Stratified Targeted Engagement From Primary Care to Physical Therapy (STEPPT)

Browse trials for

• Low Back Pain 2,811
• Neck Pain 1,230

Keywords

• Physical therapy
• Rehabilitation
• Hispanic
• Heatlh Services
• Healthcare utilization
• Federally Qualified Health Center

Study arms

• Experimental
  STEPPT Care Pathway

  The STEPPT Care Pathway is a multi-level intervention designed to improve physical therapy (PT) referral and adherence among Hispanic patients with spine pain in Federally Qualified Health Center. STEPPT includes: 1) provider training and feedback through brief in-service education on guideline-based referral and culturally responsive communication about the benefits of PT for spine pain, 2) delivery of culturally tailored patient education materials in English and Spanish via print, video, and digital platforms, and 3) enhanced care navigation by bilingual Patient Health Navigators who provide personalized outreach, barrier mitigation, and scheduling support. System-level enhancements include automated electronic health record tools for patient identification, registry tracking, and delivery of education materials to ensure timely referral and engagement in PT services.

  Behavioral: Engagement of clinic leadership (System Intervention - STEPPT) · Behavioral: Patient Registry (System Intervention - STEPPT) · Behavioral: Delivery of Patient Education Materials (System Intervention - STEPPT) · Behavioral: Patient Health Navigator Training (System Intervention - STEPPT) · Behavioral: Care Navigation (System Intervention - STEPPT) · Behavioral: Care navigation audit and feedback (System Intervention - STEPPT) · Behavioral: Primary Care Provider training (Provider Intervention - STEPPT) · Behavioral: Nurse/Medical Assistant Training (Provider Intervention - STEPPT) · Behavioral: Provider feedback on PT referral and adherence (Provider Intervention - STEPPT) · Behavioral: Patient education on spine pain condition (Patient Intervention - STEPPT) · Behavioral: Patient Education on Physical Referral by Providers (Patient Intervention - STEPPT) · Behavioral: Electronic Patient Education on Physical Therapy Referral (Patient Intervention - STEPPT) · Behavioral: Patient education on physical therapy referral by Patient Health Navigator (Patient Intervention - STEPPT) · Behavioral: Monitoring of PT referral and adherence rates (System Intervention - STEPPT)

• Active comparator
  Usual Care Pathway (Control)

  The Usual Care Arm involves the current institutional standard of referral and scheduling processes. If a patient is referred to physical therapy, a centralized Referral Specialist verifies insurance and attempts to schedule the evaluation. No provider/staff training, culturally tailored patient education, or enhanced care navigation is provided beyond the current standard of care.

  Behavioral: Engagement of clinic leadership (System Intervention - Usual Care) · Behavioral: Delivery of Patient Education Materials (System Intervention - Usual Care) · Behavioral: Referral Specialist Training (System Intervention - Usual Care) · Behavioral: Patient education on spine pain condition (Patient Intervention - Usual Care) · Behavioral: Patient Education on Physical Referral by Providers (Patient Intervention - Usual Care) · Behavioral: Patient education on physical therapy referral by Referral Specialist (Patient Intervention - Usual Care) · Behavioral: Care Navigation (System Intervention - Usual Care) · Behavioral: Monitoring of PT referral and adherence rates (System intervention - Usual Care)

Interventions

• BehavioralEngagement of clinic leadership (System Intervention - Usual Care)

  No engagement of clinic leadership in promotion or monitoring of PT referral patterns among providers or PT adherence patterns among patients

• BehavioralEngagement of clinic leadership (System Intervention - STEPPT)

  Clinic Directors and Charge Nurses engage in STEPPT onboarding meeting with STEPPT Project Manager to discuss STEPPT objectives, procedures, and need for local adaptations. Medical leaders champion provider training and facilitate change in practice patterns through regularly scheduled review of trends in PT referral and adherence patterns with STEPPT Project Manager.

• BehavioralPatient Registry (System Intervention - STEPPT)

  Patients referred to physical therapy for spine pain are stratified by ethnicity. Hispanic patients are added to STEPPT Patient Registry to facilitate targeted engagement of an underserved population known to have low rates of adherence for physical therapy referrals.

• BehavioralDelivery of Patient Education Materials (System Intervention - Usual Care)

  Neck or back pain fact sheet may be manually ordered in the printed after visit summary at the discretion of the primary care physician. No automated systems for delivery of patient education materials on spine pain or physical therapy referral.

