Promote Yourself
Consider ways to promote yourself and what you do. Put together a presentation which explains what you do and take every opportunity to use it. You want to optimise the part of the patient journey which happens prior to your involvement. Be articulate and interesting on what it is that you do so that when you get a chance to sit down with someone or a group Be able to explain the health conditions you work with and how you work. Let people know what it is you can offer and what conditions or presentations you can help with. Be able to explain how will you go about working with their patients, what to look out for in a patient before making a referral or factors to consider. Be able to explain what information you are likely to need to know. Explain how to refer to you. Explain how to contact you. And explain what mental physiotherapy is. Explain about exercise, what can be achieved with it. Who it works well for. Be able to explain about the physical problems which people with long term mental health problems have. Problems which it is likely that people on their caseload have and how you are going to go about helping them. Interest people in what you do, present what you offer as an exciting new option for a care coordinator to consider in the care package they can provide. Help keep what you do and the idea of referring to you at the forefront of their mind when they are working with their patients.
Use your presentation for when you come to work in a new team or whenever there's a new starter in your team. Use this presentation when you have a student, use this presentation when someone shows interest. Spread the word about what you do. What you do is valued, often people are just unaware that you exist. Make sure that you attend multidisciplinary team meetings. Listen to the problems which people bring to the meeting and consider how you might be able to help and take every opportunity to suggest where physiotherapy could help.
It is very easy to make the decision to avoid weekly team meetings. They are long and you may be spread across multiple regions meaning that you could attend 2 or 3 MDT meetings a week if you desired. It would seem an incredible waste of time to spend nine hours a week sitting through multidisciplinary team meetings. Often the meetings don't involve discussing any people that you're working with. You are likely to be working with patients who are potentially on the ‘weller’ end of the spectrum whereas at MDT the people brought are more likely to be closer to crisis, but there will also be patients who are just stuck and the care coordinator is looking for options, this is where you can add value and promote. Remember that many clinicians won’t know what you do and won’t ever think of you so do make time for regular attendance. You don't have to go to each one every week, but you need to maintain a profile because you can easily be forgotten about. You can you find yourself working with the same patients over and over again and only taking referrals from the same two or three clinicians who are in the routine habit of referring to you.
Your goal is to make sure the clinicians around you think of you as an option and are able to make
appropriate referrals people. You want the referrer to be able to discern who physio could work for and also who are likely to engage with this and also you as a person. If the people around you really understand what it is that you do and the way that you work then it sets up your intervention to give it a higher likelihood of success. They will positively frame what it is that you can offer with correct expectations in the patient’s mind about what to expect.
You don’t want to be under or oversold; it is important for the patient to expect the limitations or barriers to what you can offer but also the benefits. You don’t want to have to undo incorrect expectations. This may be the details of the service provision, contact time, contact regularity or any particular activities.
Expectations are important and generally you want to give the expectation that what you will offer is different to what the patient may have experienced in physiotherapy elsewhere. The patient may have had a series of experiences with physiotherapy and you never know what these may have been. A separation from past experiences and a fresh start is likely to be useful.
The development of expectations and how other staff ‘sell’ you to patients means that it is important that you consider what others know and say about you as well as what you say. Attempt to control this flow of information as it will help your treatment process in the long run.
The Referral Process
I would recommend requesting that everyone comes to speak to you before they formally refer a patient to you. Ask people to discuss the patient with you and that this becomes the bulk of your referral process. Clearly you will still need a formal referral process for audit and evidence purposes but the depth of information you will benefit from is going to be very difficult to convey in writing. Ask people to have a discussion with you and make notes on this. The formal referral process can then be as simple as an email with patient details.
When I first began as a MH physio, I would just take the referral and send out an appointment letter expecting the person to arrive to their initial assessment at the time and place I’d told them to. This approach was incredibly ineffective. I believe that the referral process should be thought of differently. It should be one of developing a way to transition into someone’s care.
