Clinically Integrated Physical Therapist Practice in Cancer Care: A New Comprehensive Approach

Abstract

Best practice recommendations in cancer care increasingly call for integrated rehabilitation services to address physical impairments and disability. These recommendations have languished primarily due to a lack of pragmatic, generalizable intervention models. This perspective paper proposes a clinically integrated physical therapist (CI-PT) model that enables flexible and scalable services for screening, triage, and intervention addressing functional mobility. The model is based on (1) a CI-PT embedded in cancer care provider clinics, and (2) rehabilitation across the care continuum determined by the patient’s level of functional mobility. The CI-PT model includes regular screening of functional mobility in provider clinics via a patient-reported mobility measure—the Activity Measure for Post-Acute Care, a brief physical therapy evaluation tailored to the specific functional needs of the individual—and a tailored, skilled physical therapist intervention based on functional level. The CI-PT model provides a pragmatic, barrier-free, patient-centric, data-driven approach to integrating rehabilitation as part of standard care for survivors of cancer. The model standardizes CI-PT practice and may be sufficiently agile to provide targeted interventions in widely varying cancer settings and populations. Therefore, it may be ideal for wide implementation among outpatient oncological settings. Implementation of this model requires a shared approach to care that includes physical therapists, rehabilitation administrators, cancer care providers, and cancer center administrators.

The calls for integrating rehabilitation services as a component of comprehensive cancer care are numerous.^1–6 Physical therapy, which focuses on functional mobility, is an integral component of comprehensive rehabilitation and should naturally support the cancer care plan. Functional mobility describes the physical function of a person’s ability to move about and perform daily tasks. This involves movements like standing, walking, lifting, carrying, and bending, which allow a person to participate in work, school, home, and community activities. The use of rehabilitation services, physical therapy in particular, is lacking in cancer care despite its apparent high value utility.⁷ The reasons for this are numerous and include lack of awareness of the benefits of rehabilitation services, health system barriers that inhibit service integration, and challenges with payment models that support services for this population.^8–15 A primary limitation is imposed by the traditional silos of medical departments and proscribed provider roles that dominate the health care landscape. Departments within a health care system are separated into different cost-centers; providers are delineated by these centers and are only integrated into care when a consult is deemed necessary. This traditional segmentation is being successfully challenged by cancer care delivery systems that enable collaborative, co-located care. Innovative models of integrating physical therapy as a key component of cancer care are emerging and are not only overcoming systemic silos but challenging the historically reactive approach of physical therapist practice.¹⁶ This Perspectives paper describes the successful integration of physical therapist services into a cancer center’s care delivery system and highlights how a clinically integrated physical therapist (CI-PT) was adopted into oncologic care teams, allowing patients to have immediate access to the physical therapist for ongoing functional assessment and proactive impairment management during cancer treatment. The CI-PT model we describe is currently implemented across 2 different diagnosis groups, though we perceive it as having potential for wider use.

Prospective Surveillance as a Framework for the CI-PT Model

Rehabilitation services have historically been reactive in nature, involving postinjury or postoperative care and providing interventions to restore lost function. The cancer care continuum, however, offers a different paradigm for rehabilitation services. At the point of cancer diagnosis, an individual is in their normal functional state. The medically directed cancer treatments following diagnosis, and their side effects, will negatively impact function in a majority of patients.¹⁷ Therefore, the point of cancer diagnosis offers an opportunity to identify the individual’s baseline functional performance and initiate a plan of care to prospectively monitor function throughout treatment.¹⁸ Prospective monitoring of functional changes during treatment enables proactive identification and management of physical impairments and may improve overall functional outcomes for patients. This model of care, the Prospective Surveillance Model (PSM), was initially developed in the breast cancer population and has been extended across cancer diagnoses.^{19  ,  20} The premise of the PSM is to provide interval functional assessments during cancer care to enable early identification and treatment of cancer treatment-related impairments.²¹

Ideally the PSM is initiated at the point of diagnosis with a baseline functional assessment, education interventions, tailored therapeutic exercise and skilled rehabilitation services, and, for some individuals, a prehabilitation course of care that optimizes their functional status prior to initiating cancer treatments. The PSM suggests continued follow-up reassessment of physical function at punctuated intervals throughout active medical treatment. The PSM framework is outlined in Figure 1.

Figure 1.

Prospective Surveillance Model Framework.