• BehavioralDelivery of Patient Education Materials (System Intervention - STEPPT)

  Automated delivery systems for patient education materials include: * Auto-order for culturally tailored neck or back pain fact sheet, general PT fact sheet, and postural exercise fact sheet printed in the AVS for all Hispanic patients with a new or existing spine pain problem * Auto-order for text message with links to culturally tailored PT referral fact sheet and video upon referral to PT for spine pain * Auto-order for culturally tailored neck or back pain fact sheet, general PT fact sheet, postural exercise fact sheet, PT referral fact sheet, and video added to the patient portal upon referral to PT for spine pain

• BehavioralReferral Specialist Training (System Intervention - Usual Care)

  Referral Specialists trained in system-wide procedures for processing referrals, calling patients, and scheduling appointments for specialty services. Physical therapy referrals processed by a dedicated team of Physical Rehabilitation Services Referral Specialists.

• BehavioralPatient Health Navigator Training (System Intervention - STEPPT)

  Patient Health Navigators (PHNs) trained in system-wide procedures for processing referrals, calling patients, and scheduling appointments for specialty services. Additional training on patient communication and enhanced care navigation is provided to address cultural factors, individual barriers, and risk factors for non-adherence. Physical therapy referrals processed by a specially trained team of Physical Rehabilitation Services PHNs.

• BehavioralCare Navigation (System Intervention - STEPPT)

  Upon referral to PT and verification of insurance coverage, patients receive a system-generated auto-call to schedule the PT evaluation followed by up to 3 phone contact attempts by a Patient Health Navigator (PHN) to 1) deliver enhanced care navigation, and 2) schedule PT evaluation. Prior to scheduling, PHN delivers semi-scripted enhanced care navigation (ECN) with mandatory components: * Summarize benefits of PT * Emphasize importance of attending PT even if prescribed medication for temporary pain relief * Confirm patient received and reviewed educational materials. Resend materials, if needed * Address privacy concerns, if present * Address risk factors for PT non-adherence, if present: scheduling, cost, transportation barriers * Address other questions or concerns * Schedule the PT evaluation * Repeat appointment details and provide PHN contact information for additional questions

• BehavioralCare navigation audit and feedback (System Intervention - STEPPT)

  Audits of fidelity to enhanced care navigation protocol using self-report checklists and review of recorded phone calls are discussed monthly with PHNs to facilitate competent and consistent delivery of enhanced care navigation for patients in STEPPT registry.

• BehavioralPrimary Care Provider training (Provider Intervention - STEPPT)

  PCPs attend training with Physical Rehabilitation Services site manager on the following topics: * STEPPT objectives, procedures, and patient education materials * Referral and adherence rates for PT among Hispanic patients at FQHC clinics * Benefits of PT referral for patients with new and existing spine pain problems * Culturally responsive strategies to improve patient engagement in PT services (e.g., explanation of how PT can improve family and social role functioning)

• BehavioralNurse/Medical Assistant Training (Provider Intervention - STEPPT)

  Nurses and MAs attend training with Physical Rehabilitation Services site manager on the following topics: * STEPPT objectives, procedures, and patient education materials * Referral and adherence rates for PT among Hispanic patients at FQHC clinics * Benefits of PT referral for patients with new and existing spine pain problems * Culturally responsive strategies to improve patient engagement in PT services (e.g., explanation of the FQHC referral process)

• BehavioralProvider feedback on PT referral and adherence (Provider Intervention - STEPPT)

  Trends in PT referral and adherence rates, stratified by ethnicity, are reviewed biannually at "Provider Huddles" along with suggestions for improvement as needed.

• BehavioralPatient education on spine pain condition (Patient Intervention - Usual Care)

  Verbal patient education on etiology, treatment, and prognosis for spine pain may be provided at the discretion of Primary Care Physician. Back Pain or Neck Pain Fact Sheet may be ordered in the printed After Visit Summary at the discretion of Primary Care Physician. Back Pain/Neck Pain Factsheet summarizes current evidence on etiology, prognosis, and treatment (medical and self-management) for back or neck pain. \[Available in English or Spanish language\]

• BehavioralPatient education on spine pain condition (Patient Intervention - STEPPT)

