Episode 57: Part 3 Tackling the MOSC - Investigating the Patient-Client Management Model

Time to dust off those cobwebs if you have been in the field for some time, and re-investigate the patient-client management model. Why do you care about this verbiage? Because you will need to overlay the ICF model and the patient-client management model when writing up your MOSC Case.  Although they are separate entities they very much intertwine and share a common theme, with very different words.

Let’s make life easy by breaking down the verbiage up front, so you can tackle your case with ease.

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Transcript

All Things Cardiopulmonary With Dr. Barisi

Rachele Burriesci 0:04

Welcome to Talking All Things Cardiopulm . I am your host , Dr . Rachele Burriesci , physical therapist and board-certified cardiopulmonary clinical specialist . This podcast is designed to discuss heart and lung conditions treatment interventions , research , current trends , expert opinions and patient experiences . The goal is to learn , inspire and bring Cardiopulm to the forefront of conversation . Thanks for joining me today and let's get after it . Hello , hello and welcome to today's episode of Talking All Things Cardiopulm . I am your host , Dr . Rachele Burriesci .

Rachele Burriesci 0:44

So we are in the end of April already . We have May coming right around the corner . I think I say this like week to week , but this year is flying . I started this podcast December 2023 , and I feel like I have said this statement a lot since then . Really , time just keeps moving fast . We're like halfway through spring and we've had some crazy weather . So we had some warm weather , like we had a week of 80 degrees , for I think maybe it was early on in April , and that was quickly turned into near freezing temps , big storms . We've lucked out so far We've had a lot of really big storms just miss us , and so we haven't had as much rain as we typically do by this time in the year . So I'm not really sure what that means for the summer . I have a feeling we have a hot summer in store and even though we had a relatively cold winter , like we had some moments of really cold this past winter , I think we hit negative 30 . And I don't remember it ever being that cold here . We typically have pretty mild winters here and I want to just make note , if anyone else is having this problem already , that the fly situation . They're like pterodactyls . These things are giant and they are out with a vengeance already . So we normally keep a screen between our kitchen door and the outside patio and so REM can go in and out . We actually have to replace said screen . So we haven't had that protection and if we have the door open for more than a few minutes , we have buzzing all around and these babies are big . I'm just like what is happening . So I'm a little bit worried about the fly situation , mosquito situation , the summer , if we're already seeing it now . So I don't know . We might have a really hot summer , we might have a really rainy May . I'm just kind of curious to see how this pans out .

Rachele Burriesci 2:55

I would like for it to just be a little even keel , like we're having one or the other 80 degrees , 40 degrees , I'd like to enjoy the season . I don't know if you feel this way . A lot of people always ask like , what's your favorite season ? I would say summer , hands down , no questions . I don't mind the heat , I don't even mind the humidity , especially if I have a place to enjoy said temperature a pool , a lake , an ocean , anything that revolves around water . It typically makes my heart very happy , so I never really complain about the summer . However , I married a ginger and so I am a little bit more aware . I'm sun aware now , and so I'm constantly making sure that she's covered enough , that she has UPF gear , that she's got sunscreen on mowing the lawn already . I'm like you know , did you sunscreen up ? You know all the things , but you will not hear me complain about it being too hot .

Rachele Burriesci 3:56

With that being said , I really do truly enjoy the seasons . Like I love spring , I love that 60 degree , 60 to 70 degree weather . I love the . The new bloom just has so much like parallels to life new growth , new starts , new beginnings , plant the seed , all the things . If you want to kind of hear me go into some of that , revisit one of my old podcasts from last year about gardening and I really get into you know , plant that seed and that can mean anything in life .