The PSM requires the rehabilitation provider to interface with individuals throughout cancer treatment. This is optimally achieved by co-locating the rehabilitation provider in the setting where oncology care is being delivered. In the last 2 decades, cancer care centers have evolved towards offering co-located services to patients, reducing the burden on patients and enabling better access to supportive care services.²² Rehabilitation services, however, are conspicuously missing in these centers, and their absence is likely contributing to significant gaps in functional mobility assessment and to unnecessary declines in physical function in most patients.²³ The CI-PT model offers great potential to mitigate these deficits as an implementation strategy for the PSM.

Integrating Physical Therapists Into Oncologic Care Teams

Our experience with embedding physical therapists in clinical environments alongside oncology medical providers has been critical for implementing rehabilitation as standard care for people with cancer. The CI-PT model is a pragmatic approach to proactively maintaining functional mobility throughout cancer treatment via ongoing surveillance. The model is guided by 2 fundamental principles:

• (1) Physical therapist integration into the oncology care team is necessary to provide sustainable, timely access to care for patients with physical impairments.

• (2) Physical therapist integration is determined by the exigencies of patients and provider clinic workflows rather than by the preferences of physical therapists.

To implement the CI-PT model, 3 essential components were identified and developed. The first, and most central, of these components is the use of a patient-reported measure to assess and track functional mobility. The information generated from this measure not only enables effective communication with the oncology care team regarding the patient’s functional status, it also serves to guide the CI-PT practice patterns towards individualized therapeutic exercise and skilled rehabilitation prescription protocols, focused educational interventions, and data-driven monitoring of functional mobility. Leveraging patient-reported functional mobility data was crucial to the development and implementation of the CI-PT model, as it helped to make the concept of functional mobility accessible to patients and members of the oncology care team. Most importantly, the use of patient-reported functional mobility data, obtained in real-time, to inform proactive clinical decision making was a key innovation of the CI-PT model, which supported a framework of prospective physical therapist practice patterns and clinic workflows to optimize patient function.

A second essential component to the implementation strategy was the integration of the CI-PT into existing oncology clinic workflows to ease provider and patient burden. Oncologic clinic workflows are well defined, with providers commonly overextended due to high case-loads. Moreover, individuals receiving cancer care experience significant treatment-related burdens of scheduled appointments and time and cost constraints.²⁴ In this setting, it is often not clinically pragmatic to refer patients to an off-site physical therapy setting or to allocate 45 to 60 minutes for a CI-PT evaluation and intervention during a clinic visit. The CI-PT model is designed as a highly flexible approach to meet the functional needs of the patient within these constraints. The model includes several modifications to the traditional physical therapy evaluation to promote expediency. The first modification is that each patient is stratified by their self-reported functional mobility level and assigned a mobility stage at every clinic visit prior to their CI-PT evaluation. This stratification narrows the focus of the CI-PT evaluation to common functional mobility deficits that are expressly identified by the individual.

The final, and likely most valuable, component of the CI-PT model is that it is designed to provide sustained monitoring of functional mobility through repeated assessment as part of standard care for people with cancer. The ongoing interval assessment points occur in tandem with standard oncology care, enabling perspective on functional changes over the course of treatment. Proactive functional assessment is identified as a critical need in oncology care, and a recent guideline from the American Society of Clinical Oncology provides guidance in this area, albeit only around the course of chemotherapy interventions.^{25  ,  26}

Implementing the CI-PT Model

At the Huntsman Cancer Institute in the University of Utah Health system, the Activity Measure for Post-Acute Care Outpatient Basic Mobility Short Form (AM-PAC) is the instrument used to perform mobility stratification and staging. The AM-PAC, a computer-adapted measure of functional mobility, consists of items sampled from a 250-item question bank derived from the International Classification of Functioning framework. Several AM-PAC short forms exist for use with specific populations based on the clinical setting, including the outpatient basic mobility short form. The AM-PAC outpatient basic mobility short form is an 18-item instrument that assesses patient difficulty with tasks such as standing from a low chair or walking in the home, and higher level tasks such as making cuts while running and engaging in sustained, strenuous activity. Based on the patient responses, a mobility stage is generated (Fig. 2) that provides insight into the individual’s level of mobility limitation. This tool is validated for use in outpatient orthopedic and general postacute populations, including postsurgical populations, and is recommended for the assessment of functional mobility in oncologic populations.^27–30

Figure 2.

