Hospital care is expensive. Unnecessary hospitalisation carries risks for patients while placing an enormous burden on the health care system. For instance, numerous studies demonstrate that for frail patients, a visit to hospital can have serious consequences. In addition, disruptions to elective surgery caused by COVID-19 mean that the health system is having to look at ways to catch up and look at new ways of delivering care.
Used effectively, allied health play a key role in the prevention and management of disease and disability. However, we rarely look at allied health services from a system perspective. Instead, most allied health interventions are examined through the lens of a particular profession, diagnosis or intervention.
There is a growing interest in ‘high value care‘ which means providing the best care possible, using resources efficiently, and optimising outcomes for each patient. This includes providing care in the most appropriate location and preventing avoidable complications. Numerous initiatives have been introduced internationally to drive high value care, many of which include allied health.
This article looks at the way that allied health can be used more effectively and ultimately contribute to high value care, by keeping people out of hospital. We propose that by taking a step back and looking at the contribution that allied health can make at a system level, organisations can consider a suite of interventions where the judicious use of allied health services can improve outcomes for patients across the continuum of care.
In 2014, the Allied Health Professions Office Queensland (Queensland Health) introduced a Ministerial Taskforce into Allied Health Extended Scope of Practice. This was a system level approach to identify ways that allied health could be used more effectively. While the taskforce interventions did not specifically examine how allied health can keep people out of hospital, they identified 116 innovations with the potential to improve patient outcomes. They included a wide range of allied health disciplines.
The Kings Fund wrote a report in 2010 on ways to avoid hospital admissions. Allied health did not specifically feature in the report, although several of the interventions proposed involved allied health services.
This article describes a number of ways that allied health can contribute to a more effective health system by keeping people out of hospital. That doesn’t necessarily mean avoiding hospital altogether, but increasing the efficiency of the patient journey, improving outcomes, reducing unnecessary interventions, and speeding up discharge home where appropriate.
This is by no means an exhaustive list, nor is it a systematic review, although published research evidence (of varying quality) is used to support each argument. Our goal is to start a discussion about more effective ways of using allied health professions across the continuum of care.
- Prevention and early intervention to reduce risks of illness, disability and injury
- Admission avoidance
- Emergency department triage, assessment and treatment
- Triage and management of surgical waiting lists
- “Prehabilitation” to improve surgical outcomes
- Post-surgical allied health interventions
- Early (and late) intervention after an acute event to reduce the serious consequences of disease
- Improve patient flow
- Facilitate early discharge
- Pre-discharge planning
1. Prevention and early intervention to reduce risks of illness, disability and injury
Prevention and early intervention are areas in which allied health professions spend a great deal of time. Keeping people mobile, healthy and independent within their communities; optimising their function so that they can participate fully in society; and promoting healthy lifestyles are the goals of several different allied health professions.
There are numerous examples of the role that allied health services can play in prevention, although, as with most prevention and intervention studies, the research is more challenging due to the long time lag for definitive outcomes and the large population sizes needed. Only a small example of possible interventions are listed here.
There is strong evidence that podiatry interventions can significantly reduce the risk of falling in older people. For example, one study found that a multifaceted podiatry intervention can reduce the risk of falling by more than 30% in older people who have disabling foot pain and are at risk of falling. A range of allied health professionals are (and more could be) involved in the introduction of routine interventions to reduce falls risks in the populations they work with.
Speech pathologists target children for early intervention to identify and prevent communication difficulties, which is essential for effective functioning in society. Similarly, occupational therapists provide a range of interventions for children and young people including programs that focus on social–emotional learning; schoolwide bullying prevention; and after-school, performing arts, and stress management activities. There is good evidence that social and life skills programs are effective for children who are aggressive, have been rejected, and are teenage mothers. There is also strong evidence that children with intellectual impairments, developmental delays, and learning disabilities benefit from social skills programming and play, leisure, and recreational activities. Additionally, there is good evidence for the effectiveness of social skills programs is for children with autism spectrum disorder, diagnosed mental illness, serious behavior disorders.
An increasing number of allied health professionals are using techniques like motivational interviewing with patients to introduce health promoting behavior changes, such as adherence to foot care for people with diabetes, to support healthy lifestyle changes in people with heart failure, and to treat adolescents who are overweight and obese. The evidence for motivational interviewing is patchy, but a recent systematic review of systematic reviews on motivational interviewing is a good source of information for people wanting to pursue this option.
A 2011 systematic review of the contribution of allied health professions to health promotion found that while health promotion is a routine component of allied health practice, the authors could not draw conclusions about the levels of practice, and there was a paucity of quality evidence demonstrating effectiveness. This study does not appear to have been repeated.
