Clinicians who learn to craft the therapeutic language are a peculiar, yet undeniably potent breed of healthcare provider. They have clarity — the kind that comes from being forced to cloak nebulous thoughts about a patient in concrete words.

Yet, the clinician who assumes that all interested parties (patient, referral source and payer) are equally interested in the same information is fooling only himself. Muir Gray, author of Evidence-Based Healthcare, helps providers understand that there are seven types of information used to assess the impact of patient care [1]:

• appropriateness
• cost-effectiveness
• effectiveness
• equity
• patient satisfaction
• quality
• safety

To clarify how to best package that information for each type of consumer, contemplate a patient referred for a bout of aquatic therapy.

What are the Patient's Needs?
In order to determine what needs the patient has, it always helps to ask. As patently obvious as that seems, it is important to notice that patients have widely varied concepts about your plans for them. Many people have no framework for reference, especially for aquatic therapy.

This became obvious the first time a patient (referred exclusively for aquatic therapy) told me she suffered from the unfortunate combination of a severe chlorine allergy and hydrophobia. Although she stood before me wearing a bathing suit and holding a referral for aquatic therapy, it was a frightening revelation to her that aquatic therapy involved getting into the pool.

Some patients are quite certain you are a water aerobics instructor. Still others believe they have come for swim lessons (on occasion assisted in this misconception by the ill-advised aquatic therapy referral which reads, in toto, "swimming instruction"). Ask them and you may be surprised with what they don't know about aquatic therapy.

In general, the patient will want to know a few things about this bout of intervention:

1. Are you going to listen to me and touch me during treatment? (patient satisfaction)

2. Will aquatic therapy make me better? (effectiveness)

3. Are you a skilled provider of aquatic therapy? (quality)

4. Will aquatic therapy be harmful to me? (safety)

5. Is aquatic therapy really necessary?

How will this fit in with my land-based treatment? (appropriateness)

What are the Referral Source's Needs?
The referring professional will have much different information needs. When a professional colleague sends a patient your way, it helps to feel the weight of the responsibility. That person has passed on the responsibility of the patient who walked in his door to you. The less known about your skill as a provider and the benefits of aquatic therapy, the more work you must do. Each new referral should be seen as an opportunity to produce trust — not only through exceptional patient care (a given), but through skillful management of information about that care.

In general, the referring professional will want to know a few things about this bout of intervention:

1. Why is this particular patient a good candidate for aquatic therapy?

How can I make this decision more instinctively about future patients? (appropriateness)

2. Is aquatic therapy contraindicated or highly precautionary for this patient? (safety)

3. Can I trust you with my patient? Will you operate beyond your scope of knowledge? (safety)

4. Has aquatic therapy been shown to be effective for impairments, functional limitations and disabilities similar to the ones demonstrated by this patient? (effectiveness)

5. Are you a competent provider of the therapeutic procedure aquatic therapy? Will you keep me informed of patient change without overwhelming me with inconsequential matters? (quality)

What are the Payer's Needs?
The information needs of the patient's payer are different still. Yes, payers look out for the health of their client (your patient), but they also have a vested interest in their own financial health. Contrary to popular opinion, this is not evil. Capitalism drives innovation. In the absence of a profit motive, there would be no private-sector third party payers. Yet, it means that you must provide much different information than you would if the payer was nothing more than an earthly version of the archetypal fairy godmother.

In general, the payer will want to know a few things about this bout of intervention:

1. Has aquatic therapy been shown to be cost-effective for impairments, functional limitations and disabilities similar to the ones demonstrated by this patient? (cost-effectiveness)

2. Can the functional status of this patient be improved by the application of the therapeutic procedure aquatic therapy? Can this functional improvement be recorded through documentation? (appropriateness)

3. By providing higher reimbursement for aquatic therapy (and thus, necessarily providing lower reimbursement for an alternative treatment), will all patients be better off? (equity)

4. Are you a skilled (educated, regulated) provider of aquatic therapy? And does this patient's treatment require your level of expertise or can it be provided by someone less skilled and less resource-expensive? (quality)

Conclusion
The provider who learns to cloak his or her thoughts with the right words is powerful. For once we accept the idea that we should be purveyors of information as well as providers of direct intervention, it all falls into place. Words can become footsoldiers in the war against therapeutic mediocrity.

Learn More on this Topic
For more on documentation, order Prove It! Justifiable Aquatic Therapy, an 130+ page manual which provides, among other things, a whole section of documentation "checklists" for the aquatic therapy provider. For more on the legal aspects of documentation and reimbursement, order Billing for Aquatic Physical Therapy. Obtain both products by phone (715) 248-7258, fax (715) 248-3065 or order online.

Reference
1. Muir Gray J.A. (1997). Evidence-Based Healthcare. How to Make Health Policy and Management Decisions. New York: Churchill Livingstone.

Author Bio
Andrea Poteat Salzman, MS, PT is the owner of two businesses, the Aquatic Resources Network and Concepts in Physical Therapy. She has received both the prestiguous Aquatic Therapy Professional of the Year Award (Aquatic Therapy and Rehabilitation Institute) and the Tsunami Aquatic Therapy Award.

Salzman is well-regarded within the industry as:

• Editor-in-Chief of an aquatic therapy trade journal and newsletter;
• Author of over a dozen publications, including the soon-to-be-released Evidence-Based Aquatic Therapy textbook;
• Freelance author and columnist;
• Aquatic therapy seminar instructor;
• Adjunct faculty and research advisor, St. Catherine Physical Therapy Program, Minneapolis, MN;
• Immediate past manager of therapeutic aquatics, St. Paul Ramsey Medical Center, St. Paul, MN;
• Researcher and grant recipient examining aquatic exercise vs. land-based exercise.

She may be reached via e-mail at asalzman@aquaticnet.com