Rachele Burriesci 4:34

I really enjoy fall too . Like I like that switch , I like the coziness of fall . I'm not a big Halloween person but Thanksgiving is my holiday so , like I do thoroughly enjoy the change in seasons , I think winter is my least favorite season . I really thrive with being outside . So not being outside as much , the gloominess , the grayness , the longer or the shorter days , I should say it just kind of hits me a little bit . But I do enjoy like a little snow flurry , I enjoy it being a white Christmas , like things like that . So I would like for the spring to just kind of like mellow out a little bit . Give me , give me spring . And I think our seasons have been changing for some time . I think our winters have pushed into spring and I think we're going to see that over time . And you know , change in temp and all that can go super deep in what that really means . But we're not here for that .

Rachele Burriesci 5:35

So , with that being said , we're going to jump into today's episode . I did totally lie to you . I anticipated that the MOSC podcast would be three episodes , so like a series of three . I decided today that it's going to be a four-part series and the reason is is because there's more verbiage nuance that exists and if you have been a clinician for a while , if this is the first time doing the MOSC , if you haven't been in the academic world for quite some time , I think we get a little bit I don't want to say lazy , but I'm going to we get a little bit lazy with our terminology and I think I realized this when I went into academia because I was teaching the patient-client management

Patient-Client Management Model Overview

Rachele Burriesci 6:24

model .

Rachele Burriesci 6:24

So pull out the cobwebs , think guide to PT practice patient-client management model . It's nothing really new . It's stuff that you're using likely every day , but I do think that we use some terms synonymously and so maybe I just want to clear that up a little bit . So the reason why I want to talk about the patient client management model is because it also is included in the case . So next week we will actually go through each section of the case and talk about , like some big pieces . But essentially , when you're thinking about building the case , you're going to have two verbiage platforms , kind of overlaying each other , side by side , intermingling . So we have ICF model , which is the WHO verbiage that is worldwide nomenclature . And then we have the patient-client management model , and so when I'm talking about patient-client management model it does make the MOSC case a little duplicative , but where it duplicates you just pull from a previous section . So I don't think it's really too overbearing in that way , but I at least wanted to talk about it because this is verbiage that you probably haven't used in such context in maybe some time . If you're a student and you are a first year PT or PTA student , this is good verbiage for you to know . So we'll just kind of go through what should be included in each section and pretty much pull out some of the big pieces to think about . So I think in the world of like synonyms we use I don't even want to say cinnamon , say that five times fast , I don't even know if we use them as synonyms we typically say a PT eval right , I have five PT evals today . No-transcript , if that makes sense , if I'm going to like play semantics .

Rachele Burriesci 8:55

So examinations , like the data gathering and evaluation is technically our assessment , our interpretation . They typically happen in the same episode of care , but when you're breaking them down into definitions they are separate entities . Okay . So when we're talking about examination . We're talking about everything in the world of gathering data , and that starts with taking history . When we're taking history , that includes everything from our chart review before we even see the patient , to our patient interview , to our discussions maybe with physicians , case managers , teachers , depending on what setting you're in even family members , especially if we have a situation where we either have a legal guardian or maybe a parent in the client care that we might be having conversations with them as well , and all of that information is data . So when we're talking about history taking , we're talking about general demographics , age , sex education , race . Those things correspond with internal factors in the world of ICF . So I'm going to try to keep the parallels and like show where they kind of overlap each other , because that's going to be helpful when you're building this picture for yourself .

Rachele Burriesci 10:25

Past medical history everything from current diagnoses , past diagnoses , surgical history , past injuries . What else do I have on my list ? Medication , right , their medication list ? Current , maybe expired or discontinued , I should say . Social history can cover a wide range . It can include things like their home environment . Specifically in the acute care setting , we talk a lot about home setup . Are you in a house or an apartment ? Do you have steps to enter ? Do you have steps inside ? That is a really big piece to our discharge plan . That might not be as important to maybe an outpatient PT who is treating a 16-year-old athlete , or maybe it's just as important because maybe they have an ACL and they're non-weight bearing for a short period of time . So why you're picking certain things depends on your typical patient and that's what you're going to include in these questions that you're pulling out . Urban versus rural setting can be very important in different discussions .