AM-PAC staging and exercise modes/dosages.

The AM-PAC basic mobility short form is incorporated into the clinical workflow, administered on paper by a medical assistant when a patient arrives at the clinic, and typically requires less than 3 minutes for the patient to complete. Using the AM-PAC mobility stage, the CI-PT tailors interventions to support patient functional mobility during cancer care, offering a more precise approach to physical therapy treatment. It is important to note that the AM-PAC is a general measure of functional mobility; there are no impairment-specific measures required for CI-PT evaluation.

In addition to the AM-PAC enabling personalized exercise and rehabilitative interventions, it also facilitates more timely physical therapy evaluation and intervention. In the CI-PT model, each mobility stage is associated with a mode and dosage of therapeutic exercise designed to target functional mobility. For example, a patient in AM-PAC stage II has impaired home mobility. Based on this stage, the individual would receive a therapeutic exercise prescription of callisthenic and basic mobility exercises, such as seated knee extensions or repeated sit to stands. A patient in AM-PAC stage III has impaired community mobility, which indicates a physical therapy-based therapeutic exercise prescription of 15 to 30 minutes of daily aerobic and resistance exercises, such as standing rows or mini-squats with resistance bands, performed at a moderate to moderate-high intensity. Moderate-high intensity is defined as being able to talk but not sing while engaged in an activity. Individuals in both of these scenarios would receive education on energy conservation, treatment-related symptom management, and other topics specific to their diagnosis and anticipated medical treatments.

It is very important to note the CI-PT retains the ability to tailor skilled rehabilitation interventions to treat specific functional mobility limitations for each patient, regardless of whether this intervention is indicated by the AM-PAC stage. In all stages, therapeutic exercise interventions are prescribed to address impairments that underlie a patient’s functional mobility limitations. The CI-PT treatment framework does not restrict the physical therapist’s clinical decision-making autonomy; rather, it organizes the decision-making process, providing standardization of treatment based on functional mobility level. Perhaps as importantly, this standardization creates valuable opportunities for oncology providers to understand rehabilitation services in the context of cancer care and provides transparency in treatment decisions to others on the oncology care team. In addition to therapeutic exercise prescription, each visit offers opportunities to provide skilled interventions including education to emphasize patient self-management, reduce the risk of adverse events, and provide strategies for overcoming impairments that are likely to occur.

CI-PT Use: Case Scenarios

The following patient scenarios will illustrate how a patient’s AM-PAC mobility stage informs the decision making of a CI-PT. The first scenario is a patient whose clinical presentation matched their AM-PAC mobility stage, allowing the CI-PT to treat the patient with exercise interventions as indicated by the AM-PAC stage. The second scenario features a patient whose AM-PAC stage and clinical presentation did not match, requiring the CI-PT to modify the therapeutic exercise prescription to skillfully address the patient’s functional mobility limitations.

Patient No. 1 is a 68-year-old male with stage IV sarcoma who consulted with the thoracic surgical team for a recently discovered lung metastasis. The patient was asymptomatic and had no functional mobility limitations at baseline, with an AM-PAC score of stage IV. This stage is indicative of patients who have no functional mobility limitations that affect them in the home or community, though limitations exist during strenuous or intensive activities. Patient No. 1 was an avid athlete and sportsman who engaged in a variety of vigorous outdoor activities. On baseline examination, the CI-PT’s clinical impression of the individual’s level of functional mobility matched the patient’s self-reported AM-PAC functional mobility stage. The CI-PT intervention for Patient No. 1 included education on the surgical procedure and its typical effects on functional mobility and a therapeutic exercise prescription that consisted of 30 minutes of high-intensity resistance and aerobic exercise daily. At baseline, the modes and dosages of therapeutic exercises prescribed were aligned with the interventions indicated by the patient’s AM-PAC stage. The patient underwent surgical lung resection and returned for a postsurgery clinic follow-up. At this point, Patient No. 1 had reduced functional mobility due to pain, fatigue, and shoulder tightness and weakness. His AM-PAC score reflected this change in status with a score that placed him in stage III. There was agreement between the patient’s AM-PAC mobility stage and his functional mobility as assessed by the CI-PT, and as a result the CI-PT reduced the exercise intervention intensity to match the indicated intervention from the AM-PAC staging scheme. There was continued agreement between Patient No. 1’s AM-PAC mobility stage and his clinical presentation at 2- and 6-month postsurgical clinic follow-up appointments, with all CI-PT interventions for this patient aligned with the interventions indicated by his AM-PAC mobility stage.