A rapid review of the contribution of allied health interventions to prevention identified nine examples of scalable, good practice with a strong evidence base for prevention. These were vision screening of school aged children (orthoptist or optometrist led), diagnostic radiography for breast cancer screening, early diagnosis by podiatrists in the management of peripheral arterial disease, speech and language therapy for management of communication disorders in children, weight management for children and adults by dietitians, occupational therapy and paramedic interventions as secondary prevention and risk management in falls, physiotherapy and incontinence as a secondary prevention intervention, management of musculoskeletal pain by physiotherapists, and speech and language therapy in aphasia and dysphagia following stroke.
2. Admission avoidance
Admission avoidance schemes generally aim to identify patients who may otherwise have an emergency admission to hospital and instead, provide an alternative intervention that lets them be treated at home, or in another setting, to avoid hospitalisation.
There are numerous models of admission avoidance, and they operate under a range of different names including reablement, enablement, intermediate care, rapid response, hospital at home… to name just a few. In addition, telehealth is being used increasingly as a way to monitor and manage people in their home, either as an adjunct to medical care, or to use vital sign monitoring to identify patients who may be at risk of an acute medical event.
There is some overlap between admission avoidance and early discharge schemes, and sometimes the same teams or settings are used to provide both services.
While these models have been around for some time, and their level of sophistication varies, the evidence for their effectiveness is limited. This is, in part, due to the methodological challenges of researching these types of interventions (which we could discuss in-depth, but is beyond the scope of this article). In general, the outcomes of admission avoidance are no worse than hospital care, they provide an alternative location of care, and they may reduce rates of admission to long-term care.
Common issues that can present as an emergency (and result in a hospital admission) but can sometimes be effectively treated using admission avoidance are urinary tract infections if the patient can be stabilised and treated at home using antibiotics; mental health; and falls risk and management.
Admission avoidance can normally be implemented by a GP or by training paramedics / ambulance drivers to triage the patient at the scene, then make an appropriate referral. This normally relies on their ability to access a team who can quickly visit the patient and assess and stabilise them in their own home (or an alternative place of care).
Effective implementation of admission avoidance schemes require an integrated approach to services which are often delivered by a range of different agencies (hospitals – ambulance – primary care – allied health) and systems to coordinate these. They also rely on the selection and screening of appropriate patients to receive the scheme.
3. Emergency department triage, assessment and treatment
There are an increasing number of examples of the employment of allied health professionals as first point of contact practitioners in emergency departments. The most common of these involve physiotherapy treating patients in triage categories 3, 4 and 5 who present with musculoskeletal conditions. The published research evidence is equivocal on the actual benefits to patients and more, high quality research is needed in this area.
Allied health roles in the emergency department can include undertaking an assessment, intervention, referral for further treatment or diagnostic testing, and supporting discharge. Some examples include extended scope tasks, such as ordering and interpretation of x-rays and pathology, prescribing, plastering and suturing.
Multidisciplinary allied health assessments of older people in the emergency department, occurring before or alongside medical assessment, were found to have a significant effect on reducing hospital admissions when applied to appropriate patients (eg people with musculoskeletal pain and angina pectoris).
There are several other examples of ways that allied health can be involved in emergency department interventions to keep people out of hospital, although the strength and quality of evidence around their effect on admission avoidance and patient outcomes varies.
- Social workers have been used in several emergency department interventions. They are often employed to work with people with a primary psychosocial need. A recent study found that the use of social workers in the ED resulted in a slightly increased length of stay in the ED. Other studies have also shown mixed results on length of stay and admission outcomes.
- Employing podiatrists to assess lower limb injuries and work with high risk diabetic patients
- Occupational therapists working with patients with hand injuries, providing functional assessment, equipment provision and referrals to community services
- Employment of psychologists to work with people with a primary mental health need (for example, see this paper)
4. Triage and management of surgical waiting lists
Long elective surgery waiting lists, particularly for orthopaedic interventions such as hips, knees and ankles are an area ripe for allied health intervention.
Possibly the most extreme (and perhaps contentious) illustration of this is Alan Borthwick’s work which documents the formal recognition and registration of podiatric surgeons in the UK (and subsequently Australia) as a response to long waiting times for orthopaedic surgery in Scotland. In this case, specially trained podiatric surgeons took on some of the foot surgery formerly performed by orthopaedic surgeons. While this did not prevent surgery, per se, it reduced patient time on waiting lists, and importantly costs.
More conservatively, there is a growing body of evidence that triage, assessment and treatment of patients on orthopaedic waiting lists by physiotherapists and podiatrists can reduce the need for surgery at all, reduce the discomfort of patients while they wait for surgery, and improve outcomes for patients who subsequently receive a surgical intervention. There is also evidence that including physiotherapists in orthopaedic surgical screening and interventions can reduce hospital costs.