Consider a continuum which represents the level of intervention needed to help the patient engage with physiotherapy. At one end is minimal intervention, a referral from someone else and a letter to the patient and the arrive at the appointment when asked. At the other end is a process that involves a lot of care from different people to allow the person to engage with the intervention. It is important at this stage to decide how much intervention you and the referrer think that the patient will need. The more skilled the MH physio the more options they will have to go further up the scale and increase the likelihood of engagement.
If you both decide that you can just send out a letter, then save time. But through this discussion decide where you would put them on the continuum and aim your level of intervention there, but it is always best to err on the side of caution and over-estimate what is needed. An underestimation will waste time in the long run with increased non-attendance and cause more work trying to rectify a poor relationship.
The following describes a maximal level of intervention which has a high likelihood of success with any patient but is resource heavy. Remove parts as you feel necessary.
Instead of a referral process consider a transition process. Where the physio transitions into the patient’s care. The patient does not get referred onto the case load of the physio. The physio transitions into the patient’s circle of care. I imagine a jelly bubble around a patient with inside is everyone that the patient feels safe with. This bubble can be thick and hard, this bubble can be thin and soft. The role of the physio is to work their way through this bubble into the patient’s world. Some patients have a big bubble with many people in there for others there will be little space in there. It will help if there is already someone in there who can offer a hand to pull you inside.
The goal of your discussion is to work out whether it is going to be possible to work with the person for the broad reasons that they are being referred and how it would be best for you to work with them using the knowledge of the patient which the referrer has.
Once This discussion is complete the next step is to mine the clinical notes for information. Read reports and look for information which may dictate how you will work with the patient. You may find topics to avoid talking about, or problems that the person may have working with a particular gender. You may find things that have caused treatment or professional relationship to break down in the past. Some things to specifically look for is the medication which the person may be on and any side effects which are relevant. Look for recent changes in medication that coincide with the onset of symptoms. Check any diagnosis and understand the relevance of this for how they may experience pain. Look for diagnoses like depersonalisation which may affect how the person is able to control their body. Look at what risks this patient may bring.
From the notes mining you may need to ask additional questions to find out if certain information is relevant. It may be necessary to ask their psychiatrist about medication side effects or ask their nurse or psychologist about the relevance or certain information that you have found. Collate all this information and develop a basic plan.
An effective process from here would be for the referring clinician to float the idea of them referring to you and what you would be able to offer. Assumedly the referrer will already have a positive relationship with the patient so it can help for them to be part of the transition. In the referral discussion the referrer can be asked to pitch the idea of physio to the patient (if they already haven’t). It is helpful to discuss what the referrer is going to say so they are able to make an accurate offer. It’s really important that no offer gets made until you are in agreement with it as you really don’t want someone to offer something which you then have to withdraw. It will make the process inefficient and slow down the process of rapport building. They could say what you help with and in simple terms how you do it. They can say that they won’t need to take any clothes off, they can say that you won’t make them do exercise, they can say that you don’t offer massage, they can say that you will go about things differently to what has happened in the past, they can say that they would need to attend clinic and it can’t be a home visit. They can then ask them if they would like to meet you. All this before the patient has accepted the offer of a referral to physio. The referrer can make the offer that you will come to their next appointment and then explain to them what you can offer. They can then decide whether they would like to take up the offer of physio.
Within this offer the referring clinician can ask the patient if they would like you to join for a short period within one of their appointments for you to come and speak to them about what you can offer. I imagine this as the opportunity to pitch to the patient, making them an offer for you to be part of their care.
At this stage you may also want to work out any specific boundaries that may been necessary. If the during the discussion you both agree that some personalised boundaries will be necessary for this patients care then discuss what they may need to be. It is best for these to be set out as early as possible. You may want the appointments to be in clinic, and you want to make sure that the option of a home visit is never considered. You may want to make sure that you will only be seeing them for their knee pain and you won’t be discussing their neck pain. You want to be clear that there will only be 8 sessions or 12 sessions. You may want to set out the boundary that sessions can only be 45 minutes and the person mustn’t run over. If you get to 45 then the session will have to be drawn to a close. You may wish to set a boundary such as the sessions have to be on the same day of the week and at the same time and they cannot be moved if the person has a pattern of avoiding or trying to take control by calling reception and rearranging appointments. You may want to set up a DNA or cancellation rule if the person has a history of sabotaging. Many of these boundaries are structural in other areas of physio, such as length, location and number of sessions. In MH physio you should be given the structural freedom to adapt to meet the patient where they are. This structural freedom coupled with the inclination of a MH professional to adapt, care and help. Can lead to the patient dominating the nature of the relationship and the sessions no longer being clinically effective in the way that you would want. So, consider any boundaries that you would like setting and if they are non-negotiable then a good place to put them is before they have decided to accept meet you. If they are set from before the first session, there is a greater likelihood that they will be accepted and stuck to.