In our second scenario, we consider an example of CI-PT intervention that deviated from what was indicated by the AM-PAC mobility stage due to presenting impairment. Patient No. 2 is a 72-year-old female with primary lung cancer who underwent surgical lung resection with the intent to cure her illness. At her baseline presurgical consult appointment, her self-reported functional mobility level placed her in AM-PAC stage IV, indicating no functional mobility limitations. However, unlike Patient No. 1, on further examination the CI-PT identified that Patient No. 2 had undergone bilateral total knee arthroplasty 8 months prior to her initial thoracic surgical consult and had only recently completed her rehabilitation for those procedures. Despite her self-reported functional mobility level being in stage IV, the CI-PT clinical examination revealed measurable lower extremity weakness, knee pain, and balance deficits that limited Patient No. 2’s ability to walk on uneven terrain or ascend and descend stairs.

The CI-PT intervention indicated by her AM-PAC stage would have been identical to the intervention that Patient No. 1 received, including 30 minutes of daily high-intensity resistance and aerobic therapeutic exercises. For Patient No. 2, however, this intervention was not appropriate. In this case, deploying the exercise program solely based on her AM-PAC stage may have exacerbated her difficulties and likely would not have addressed the pain and weakness that she was experiencing. Instead of high-intensity aerobic and resistance exercise, the CI-PT, based on clinical judgement, prescribed a skilled rehabilitation intervention to manage and reduce her knee pain and lower extremity weakness. In addition to patient education, Patient No. 2 was prescribed a home exercise program, including quadricep- strengthening exercises (straight leg raise, short-arc quad, and long-arc quad) as well as a short (approximately 10 minutes) bout of daily high-intensity resistance exercise. As she progressed through the course of cancer care, subsequent CI-PT follow-up visits enabled reevaluation of her mobility and adaptation to her exercise interventions as her knee pain and lower extremity weakness began to resolve. Despite the indications of the AM-PAC staging scheme, which called for her therapeutic exercise prescription to focus on high-intensity aerobic and resistance, the skilled intervention that Patient No. 2 received was appropriate for her functional mobility level and rehabilitation needs. In fact, her rehabilitation needs were more aligned to the exercise interventions indicated for a patient with AM-PAC stage III or below.

In these 2 case scenarios, we see examples of patients with very similar self-reported functional mobility levels receiving markedly different interventions due to the application of CI-PT clinical reasoning and decision-making autonomy. In this way, we see how the CI-PT provides pure exercise and skilled interventions prompted by the patient’s AM-PAC mobility stage, yet skillfully modifies interventions depending on the clinical scenario. This is a critical and nuanced need in cancer care delivery as the continuum is dynamic, introducing new and different medical treatment modalities at varied intervals. Each modality brings side effects that may negatively impact function, and each individual responds to medical treatments with varying degrees of symptom severity. Disease treatments frequently diminish function but may also substantially worsen preexisting functional limitations, leading towards greater disablement over the often-protracted trajectory of cancer care.

In addition to guiding the CI-PT evaluation and intervention, these scenarios demonstrate the importance of longitudinal measures of patient functional mobility. Although numerous clinical measurement tools exist for the cancer population, the specific measures used to track functional mobility should be determined by the individual patient needs and by clinic workflows.^31–34 The AM-PAC tool was already integrated into the Huntsman Cancer Institute, making it our tool of choice. Due to its brevity, ease of collection, and repeatability, we have found it to be well suited for monitoring patient function in our outpatient bone marrow transplant (BMT) and thoracic surgical clinics. Similar tools appropriate for the CI-PT model (eg, Patient-Reported Outcomes Measurement Information System) and various performance batteries such as the Comprehensive Geriatric Assessment and the Short Physical Performance Battery, among others, exist.