Rachele Burriesci 11:34

Social support Do they have parents available to support them ? Do they have a spouse ? Are they a primary caregiver ? Do they have friends or family that can check in on them or assist with IADLs ? Do they have equipment ? What kind of equipment Do they have ? Walkers , crutches , commodes , do they have things like a treadmill , exercise bike ? Right , all of that is included in it . And then , what types of services are available ? Or maybe , what kind of support groups are they a part of ? I actually just had a patient this past weekend . I put a poll out on not a poll a question box out on Instagram asking for some resources for a patient , but he was a 25-year-old male with Asperger's and CRPS and one of the questions I asked was are you a part of any CRPS support groups ? Because that is a very specific diagnosis that has a lot of impact on every aspect of life and can very much isolate you from your family , from your friends , from the ability to have a job , that kind of thing . So support groups part of that social piece , that right , that social history reflects back on external factors in the ICF right . What kind of support do they have available If a person is discharging to home with a spouse versus they live alone ? It's two different pictures so they impact the full picture .

Rachele Burriesci 13:13

Things like clinical tests In the acute care setting I think we have so much access to past medical history , surgical history , lab values , every test that they've had , probably over the past year and maybe even lifetime , depending on how much you can see in one episode of care . But in my setting , knowing new lab values or updated lab values can be very important can impact whether you may or may not see a patient or the expectation of the person's ability . For instance , if someone has a hemoglobin of 6.8 , but you know they're not going to do a blood transfusion , that piece of information is going to impact the tests and measures that you're going to perform and the expectations of that patient . Potentially , things like chest x-ray , mri results , pet scan , eeg , any sort of medical test that has some sort of outcome that may affect your examination or affect the overall course of care , is a part of the examination the history taking piece . Then , of course , you want to know about the current condition . What is happening in this current episode of care ? What are their primary symptoms ? If it was an injury , what was the mechanism of injury ? What are their specific goals ? What types of things have they tried before ? Have they had PT before ? Have they been successful in PT ? What was their experience like with their previous hospitalization ? Same thing . This can really impact your current episode of care , prognosis , all of the things . And it also reflects back on internal factors for ICF , because that patient experience can play a role in now , their current and future experience . Things like health habits may or may not be part of your normal questionnaire . Typically , knowing if someone is a smoker , uses alcohol or drugs , vapes can be a very important piece of information , especially in the cardiac and lung population , level of fitness or prior level of function . You can put those two together or separate , however specific you want to get . But that plays a big role in understanding the person's capacity , their optimal level of movement , movement function , whatever it might be . And then those things again can play a big role in your plan of care , your discharge summary , right . So examination , history taking is a really big piece of opening that start of care .

Comprehensive Physical Examination Overview

Rachele Burriesci 16:13

Then typically in an examination you do a medical review of systems and so this is typically a brief overview of body systems . This is typically ruling out red flag questions . This might be questions related to medication list . So in the outpatient setting I can remember doing an examination and you know , taking history and asking about past medical history , because you don't always have access to their chart . And so now you're relying on patients to give their past medical history and a lot of times you would ask any issues with heart or lungs and they would say no , and then you would say I see that you're on a beta blocker and an ACE inhibitor . Do you know why you're taking those medications ? And then typically they would say , oh yeah , it's because I had high blood pressure . So I then you kind of reveal that past medical history . So medical review of systems is typically a big overview you can think of like red flag questions pain while sleeping , urinary incontinence , anything that's going to flag something bigger chest pain with activity , that kind of thing Then a part of exam should be some sort of PT system review .

Rachele Burriesci 17:34

This is typically very brief , very gross assessment of your major systems . So things like for cardiovascular and pulmonary that we are assessing vitals at the start of every examination . Right , because you want to know prior to doing whatever you have planned for that day is there blood pressure , heart rate , spo2 within normal limits ? If you are just starting to work with this patient and you get a blood pressure of like 220 over 99 , that might be enough for you to hold the rest of that examination and refer back to the physician , have a call with the physician , potentially call 911 if there's other symptoms related because we're at that hypertension urgency level .