The Osteoarthritis Chronic Care Program (OACCP) in Australia involves a multidisciplinary team of physiotherapists, podiatrists, orthoptists, dietitians and the implementation of mobility aids to improve clinical outcomes such as pain, mobility, and functionality for patients with osteoarthritis. An evaluation of the program found that it saves over $28 million per year by preventing hip replacements in people with osteoarthritis as well as reducing pain and increasing function.
5. “Prehabilitation” to improve surgical outcomes
For patients that subsequently undergo elective or planned surgical interventions, there is evidence across a range of procedures that “prehabilitation“, or the use of allied health rehabilitation before the surgical procedure can improve surgical outcomes.
For example, one study found that eight weeks of physiotherapy before hip and knee joint arthroplasty was associated with better functional outcomes, reduced pain and better patient satisfaction. Pre-surgical exercise has been found to improve the functional outcomes of patients undergoing cancer surgery.
There are several other good examples of the benefits of pre-operative physiotherapy on improved patient outcomes, including surgery for urinary incontinence for women; outcomes of surgery for lung cancer; pre-surgery physiotherapy increased walking ability and lower extremity strength for patients who underwent surgery for degenerative lumbar spine disorders compared to waiting-list controls… to mention only a few.
In some cases, the evidence for pre-surgical physiotherapy is equivocal, largely (it appears) due to lack of high quality studies or data, however the large scale benefits across multiple interventions suggest that “prehabilitation” is a high impact and potentially low cost intervention to lead to substantially improved surgical outcomes across numerous interventions.
Postscript: A systematic review of prehabilitation across the wide range of allied health interventions would make a great research topic.
6. Post-surgical allied health interventions
The employment of allied health professionals in the post-surgical and rehabilitation areas is probably what we do best and are most known for (well, for some professions).
This is also an area in which allied health can contribute strongly to research evidence, because the clinical environment, interventions, and outcomes tend to be more clearly definable and measurable than several of the other interventions listed here.
However the application of allied health in post-operative and rehabilitation settings can vary widely. The development and application of high level evidence in this area has the potential to substantially improve outcomes and reduce variations in clinical practice.
There are several examples of good research in this area. For example: the early introduction of physiotherapy in the acute phase following elective lower limb arthroplasty can lead to better patient outcomes; rehabilitation following breast cancer surgery; and occupational therapy following total hip replacement to mention only a few.
7. Early (and late) intervention after an acute event to reduce the serious consequences of disease
It is well documented that early identification and intervention improves patient outcomes following an acute stroke. Medical practices have adapted to this and tailored several specific targeted interventions to the management of stroke within the first few hours of the event.
The longer term outcomes of a stroke can be substantially improved through the early introduction of a multidisciplinary allied health intervention. For example, early introduction of speech therapy can help improve dysphagia outcomes and prevent aspiration pneumonia.
Australian peak body SARRAH (Services for Australian Rural and Remote Allied Health) commissioned Novartis to prepare an economic analysis of the impact of allied health professionals in improving outcomes and reducing the cost of treating diabetes, osteoarthritis. The report found that early intervention (< 48 hours) by a dedicated allied health stroke team (including an occupational therapist, speech pathologist and physiotherapist) can reduce the number of patients discharged to residential aged care facilities, saving over $22 million per year.
A systematic review of occupational therapy interventions in acute geriatric wards found that occupational therapy improves acute geriatric patients’ functionality in activities of daily living and can contribute to reduction in delirium and can improve cognitive function in acute geriatric patients.
A US based study examined the relationship between hospital spending for specific services and the 30 day readmission rate for acute myocardial infarction, heart failure and pneumonia. Most patients (>70%) did not receive any occupational therapy intervention. For those that did, the cost of occupational therapy was less than US$20 per patient. Spending on occupational therapy was the only variable that was associated with lower readmission rates.
Even late interventions can have an improved effect on patient outcomes. For example a meta-analysis of physiotherapy interventions administered at least six months after a stroke was found to be beneficial to patients compared with no intervention or a placebo.
The introduction of multidisciplinary, perioperative interventions, including physiotherapy for emergency abdominal surgery is another area showing promise for early post-surgical intervention and may result in significant cost savings for hospitals.
8. Improve patient flow
Patient flow refers to the way a patient moves through the health system. Generally, in hospitals, there are numerous step-limiting factors that can reduce the efficiency of the way the patient moves through the hospital or accesses appropriate health care. In fact, all of the interventions listed in this article are directly or indirectly related to patient flow.
Patient flow can be inhibited by lack of timely access to: beds, appropriate clinicians, interventions or diagnostic tests; delayed discharge or challenges to initiating discharge; delays receiving appropriate treatment or services; clinical or administrative errors, administrative inefficiencies; and transfers between facilities, to mention only a few.