Implementation Requires Champions of the CI-PT Model

Implementation of the CI-PT model into standard care for people with cancer has been sustained and enhanced by Huntsman Cancer Institute’s medical directors and senior researchers and via the support of champions from divergent areas of the University of Utah Health system. Engaging these champions was a crucial early step in the development of the CI-PT model and remains vital to continuing implementation efforts. In our experience, physician champions are fundamental; they must be willing to reallocate clinic space and time to foster the inclusion of value-added components in their clinic workflow. Once oncology providers understood a CI-PT could stage patients by functional mobility and provide real-time, tailored physical therapist interventions in their clinics without a cumbersome referral process to outside physical therapy clinics, they quickly embraced the model. Quantifying functional mobility stage and providing a clinical team member to manage their patients’ functional mobility level was a potent step in nourishing medical providers as CI-PT champions. With oncology providers’ support, rehabilitation manager champions became more eager to identify and develop physical therapy staff to commit to the CI-PT role.

Oncology Provider Champions

CI-PT adoption among oncology providers at Huntsman Cancer Institute began with 2 initial physician champions: a thoracic surgeon specializing in lung cancer and a medical oncologist/hematologist specializing in bone marrow transplantation. Both providers could perceive the loss of functional mobility that their patients commonly experienced during treatment but were unaware of the true severity or prevalence of functional deficits among their patients. They were also both open to the idea of greater integration of rehabilitation services in their clinics and agreed to have medical assistants in their clinics collect the AM-PAC as part of their standard rooming procedure. The initial key data that convinced physicians of the necessity to develop the CI-PT model were the descriptions of patient-reported functional mobility level, as represented by the AM-PAC stage distribution, in the outpatient surgical lung cancer and BMT clinics. Figure 3 shows the AM-PAC stage distribution among patients in surgical lung cancer clinics and in BMT clinic populations. In both clinic populations, roughly 2 out of 3 patients had difficulty with mobility in their homes or community. Seeing these data was an eye-opening experience for the CI-PT physician champions, allowing them to appreciate how functional impairment was affecting their patients and deepening their resolve to integrate physical therapists into their clinic teams. The importance of this initial data set to the success of CI-PT model development and implementation cannot be overstated. It facilitated early consensus on the necessity of moving forward with CI-PT model development and later gave rise to CI-PT quality improvement and research projects. The CI-PT initiative in the lung clinic quickly reached a level of success that spawned a randomized phase III clinical trial (National Cancer Institute R01 CA211705), which is currently ongoing.³⁵

Figure 3.

AM-PAC Stage distribution—lung and BMT clinics.

The CI-PT model has been strengthened by subsequent data that give positive indications of its feasibility and financial sustainability. CI-PT adoption occurred in late 2016 in surgical lung cancer clinics and BMT clinics. Over approximately 2 years’ time, 646 patients have received 2933 functional mobility assessments (lung: 582; BMT: 2351), and 686 CI-PT treatments (lung: 142; BMT: 544) as part of standard care. Due to the barriers to rehabilitation services in standard outpatient oncologic care prior to CI-PT implementation, evidence suggests that almost none of these patients would have received functional assessment or intervention under previous standard care models.^{13  ,  36} This marked increase in physical therapy utilization is an early measure of success for CI-PT implementation.

In BMT clinics at the Huntsman Cancer Institute, the CI-PT model has been implemented as part of a quality improvement project. Consequently, CI-PTs in BMT clinics have had to sustain themselves through regular billing, the same as any other physical therapists in the University of Utah Health system. To reach sustainable billing and collection levels, it has been necessary to achieve sufficient CI-PT treatment volumes in BMT clinics. When BMT clinics have operated at full capacity (ie, no BMT medical providers on leave), CI-PTs have been able to bill and collect at financially self-sustaining levels. Importantly, downstream referrals to physical therapy among BMT patients have remained flat during CI-PT implementation, indicating that CI-PT financial sustainability does not depend on generating referrals. This has validated our approach to CI-PT development, confirming that it is possible to sustainably integrate physical therapists in oncology clinics, while eliminating the barriers to access that are inherent with outside physical therapy referrals. Further work to establish the value of the CI-PT model for patients, providers, and health systems is needed. To this end, the trial of CI-PT intervention among patients in surgical lung clinics currently underway at the Huntsman Cancer Institute is designed to investigate the cost effectiveness of the CI-PT model.³⁵

