Talking All Things Cardiopulm
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.
Talking All Things Cardiopulm
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.
MOSC Online Portal: https://abptsportal.apta.org/Learner/LearningPlan/List
MOSC Requirements: https://specialization.apta.org/maintain-certification/mosc-requirements
Join my newsletter: https://allthingscardiopulm.ck.page/9bb2730421
Need further guidance on the MOSC?
Sign up for 1:1 mentoring session: https://www.allthingscardiopulm.com/mentoring
Find me on:
IG: @all_things_cardiopulm
Threads: @all_things_cardiopulm
Website: www.allthingscardiopulm.com
Twitter: @allcardiopulm
Linked-In: Rachele Burriesci
Text at 913-308-4494
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: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: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: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: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: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 model.
Rachele Burriesci: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: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: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: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: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.
Rachele Burriesci: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: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: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: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: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: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: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: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.
Rachele Burriesci: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: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: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: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: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: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: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.
Rachele Burriesci: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.