Allied health have the ability to contribute to the efficiency of patient flow by effecting timely and appropriate discharge, providing timely and appropriate interventions (for example, before admission, within the emergency department); and providing restorative and rehabilitative treatments in a timely way.
An often cited impediment to patient flow is lack of access to allied health rehabilitation on weekends. There is some evidence that providing weekend based rehabilitation services can improve patient flow. Another study (a systematic review and meta analysis) found that the benefit of providing additional allied health services is clearer in subacute rehabilitation settings than for acute general medical and surgical wards in hospitals.
Patient flow is also impeded where there are ‘therapeutic partitions‘ introduced into service access. For instance, requiring a referral for certain types of interventions or diagnostic tests where allied health can provide first contact treatment introduces unnecessary delays to treatment and diagnosis (see for example the Queensland Allied Health Ministerial Taskforce which aimed to reduce this).
9. Facilitate early discharge
As lengths of hospital stay have decreased, the need to provide supportive and transitional care for patients returning home has increased. There are several examples of this. Early discharge programs are slightly different to pre-discharge models (see below), because they tend to be targeted at specific clinical groups or needs and include a tailored approach to meet those needs. Pre-discharge models may be targeted at specific clinical or patient groups, but tend to be applied more broadly.
In one study, multidisciplinary teams (physiotherapist, occupational therapist and social worker) were effectively used to facilitate early discharge home for patients who had received acute orthopaedic interventions. The multidisciplinary allied health team provided interventions in the community, the emergency department, pre-admission clinic and orthopaedic wards to patients with hip and knee replacements, back pain and upper femoral fractures. This is an older, observational study, but the authors reported that they were able to reduce length of stay by 24% in the target group.
Another, more recent study of rapid discharge using an allied health team to facilitate early discharge of a complex, aged, sub-acute in-patient cohort demonstrated shorter length of patient stay, fewer readmissions within 30 days, greater change in functional independence, and high staff morale.
10. Pre-discharge planning
Pre-discharge interventions are provided to patients within a hospital setting to provide a safe and timely discharge to an appropriate destination.
Pre-discharge interventions include a diverse range of approaches, and can include educational programs, telephone support, multi-disciplinary clinical programs, rehabilitation interventions and pharmacological support. Many of these programs are nurse led but involve multidisciplinary teams. As we highlighted above, there is often some overlap between pre-discharge programs and admission avoidance.
Other models include ‘in reach’ services where, for example, community based occupational therapy services are provided to the patient in the hospital prior to discharge to promote continuity of care.
As with admission avoidance, the overall evidence for pre-discharge planning is generally patchy in terms of having better outcomes than normal care, however patients generally express a preference to receive care at home. Overall, the elements that predict successful primary care interventions are having a multidisciplinary approach, and community-based intervention.
Conclusion – how can allied health keep people out of hospital
The ideas and evidence presented above are not exhaustive. With at least 30 different allied health profession groups, there are endless opportunities for allied health professions to contribute to better health system outcomes across the continuum of care.
Given the high cost of hospital admissions – both socially and financially – the quality of evidence for allied health interventions to reduce or prevent hospitalisation is pretty limited. From the discussion above, it appears that the allied health professions individually and collectively have the potential an play an enormous role in the prevention of hospital admissions and improvements in patient outcomes.
This was in no way a systematic review, but where possible we have used high quality, recent studies (meta-analyses where available). The arguments used by allied health professionals are still, largely, unidisciplinary and with a few exceptions, draw on small scale, poor quality studies with outcomes that cannot be compared using meta-analyses or economic tools.
Admittedly, for many allied health interventions, accessing quality data can be challenging – particularly in the areas of prevention and early intervention where outcomes can be difficult to measure and / or capture within a useful timeframe.
Not surprisingly, the quality and volume of evidence is greatest around those interventions and patient groups that can be more easily defined, are generally more acute, achieve a clearly definable outcome in a short time-frame, and where success is commensurate with a measurable improvement. Conversely, those interventions involving heterogeneous patient groups; that are less well defined; where the outcomes of the intervention can take some time to achieve; where outcomes are more difficult to define / measure, or are not expected to improve (for instance in many admission avoidance studies, no change or a slight decline in certain measures can be a good outcome) – have poorer quality evidence.
The options presented in this article are only a miniscule list of the possibilities available to use allied health professionals to keep people out of hospital. There is room for creativity and innovation in this space – and a lot more research to understand where the best value allied health interventions can be applied.
We would love to hear your experiences of introducing allied health to keep people out of hospital. Join our Facebook discussion group, or leave a comment below.