Development and implementation of the CI-PT model in these environments has led to the creation of longitudinal data sets of functional mobility level among patients in BMT and thoracic surgical clinics before and after undergoing treatments. These data have been used to inform everyday physical therapist practice, closing the loop between clinical data and decision making. It has also been used to investigate the possible use of patient-reported functional mobility level as a prognostic or diagnostic indicator for people with cancer. In the BMT setting, the use of the provider-assessed Karnofsky Performance Scale (KPS) to categorize patient physical function is standard practice in all outpatient clinic visits. KPS scores have validity as a prognostic tool in the treatment of people with BMT.³⁷ For every patient at every clinic visit, it is also standard to assign a National Institutes of Health Consensus (NIHCC) score, a measure of the severity of graft-vs-host disease, a common, serious complication of BMT. The addition of a patient-reported functional measure to the clinical data that were already being collected in BMT clinics created the opportunity to examine associations between AM-PAC, KPS, and NIHCC scores. To explore the relationship between these measures, panel regression analyses were performed, adjusting for patient age, sex, and comorbidity level. Figure 4 shows mean AM-PAC scores by KPS score for people with BMT at regular posttransplant clinic appointments, and Figure 5 contains mean AM-PAC scores by NIHCC score. Both figures demonstrate significant (KPS: P < .001, NIHCC: P = .04) downward trends in AM-PAC scores, indicating that patient-reported decline in functional mobility was linked with deterioration in clinician-assigned measures of physical function and disease severity. In particular, the association between AM-PAC and KPS scores suggests that a patient’s self-reported functional mobility level may have validity as a prognostic tool. It is also important to note that the close association between AM-PAC and NIHCC scores indicates that patient-reported functional mobility may have utility in monitoring graft-vs-host disease severity. We have already seen how AM-PAC data are used to inform and direct CI-PT intervention and to support CI-PT implementation, but we now see that the scope of changes made possible by the AM-PAC includes the possible development of clinical tools. Collectively, these activities have increased the enthusiasm of CI-PT champions and reinforced the value of the CI-PT model.

Figure 4.

Adjusted mean AM-PAC score by KPS score.

Figure 5.

Adjusted mean AM-PAC score by NIHCC score.

Physical Therapy Champions

Champions within the physical therapist workforce were then required to trial changes in physical therapist practice patterns essential to CI-PT implementation. These champion physical therapists needed to embrace the use of patient-reported functional data as a key element of their patient evaluation. Further, they had to embrace the few delimiters placed on their practice to allow immediate rehabilitation access to people with cancer treatment-related physical impairment. Using patient-reported functional mobility data to focus the examination allowed the CI-PT evaluation to be reduced to 15 minutes from the traditional 30 to 45 minutes. Additional time-saving was achieved through the use of AM-PAC data to guide CI-PT interventions. In a very real sense, the CI-PT model asks physical therapists to reduce the intensity and scope of intervention to conform to the oncology provider’s team’s clinical needs. Due in part to the work of champion physical therapists, this level of intervention has been found to be appropriate and beneficial for patients.

In a pilot study of CI-PT intervention for surgical lung resection patients, those who were treated by a CI-PT experienced a 6.8% pre- to postoperative decline in median 6-Minute Walk Test distance compared with an 18.7% decline observed among patients who did not receive CI-PT intervention. Similarly, BMT patients who received CI-PT treatment as part of a quality improvement project have demonstrated maintenance of 2-Minute Walk Test distances despite their aggressive and ongoing cancer treatments. Thus, we see that the collection of patient-reported functional mobility data has been useful not only for monitoring and intervention to improve patient mobility throughout the course of care but also to create data sets that have been leveraged to identify and recruit champions to support CI-PT adoption. Table 1 includes several types of CI-PT champions with their specific roles in CI-PT development and the ways in which AM-PAC data helped to engage them in the implementation process.

Table 1.

CI-PT Champion Roles and Use of AM-PAC Data

Champion Type	Role/Contribution	AM-PAC Data Leverage
Physical therapist champions	Advocate for change in practice pattern	Described patient functional loss, framing the utility of CI-PT, and the need for change in physical therapist practice
Oncology provider champions	Lead change in clinic workflow to integrate rehab	Made patient functional loss clear/understandable to oncology providers
Rehabilitation management champions	Foster cultural and administrative change	Enabled rehab managers to successfully advocate for CI-PT case with health system administrators
Health system champions	Facilitate data utilization	Clarified achievable data acquisition and analysis goals and processes
Research champions	Facilitate quality improvement and research projects as part of implementation	Data supported the creation of new treatment models, continuous monitoring/improvement, and research projects

Challenges to Adoption

Efforts at University of Utah Health and Huntsman Cancer Institute to provide integrated rehabilitation services as part of standard care for people with cancer are challenged by barriers common to health systems and comprehensive cancer care centers.³⁸ These barriers include generalized lack of knowledge among oncology providers regarding management of function, lack of access to physical therapy services, and wide variation in practice patterns due to poorly standardized protocols for rehabilitation management of the cancer population.