Rachele Burriesci 18:25

In the gross assessment , you might do an overall skin assessment . What does the color look like ? Is there anything notable , especially like in the cardiovascular world ? I'm going to be looking at skin color on the legs . Is it dry , is it scaly , is it brawny , is it shiny ? That's going to give me a ton of information . Are they cyanotic ? Do they have any open wounds ? Is there a problem with the integumentary system in any way , shape or form . So just a quick overview , right ? You don't typically get into a more specific test and measure unless there is a finding in the gross assessment For musculoskeletal , gross range of motion , gross MMT , maybe a gross functional movement , maybe assessing gait as you see them .

Rachele Burriesci 19:13

Again , if you're an outpatient , if they walk from the lobby to the treatment area , being able to assess balance , gait , just with that , you know , 10 to 20 foot ambulation can give you a lot of information . Maybe it's assessment of posture . A quick , quick and dirty overview Neuromuscular , maybe you do something related to balance , maybe again , you're assessing gait and assessing balance as they're walking in , right , so it's very gross , very basic , very brief , just to cover all the main systems . You're also , in this time , assessing affect , cognition , the ability to communicate . It doesn't take specific questions necessarily to determine that there might be impairment with communication , right , if your patient has a history of stroke , they might be dysarthric . If your patient has dementia , maybe they're not oriented , and then maybe you would ask the orientation questions to see if they're A&O times one versus three or four . This could be a simple question of how do you prefer to learn ? Do you like written handouts ? Do you like videos ? Do you like demonstration ? Whatever it might be . But all of that information gives you more information for the next piece , after you do your gross overview .

Rachele Burriesci 20:46

Now you actually get into your specific tests and measures , and those specific tests and measures are really meant to identify the major problems . They should reflect back on the chief complaint , right ? If you have a patient who's coming in with shoulder discomfort or pain , it is very unlikely that you're going to perform a Lachman's test to assess ACL . If you have a person who's coming in for a pulmonary issue , it's very unlikely that you're going to do a special test to assess Achilles . This test and measures obviously are very specific to the problem that they're here for . So this is your comprehensive screening . These are your main objective findings for this examination . So basically , create a hypothesis to prove yourself right or wrong , whatever it might be . If , for instance , we have someone who comes in with , let's say , pulmonary disease , copd maybe they're newly on oxygen . Maybe we are going to do a six-minute walk test to assess overall aerobic capacity and ability to maintain stats with continuous ambulation . If you have a patient who's specifically coming in with something neuro-related , maybe you're doing a specific balance test , like a Berg , to assess or determine their falls likelihood . If you have a patient who maybe has a productive cough , maybe now you're doing something more specific like cough assessment or peak expiratory flow assessment . So the tests and measures are going to be specific to your chief complaint .

Rachele Burriesci 22:36

What I do want to kind of throw out ahead of time is two things . This is all for building your case . When you're thinking about your case , if you haven't picked a person yet and you are just like waiting for that , that diagnosis to come in , that you just like really want to showcase Two important things to think about . One , you definitely want to have some outcome measure that has maybe a minimal detectable change . So , like for a pulmonary patient , a six minute walk test would be incredible because it is a wonderful test to assess that capacity and it has a lot of cutoff scores for improvement as well as cutoff scores for morbidity and mortality . If you have someone who is coming in with increased risk of falls or had a recent fall , you definitely want to do an outcome measure related to falls risk and something that you can then utilize on reassessment . That's important because objective measures is a part of the case .