  Verbal patient education on etiology, treatment, and prognosis for spine pain may be provided at the discretion of Primary Care Physician. Patient education materials auto-ordered in the printed After Visit Summary for all patients with a new or existing spine pain problem on the electronic health record Problem List. STEPPT patient education materials include: (1) Back Pain or Neck Pain Facts, a culturally tailored factsheet summarizing current evidence on etiology, prognosis, and treatment (medical and self-management) for back or neck pain, (2) Physical Therapy Fact Sheet, culturally tailored information describing physical therapy evaluation and treatment options for pain with a QR code linking to a Physical Therapy Education Video, (3) Posture Exercises, culturally tailored instructions for standing posture, seated posture, and supine diaphragmatic breathing. \[All patient education materials available in English or Spanish language\]

• BehavioralPatient Education on Physical Referral by Providers (Patient Intervention - Usual Care)

  Verbal patient education on physical therapy referral may be provided at the discretion of Primary Care Physician, Nurse, and/or Medical Assistant at index encounter. Patients are notified of referral for physical therapy consultation in the printed After Visit Summary. No written instructions on physical therapy referral process are provided.

• BehavioralPatient Education on Physical Referral by Providers (Patient Intervention - STEPPT)

  Following training in best practices, primary care providers encouraged to provide culturally responsive patient education on benefits of PT for spine pain at index encounter. Nurses and medical assistants encouraged to review printed patient education materials on benefits of PT and institutional referral process. Patients are notified of referral for physical therapy consultation in the printed After Visit Summary at index encounter.

• BehavioralElectronic Patient Education on Physical Therapy Referral (Patient Intervention - STEPPT)

  Patient receives auto-email from patient portal and auto-text message with links to electronic patient education materials upon being referred to PT: * Physical Therapy Referral Information - Culturally tailored information highlighting the importance of attending PT, resources to support regular attendance, and instructions for scheduling and preparing for the PT evaluation. \[Eng/Span\] * Physical Therapy Education Video - Culturally tailored video showing how to schedule and attend the PT evaluation with testimonials from former FQHC patients highlighting benefits of PT for spine pain. \[Eng/Span\]

• BehavioralPatient education on physical therapy referral by Referral Specialist (Patient Intervention - Usual Care)

  Verbal patient education on physical therapy referral may be provided at the discretion of the Referral Specialist when scheduling the physical therapy consultation.

• BehavioralPatient education on physical therapy referral by Patient Health Navigator (Patient Intervention - STEPPT)

  Culturally responsive, semi-scripted patient education on benefits of physical therapy and logistics of physical therapy appointments provided verbally by a Patient Health Navigator (PHN) when scheduling the physical therapy consultation. PHN identifies and helps mitigate individual barriers for attending physical therapy appointments.

• BehavioralCare Navigation (System Intervention - Usual Care)

  Upon PT referral and verification of insurance coverage, patient receives up to 2 system-generated auto-calls to schedule PT evaluation. If no contact is made after 30 days, a system-generated letter is sent by mail requesting the patient call a centralized Referral Specialist to schedule the PT evaluation. Additional care navigation services may be provided at the discretion of the Referral Specialist.

• BehavioralMonitoring of PT referral and adherence rates (System Intervention - STEPPT)

  Automated EHR analysis monitors daily PT referral and adherence rates for spine pain. PowerBI custom graphical interface with monthly trends in PT referral and adherence rates, stratified by ethnicity, are reviewed biannually by Vice President of Specialty Services, Physical Rehabilitation Services site manager, medical leadership, and providers.

• BehavioralMonitoring of PT referral and adherence rates (System intervention - Usual Care)

  PT referral and adherence rates monitored as needed by Vice President of Specialty Services.

Primary outcomes

1. Physical Therapy Referral

   Proportion of enrolled patients who receive an internal or external referral to physical therapy following Primary Care Provider (PCP) index encounter for a new or existing episode of spine pain.

   Time frame: Patient level: 3-months after index PCP encounter; Clinic level: 6-, 12-, 18-, and 24-months after start of trial

2. Physical Therapy Adherence

   Proportion of enrolled patients who complete a physical therapy evaluation at the Federally Qualified Health Center following an internal referral to physical therapy for a new or existing episode of spine pain.

   Time frame: Patient level: 6-months after index physical therapy referral; Clinic level: 6-, 12-, 18-, and 24-months after start of trial

Secondary outcomes

1. Maintenance Physical Therapy Referral

   Proportion of enrolled patients who receive an internal or external referral to PT following Primary Care Provider (PCP) index encounter for a new or existing episode of spine pain during the maintenance phase.