In general, oncology providers lack an understanding of how to proactively assess meaningful clinical indicators that identify loss of functional mobility among their patients. This is further compounded by the lack of pragmatic or standardized processes to address access to cancer rehabilitation care. For most cancer patients, rehabilitation services are accessed by referral to an off-site physical therapy clinic or wellness center, which adds a time and cost burden to the patient. Our cancer center’s implementation and use of patient-generated functional mobility data to link a mobility stage to exercise and a skilled physical therapist intervention has proven to be an elegant way to induce enthusiasm and support from oncology providers by providing a solution to the near-ubiquitous problem of access to rehabilitation services in the oncology space. Furthermore, the continuous process of leveraging data-driven engagement with administrative stakeholders to craft pragmatic solutions is a hallmark of the CI-PT approach. This process has been employed to address several other CI-PT implementation barriers: promoting greater advocacy by rehabilitation managers for the CI-PT model, prompting physical therapists to consider the CI-PT role, and making physical therapy care for patients with varying levels of functional mobility more understandable to interdisciplinary oncologic care teams.

Established approaches to implementing rehabilitation services in the standard of cancer care are typically referral based. These strategies have generally sustained the service of physical therapy as a cost center but have not given people with cancer treatment-related functional impairments sufficient access to physical therapists.³⁹ This access deficit is primarily what prompted the development of the CI-PT model and its core principle of embedding physical therapists in oncologic clinic teams. Advocating for this commitment to integration has required managerial acumen and forethought and the willingness to embrace modifications to the provision of rehabilitation services that had not been previously attempted. The data-driven approach to CI-PT implementation at University of Utah Health and Huntsman Cancer Institute provided tools for rehabilitation managers to make the case for integration, allowing them to justify ongoing financial and staffing support for CI-PT model development and adoption.

The value-added role of physical therapists in the provision of skilled interventions for people with cancer is at best not clearly understood and at worst not appreciated. This uncertainty is common, leading to wide diversity in the implementation of cancer rehabilitation among cancer centers and health systems and often highly circumscribed and ill-defined roles for physical therapists in the oncology setting.¹⁹ For example, it is common for patients to be referred to physical therapists in cases of lymphedema or other specific impairments during cancer treatment but rare for patients to receive interventions proactively to support functional mobility.⁴⁰ The construct of functional mobility goes beyond physical endurance and strength, which are purported to be addressed by exercise guidelines for the cancer population. Exercise is an important and necessary modality, but attaining and maintaining function requires attention to more specific nuances of abilities. Consequently, oncology providers, health system administrators, and, most importantly, patients have had difficulty understanding the difference between rehabilitation and wellness services, often conflating physical therapists with exercise physiologists or other nonclinicians.¹⁴

This lack of role delineation can affect patient care by confusing oncology providers; reducing the likelihood of timely, meaningful intervention by rehabilitation professionals; and increasing the likelihood of patients being treated in inappropriate settings or with interventions that are not dosed correctly. At the Huntsman Cancer Institute, the adoption of the CI-PT model has helped to clarify the complementary roles of rehabilitation and wellness professionals, creating an accessible, pragmatic way to triage patients by functional mobility and direct them to appropriate care. Notably, the CI-PT model does not merely assert that all patients should be treated by physical therapists, regardless of their clinical presentation. This antiquated perspective on increasing physical therapy access has been replaced with a data-driven approach that uses functional data to direct patients to the most appropriate level of care.