Hopefully the offer will be accepted, and you will be able to come to their next appointment and pitch for a place in their circle of care. Consider when during this appointment to come in. It could be best to come in at the beginning if the person can be frazzled by the end of their nursing or psychology appointment. So, speak to them before they become psychologically frazzled. Or it could be that they will need time settle and they best time to speak is after 15 minutes or towards the end of the session. Or it may not matter so arrange the time to suit yourself. It is considering these small aspects that that will make your intervention more likely to succeed in the long term. Letting patients know that you have considered them will also help convey a message that you understand what they are going through and you understand them and their situation. You are attentive to these details and are experienced. The implication for the patient will be that you will then be attentive and thoughtful to further problems or subtleties.
Being able to explain what you do is an important skill. You want to develop a pitch to a patient which explains what you do, and shows how you will be attentive to their needs. This pitch needs to avoid medical language last at most 5 minutes. It needs to involve an explanation of what mental health physio is and how it differs from primary care physio. It can involve an explanation about who you are and what your education, training and experience is. It can explain why you work in mental health and what your interest in this area is. You are not just pitching physio you are pitching yourself. This needs to be practiced but not so slick that it becomes impersonal. Once the pitch has been made you can decide what to do next. It may be that the patient is clearly interested in the idea of working with you so you can go straight to organising an appointment in your diary. It may be that you are unsure of how they have received it so you ask what they would like to do giving them the option to discuss what you have just presented with the referrer and you will leave them to it. It may be that its clear you should now leave and let them discuss it with the referrer. The skill is to be able to judge a situation like this and to respond accordingly.
Following the pitch I have had patients just book an appointment and I have had patients ask for time to think about it and I have had patients come back with a series of written questions.
The pitch and then acceptance also functions as consent when documented. It just needs to be documented that the explanation of what was being offered included an assessment and some degree of touch may be necessary but only if appropriate. I would also say in my pitch (because it was a conversation that was bound to come up) that I was very used to assessing people without asking them to remove clothing. I would only ask people to remove clothing if it was absolutely necessary and this would probably be removing shoes and socks but generally people would just wear clothing that allowed them to be assessed such as shorts. If someone didn’t wear the needed clothes and it is was absolutely necessary to see the body part then it’s best to wait until the correct moment, including the relationship being built and the attempt to assess without has been shown and failed before casually asking if the person could wear something difficult that would make it possible to achieve what you are clearly struggling at. The problem of the clothing is being presented and the need to see for their benefit is being shown. Hopefully the person will be able to make the instinctive link without you saying anything and then when you do say something the solution is already in the patient’s mind ready and waiting. You just trigger it and what is needed will happen without challenge.
There are other options that can be used if a meeting to pitch is considered unnecessary. The patient may have accepted the offer of an appointment, but you want to give them the opportunity to put a face to a name and dispel the negative thought that you could be scary. You could meet them to book the appointment in person. Instead of phoning or a letter. This would be a casual meeting in reception where you join them with your diary and ask them what time would be best for them. You could engineer it to feel like a chance meeting at the end or beginning of the appointment. As though you have just happened to meet in the corridor or reception. This can help with minimising any fear of expectation, avoiding any build-up to a meeting. Just doing this I found was very effective at increasing attendance at the first appointment. You could use a phone call to introduce yourself and book an appointment, or just phone to book an appointment. I would avoid only sending a letter out informing the patient of their upcoming appointment. Unless you are sure that this will be ok
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