali should have made sure Judy was aware of the signs and symptoms of infection after a TKR, especially if she was to assign care for the next four weeks.
Scenario 3: Altering Treatment Plans to Meet the Needs of the Client
Hannah and Rikki are attending a virtual group physiotherapy program for post-op ACL’s. They both met the requirements to attend the group classes but three weeks into the programming they see a significant difference in their progress.
Hannah is struggling to regain her extension, has quite a bit more fear around her knee’s ability to function, and is hesitant to push herself very much. Rikki is seeing good progress thus far and has expressed no concerns regarding her care or progress.
The group program doesn’t typically do a full, in-person reassessment of clients until the six-week mark, but the physiotherapist picks up on some of Hannah’s struggles. They see that during the exercises Hannah is struggling to regain extension and hasn’t appeared to progress much in the first three weeks. During a discussion after class the physiotherapist talks to Hannah about some of her fears regarding movement and about some options to address it. Although Hanna prefers the virtual classes, she recognizes that things aren’t progressing as they should and agrees that accessing a physiotherapist for in-person one-on-one care would be best.
Adjustments to client programs are a normal part of physiotherapy practice and can cut both ways.
- Clients may want to increase or decrease the frequency of their sessions based on many different factors. Their injury or condition, their progress, their finances, etc. You are making these decisions on frequency of treatment or modification of treatment plans based on assessment, objective measures, clinical judgement, and the client’s needs and wants.
- Adjustments should be discussed with the client and a review of your clinical reasoning is an integral part of this discussion. The adjustment to Hanna’s physiotherapy services was due to a lack of progress and the discussion focused around what would be in Hanna’s best interests to achieve her goals of care.
Scenario 4: Lack of Progress
Lena is a recent graduate and has been treating a client for several months. The client enjoys coming to physiotherapy and gets along great with Lena. The client reports feeling improvements after physiotherapy, but they only last a day or two. There has been no significant lasting change in her symptoms over the past six weeks, and the client is still coming twice a week for care.
Lena’s clinic owner, Rochelle, has requested a chart review of this client to check in with Lena and see how she is doing. During the review Rochelle finds that:
- The last outcome measure was performed at the initial assessment
- The last 13 chart notes show many “as previous” chart entries.
- There is no mention of changing treatment plans, referring onwards for further consultation, or any indication Lena was concerned that there wasn’t much change in the client’s condition.
Lena and Rochelle meet to discuss:
- Lack of re-assessment and consideration of alternative treatment options.
A failure for Lena to conduct re-assessments or recognize that little has changed in the client’s condition are major concerns for Rochelle. Assessment and objective measurements are cornerstones of physiotherapy and must continue throughout a client’s care plan. The frequency of these may vary depending on the client, the practice setting, the condition being treated, etc. but they cannot be absent.
Lena should have recognized the lack of significant change over the weeks as she monitored her client and would have if she had taken the time to reassess her client. It also would have been beneficial if Lena discussed this case with a colleague, referred her client to a more experienced physiotherapist or back to the physician for further review. It is not a guarantee that they can solve the problems Lena was having but it would be in the client’s best interest to explore those options.
- Lack of adjustments to the treatment plan.
Different conditions have different timelines and trajectories, so decisions around re-assessment, monitoring, and adjustments to care should reflect that. Issues can arise from either making changes too frequently or not frequently enough. However, a complete lack of change in symptoms and treatment plans over the course of six weeks raises concerns.
- Poor documentation.
Rochelle and Lena reviewed several chart notes together to find areas in which Lena was consistently missing details of the care being provided. They found that there were instances in other client files that also had similar issues where Lena pulled forward notes, or had stated only “as previous” or “continue”. They discussed the importance of having the necessary details in her chart notes and that the use of these charting short cuts are not in alignment with the Documentation Standard of Practice.
- Plans moving forward to better support Lena.
Rochelle recognizes that Lena may need some mentorship to improve the quality of the care being provided and help Lena feel more supported at the practice site. As laid out in the Code of Ethical Conduct physiotherapists should be providing their colleagues with the support they need and physiotherapists should recognize when they are struggling and be willing to ask for help.
Key Takeaways:
- Review your care plans and cases to check if you are appropriately monitoring, reassessing, and adjusting your care plans.
- Reassess to objectively measure and evaluate whether you need to adjust your approach and make decisions backed by evidence-based clinical judgements aligning with the client’s goals of care and gaining their consent.
- It is your responsibility to work autonomously and make decisions based on sound clinical judgement rather than organizational models of care and pressures from support workers or colleagues.
- Failure to reassess and adjust can result in negative therapeutic relationships, delayed recovery from injuries, and can lead to gaps in care that can have more significant poor outcomes for clients.
- When assigning services to support workers, ensure that plans include strategies for monitoring and reassessment, and direction for when the support worker should deviate from that plan (e.g., in the event of a negative change in the client or failure to progress as expected).