Rachele Burriesci 23:43

The second piece of that is utilizing tests and measures and or interventions , which we haven't gotten to yet , that are evidence-based . And then , when you are choosing these tests and measures or interventions , that you are thinking about specific sources that show that it is evidence-based , because at the end of the case you do have to reference specific articles or textbooks or you have to have a citation list proving your case . So I want to say that early on because I don't want you to get to the last section , section nine , and be like , oh , I'm done , but now I have like to add all these citations and I have to go way back to the beginning . So I wanted to tell you right at the start so that you can start , you know , building that list . For instance , if maybe I had a patient who was an ICU for a long period of time , maybe they have diaphragm weakness , maybe they're coming to see me because they're short of breath , fatigued , I'm definitely going to do some sort of assessment to assess the diaphragm . I'd probably do something in the world of MIP and MEP and then I would have an intervention related to MIP and MEP , like respiratory muscle training , and then , on re-eval or re-exam and discharge , I would have a follow-up , a repeat measurement , and so then I can show change , which will then be important later on . Did you actually make an impact ? So I want to kind of throw that piece out there now . So I mean , we all know what tests and measures are right . I'm not telling you anything new here , but I want you to kind of piece it and package it so that you can utilize this information to write up your case effectively and efficiently , so that you're not having to go back and forth and be like , ah , I put that in the wrong section or I was planning on putting it somewhere else .

Rachele Burriesci 25:48

The evaluation piece of this is your interpretation of those findings , your interpretation of the examination , your tests and measures compiled on top of their history , their internal , external factors , all of that right . So you're now giving your assessment . So evaluation and assessment are actually synonymous . So you're interpreting what you found right . So some examples would be patient demonstrated less than 300 meters on a six-minute walk test requiring multiple seated rest breaks , maybe desaturated below SpO2 goal , is limited in ability to participate in community , has poor overall aerobic capacity and is at high risk for morbidity and mortality within a year . Based on this article , maybe you did a five-time sit-to-stand with someone and they scored greater than 20 seconds . You might indicate that they're at high risk for falls because their age-controlled match should be less than . Maybe 12 seconds is a common number in that test and measure . Maybe you have a patient and you noted that they had pectus excavatum or they had a right scoliosis curve and on further chest exam they have significant decreased lateral costal excursion . Maybe then you did a more formal objective assessment using a tape measure to show differences between sides and maybe then you can show change . After you've incorporated said breathing activities In the evaluation piece , you are interpreting your findings from your tested measures .

Developing PT Diagnosis, Plan, & Goals

Rachele Burriesci 27:43

You are developing that problem list , the list that is going to show me my impairments . So your problem list is your impairment list , which goes back to your ICF model Impairment of strength , impairment of balance , impairment of aerobic capacity , impairment of gas exchange , impairment of aerobic capacity , impairment of pain , impairment of healing , wound healing , whatever it might be . You're developing that list . That list helps determine your PT diagnosis . Patient presents with impairment of fill in the blank , secondary to fill in the blank , and that's the start of your sentence , right ? So patient presents with impairment of aerobic capacity , gas exchange and airway clearance in the setting of cystic fibrosis . That's my opening line . On examination , they demonstrated poor aerobic capacity with a gate speed of I'm sorry , with a six minute walk test of less than , let's say , 300 meters . Maybe we throw gate speed in the mix as well . Maybe we throw in poor cough technique with limited inhalation and glottal closure wet , tenacious cough with green , copious sputum , right ? So you're giving that I like to call the evaluation ESPN snapshot .

Rachele Burriesci 29:20

You're giving the play-by-play with your spin on it to determine the next piece , which is the prognosis . Patient will benefit from physical therapy because they show high motivation you know , fill in the blank on that Because they have good family support , because they've had prior experience with good outcomes . Whatever your reason for prognosis with good outcomes , whatever your reason for prognosis , maybe they have good overall prognosis due to prior level of function and minor setback due to weight-bearing status . So you're giving the spin as to why or why not , they're a good PT candidate or not . There are many times that I have written , especially in the acute care setting , where maybe the patient is at current baseline level , has been bed bound for greater than five years , has been non-ambulatory since whatever lacks ? Poor family support lacks , poor emotional intelligence lacks fill in the blank , right , whatever the reason for the outcome , that they're going to be a good candidate or maybe not , and so you know being able to articulate that in some way , shape or form .