   Time frame: Patient level: 3-months after index PCP encounter; Clinic level: 30-months after start of trial

2. Maintenance Physical Therapy Adherence

   Proportion of enrolled patients who complete a physical therapy evaluation at the Federally Qualified Health Center following an internal referral to physical therapy for a new or existing episode of spine pain during the maintenance phase.

   Time frame: Patient level: 6-months after index physical therapy referral; Clinic level: 30-months after start of trial

3. Patient age

   Patient age in years recorded in electronic health record

   Time frame: Upon enrollment

4. Patient sex

   Patient sex at birth recorded in electronic health record

   Time frame: Upon enrollment

5. Patient race

   Patient race recorded in electronic health record

   Time frame: Upon enrollment

6. Patient ethnicity

   Patient ethnicity recorded in electronic health record

   Time frame: Upon enrollment

7. Patient birth place

   Patient country of birth recorded in electronic health record

   Time frame: Upon enrollment

8. Patient education

   Patient highest level of education recorded in electronic health record

   Time frame: Upon enrollment

9. Patient employment

   Patient employment status recorded in electronic health record

   Time frame: Upon enrollment

10. Patient relationship status

    Patient relationship status (e.g., married, divorced, etc.) recorded in electronic health record

    Time frame: Upon enrollment

11. Patient neighborhood status

    Neighborhood healthy places index (HPI) score based on patient zipcode

    Time frame: Upon enrollment

12. Patient food insecurity

    Patient food insecurity status based on PREPAR questionnaire recorded in electronic health record

    Time frame: Upon enrollment

13. Patient transportation status

    Patient transportation status based on PRAPARE questionnaire recorded in electronic health record

    Time frame: Upon enrollment

14. Patient insurance

    Patient insurance status (federal, private, uninsured, etc.) recorded in electronic health record

    Time frame: Upon enrollment

15. Patient language

    Patient preferred language recorded in electronic health record

    Time frame: Upon enrollment

16. Patient interpreter

    Patient request for interpreter during primary care visit recorded in electronic health record

    Time frame: Upon enrollment

17. Index clinic

    Name of Federally Qualified Health Center clinic at which index encounter for spine pain occurred recorded in electronic health record

    Time frame: Upon enrollment

18. Spine pain region

    Region of spine pain (neck, low back, both) recorded in electronic health record at index encounter

    Time frame: Upon enrollment

19. Spine pain acuity

    New or existing spine pain problem recorded in electronic health record at index encounter

    Time frame: Upon enrollment

20. Patient comorbidity

    Functional comorbidity index recorded in electronic health record

    Time frame: Upon enrollment

21. Patient existing prescriptions

    Type and number of existing prescriptions recorded in electronic health record at index encounter

    Time frame: Upon enrollment

22. Patient new prescriptions

    Type and number of new prescriptions recorded in electronic health record at index encounter

    Time frame: Upon enrollment

23. Patient referrals

    Type and number of specialty referrals recorded in electronic health record at index encounter

    Time frame: Upon enrollment

24. Clinic size

    Number of spine pain encounters during baseline period for each participating primary care clinic

    Time frame: Upon crossover to STEPPT

25. Clinic location

    Geographic location of each participating primary care clinic

    Time frame: Upon crossover to STEPPT

26. Clinic PT Services

    Availability of onsite physical therapy services for each participating primary care clinic

    Time frame: Upon crossover to STEPPT

27. Provider age

    Ages of primary care providers employed at each participating clinic recorded in clinic operations records

    Time frame: 6-, 12-, 18-, 24-, and 30-months after start of trial

28. Provider sex

    Sex of primary care providers employed at each participating clinic recorded in clinic operations records

    Time frame: 6-, 12-, 18-, 24-, and 30-months after start of trial

29. Provider race

    Races of primary care providers employed at each participating clinic recorded in clinic operations records

    Time frame: 6-, 12-, 18-, 24-, and 30-months after start of trial

30. Provider ethnicity

    Ethnicities of primary care providers employed at each participating clinic recorded in clinic operations records

    Time frame: 6-, 12-, 18-, 24-, and 30-months after start of trial

31. Provider education

    Highest clinical degrees for primary care providers employed at participating clinics recorded in clinic operations records