An initial lackluster enthusiasm of physical therapists to engage in the development of the CI-PT model was perhaps the most unexpected barrier to CI-PT adoption at University of Utah Health. Although it was anticipated that introduction of the CI-PT model would possibly be resisted by oncology providers, care managers, and system administrators, our expectation was that physical therapists would enthusiastically support model adoption. It is possible that the novelty of the new CI-PT care model, particularly its greater levels of autonomy of the physical therapist relative to the traditional reliance on patient referral from a medical provider, contributed to this initially reserved physical therapist response. As a result, identifying physical therapists willing to take on the new CI-PT role, and to trial the CI-PT model, was a key implementation task. In the University of Utah Health system, staffing of early CI-PT roles required both internal and external recruitment efforts. As CI-PT implementation has progressed, there has been increasing interest from staff physical therapists about the details of CI-PT practice, largely responding to early demonstrations of CI-PT value and the increase in access to patients offered by adoption of the CI-PT model. It is worth noting that the first generation of CI-PTs had previously practiced in acute care. This likely made the transition to CI-PT easier than it would have been for an outpatient physical therapist because of the similarities in the scope and intent of CI-PT and acute care physical therapist practice. The challenges of identifying suitably trained and engaged physical therapists to take on CI-PT roles is a barrier to widespread CI-PT adoption that will likely require extensive education and clinical mentorship to overcome.

These challenges to CI-PT adoption have acted as choke points, reducing patient access to rehabilitation services. Overcoming the need for outside referral to physical therapy is the most visible process innovation in the CI-PT model, but it would not be possible without also addressing the collective suite of barriers that challenge adoption. By using data processes to enlist an interdisciplinary team of champions, the opportunity for wide-scale implementation of the CI-PT model has been made possible.

Conclusion

The CI-PT model may provide a pragmatic, barrier-free, patient-centric, data-driven approach to integrating rehabilitation as part of standard care for cancer survivors. Current implementation in Thoracic Surgical and Bone Marrow Transplant clinics at the Huntsman Cancer Institute and University of Utah Health have provided knowledge about aspects of the CI-PT model that may make it broadly generalizable. Although there are aspects of these implementations that are specific to each setting, the core elements of the CI-PT model are agnostic to care setting or clinical population. Therefore, we perceive the CI-PT model as potentially suitable for implementation as the standard of care for cancer rehabilitation in outpatient oncological settings. Implementation of this model requires a comprehensive and unifying approach to care that includes physical therapists, rehabilitation administrators, cancer care providers, and cancer center administrators.

Author Contributions and Acknowledgments

Concept/idea/research design: C.A. Barnes, N.L. Stout, T.K. Varghese, Jr, C.M. Ulrich, C.S. Noren, P.C. LaStayo

Writing: C.A. Barnes, N.L. Stout, T.K. Varghese, Jr, P.C. LaStayo

Data collection: C.A. Barnes, D.R. Couriel, C.J. Lee, P.C. LaStayo

Data analysis: C.A. Barnes, P.C. LaStayo

Project management: C.A. Barnes, P.C. LaStayo

Fund procurement: C.M. Ulrich, P.C. LaStayo, T.K. Varghese, Jr

Providing participants: D.R. Couriel, C.J. Lee, T.K. Varghese, Jr

Providing facilities/equipment: C.M. Ulrich, D.R. Couriel, T.K. Varghese, Jr, P.C. LaStayo

Providing institutional liaisons: C.M. Ulrich, C.S. Noren, P.C. LaStayo, T.K. Varghese, Jr

Clerical/secretarial support: C.A. Barnes

Consultation (including review of manuscript before submitting): C.A. Barnes, T.K. Varghese, Jr, C.M. Ulrich, D.R. Couriel, C.J. Lee, C.S. Noren, P.C. LaStayo

The authors acknowledge the contributions of the Precision Exercise Prescription (PEP) study co-investigators: Kenneth Boucher, David Wetter, Rachel Hess, Jaewhan Kim, Samuel Finlayson, and Jennifer Ligibel. The authors also thank the PEP study staff: Caroline Himbert, Kelly Lundberg, and Bailee Daniels, and the care teams in the thoracic surgical oncology and BMT clinics at the Huntsman Cancer Institute. Finally, the authors thank Robin Marcus, Ryan Rushton, and Erin Sweetser for their contributions to developing the CI-PT intervention.

Funding and Disclosures

The authors received partial support from the PEP study, funded by the National Institutes of Health (NIH)/National Cancer Institute (NCI) R01 CA211705, the Huntsman Cancer Foundation, and the University of Utah African American Doctoral Scholarship Initiative.

The authors received partial financial support for the development and execution of the clinically integrated physical therapist practice in cancer care.

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors acknowledge these competing interests: N.L. Stout is paid consultant to BSN Medical and McKesson Health. The views and opinions expressed are the authors’ own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the US Government.