Rachele Burriesci 30:47

And then you are then going to create a plan of care . So , when we're talking about plan of care , this is your prediction . This is what I like to call the crystal ball . How long is it going to take for this patient to reach said goals , which is part of this . How many days a week , times per day , that frequency , that time that it's going to take to meet this expectation ? That is part of your plan of care . What is also part of your plan of care , which most people know , is goals , right , your short and your long-term goals . And then , when you're writing goals , that you're writing them specifically , that they are specific to the patient , that they are intertwined in the patient's goals , that they are measurable , that they are realistic , that they have a time component and , very importantly in the world of PT , that there is a functional component to it . Patient will be able to ambulate 1.2 meters per second in order to successfully cross the street . This was a very common thing that you might see in New York when you have patients that live independently and maybe rely on public transportation , gate speed would be a very specific goal , a great outcome measure and there's a very obvious functional reason for it . So , breaking down short and long-term goals , what that timeframe looks like .

Rachele Burriesci 32:16

And then one piece that I think a lot of people maybe don't realize as part of the plan of care is the interventions list . So your interventions list should mirror your impairments list , right ? They should have some sort of parallel to it . So if my patient has impairment of gas exchange , that I'm going to be doing some sort of breathing exercise . If my patient has impairment of airway clearance , that I'm doing airway clearance techniques . If my patient has impairment of range of motion , maybe I'm doing something in the world of range of motion . If my patient has impairment of strength , I'm doing strengthening exercises , right . So there should be some sort of parallel and you're writing that out .

Rachele Burriesci 33:02

And then the last one is your discharge plan . In the acute care world that usually revolves around where they're going to discharge to . Are they going to discharge back to home with support with home health , with outpatient PT ? Are they going to a SNF or a subacute facility or an acute rehab . In the world of outpatient , maybe it's return to sport , return to work , return to school . So , pending your setting , pending your population , that discharge plan is going to obviously correlate to their goals and to the setting itself . Part of that could also be related to equipment needs right , patient might need equipment like a walker or crutches or a wheelchair or slide board or what have you . So that could be very much part of a discharge plan .

Rachele Burriesci 34:04

Outcomes is technically its own section and it is its own section again on the MOSC . So even though you typically will do an outcome measure as a test and measure , they have it as its own category . So definitely pick a patient that you perform some sort of outcome measure that has you know a pre and post , and even better if it has a minimal detectable change so that you can show potential change in your case . That outcome measure will then have citations related to its evidence , and so you definitely want to include that . And the last piece is re-exam . How often are you performing a re-examination ? Very commonly you'll see every 30 days or every four weeks . Maybe you perform them sooner , especially if they're not making progress . Maybe there's a new clinical finding so you might do another test and measure In the acute care setting .

Rachele Burriesci 35:02

I think that even though we technically do a full re-exam every 30 days , because there's so much rapid change in such a short length of stay , you typically are doing some sort of reassessment , re-exam , maybe an additional test and measure as the person becomes more capable of performing it . So just something to consider , again very much related to your setting . So when you're thinking about this case , you have two models that you're going to be referring to the ICF model and the patient-client management model . They are very similar , they mirror each other . I think they really do work well with each other , but they are different verbiage and so they very much intertwine . But they also might have its own section . So I think that's where it gets a little duplicative . But I think if you go in knowing it and you have a little bit of background , it kind of makes the whole process a lot easier .

Preparing for Success

Rachele Burriesci 36:07

So hopefully this was helpful for you . I was trying to keep it a little bit short . I think I went longer than I expected . But hey , here we are . I'd like to make sure that we are closing all of those questions and making sure that you go into this thing prepared and can just get in , get out and be done . If you need any further assistance , please let me know . I do one-on-one mentoring for specific cases or if you are doing something like the mosque or applying for your CCS . If you want a little bit more personal , one-on-one guidance , I'm here for you . I'll put my link in the show notes and please reach out . If this was helpful , share it with a friend , write a review . All of those things help tremendously and I am so thankful that you're here and I hope you have a wonderful rest of your day , rest of your week and whatever you have to do and get after it .