    Time frame: 6-, 12-, 18-, 24-, and 30-months after start of trial

32. Provider specialty

    Types of clinical specialties for primary care providers employed at each participating clinic recorded in clinic operations records

    Time frame: 6-, 12-, 18-, 24-, and 30-months after start of trial

33. Provider experience

    Time elapsed between date of highest clinical degree for primary care providers at each participating clinic and date of index encounter

    Time frame: 6-, 12-, 18-, 24-, and 30-months after start of trial

34. Duration of provider employment

    Duration of employment at federally qualified health center for primary care providers at each participating clinic recorded in clinical operations records

    Time frame: 6-, 12-, 18-, 24-, and 30-months after start of trial

35. PCP frequency of PT education

    Primary care physician self-reported frequency of educating patients with spine pain about the benefits of physical therapy (never, rarely, sometimes, often, always)

    Time frame: Prior to training, 6-months after crossover to STEPPT

36. PCP qualitative interviews

    Qualitative interviews with primary care providers to assess motivations, barriers, and facilitators for any changes made in the rate of physical therapy referral and the frequency, content, and approach for patient education on benefits of physical therapy

    Time frame: 3-months after cross over to STEPPT

37. Allied provider frequency of PT education

    Nurse and Medical Assistant self-reported frequency of educating patients about the benefits of physical therapy and referral process (never, rarely, sometimes, often, always)

    Time frame: Prior to training, 6-months after crossover to STEPPT

38. Allied provider qualitative interviews

    Qualitative interviews with nurses and medical assistants to assess motivations, barriers, and facilitators for any changes made in the rate of physical therapy referral and the frequency, content, and approach for patient education on benefits of physical therapy

    Time frame: 3-months after cross over to STEPPT

39. Training Involvement Rating Scale (IRS) score

    Scale ranging from 0-15 points quantifies unsatisfactory (0-5 points), moderate (6-10 points) and satisfactory (11-15 points) involvement of clinic staff in STEPPT trainings. IRS score assesses the following training domains: 1) clinic administrator orientation, 2) primary care physician orientation, 3) Nurse/Medical Assistant orientation, 4) Review of progress reports, 5) ECN training and audit reviews

    Time frame: 12-, 18-, 24--months after start of trial

40. ECN contact attempts

    Proportion of Hispanic patients referred to PT with 0, 1, 2, 3, and ≥4 call attempts prior to scheduling first PT appointment or discontinuation due to failure-to-contact

    Time frame: 12-, 18-, 24-, and 30-months after start of trial

41. ECN completed contacts

    Proportion of Hispanic patients referred to physical therapy who were able to be contacted by patient health navigator, regardless of whether enhanced care navigation was delivered

    Time frame: 12-, 18-, 24-, and 30-months after start of trial

42. ECN delivery

    Proportion of Hispanic patients who were successfully contacted for whom each mandatory component of enhanced care navigation was delivered

    Time frame: 12-, 18-, 24-, and 30-months after start of trial

43. Order Printed PT Education Materials

    Proportion of Hispanic patients with a new or existing spine pain problem who receive an auto-order for physical therapy education materials printed with the after visit summary at index encounter

    Time frame: 12-, 18-, 24-, and 30-months after start of trial

44. Order Portal PT Education Materials

    Proportion of Hispanic patients referred to physical therapy who receive an auto-order for electronic physical therapy education materials, referral information, and educational video in the patient portal

    Time frame: 12-, 18-, 24-, and 30-months after start of trial

45. Order Text PT Education Materials

    Proportion of Hispanic patients referred to physical therapy who are sent an auto-order for text link to physical therapy referral information and education video

    Time frame: 12-, 18-, 24-, and 30-months after start of trial

46. Patient Portal Views

    Proportion of Hispanic patients referred to physical therapy who view electronic physical therapy education materials, referral information, and education video from links provided in patient portal

    Time frame: 12-, 18-, 24-, and 30-months after start of trial

47. Patient Text Views

    Proportion of Hispanic patients referred to physical therapy who view physical therapy referral information and education video from links provided from the auto-text message

    Time frame: 12-, 18-, 24-, and 30-months after start of trial

Individual participant data

Plan to share: Yes — De-identified individual participant data (IPD) underlying published results will be shared via the Open Science Framework (OSF) repository, along with the study protocol, data dictionaries, statistical analysis plan, and intervention materials.

Supporting information: Study protocol, Sap