Optimizing Care Pathways: The Next Frontier in Rehabilitation Performance
The release of CMS’s new innovation center strategy is not just a change in policy; This is a profound adjustment to the entire patient journey. For decades, the health care system has been run on a fee-for-service (FFS) model, which incentivized volume—more appointments, more procedures, more spending. As value-based care gains new momentum, we are asked to think of care not as a series of isolated interventions, but as a coordinated, data-based pathway that delivers demonstrably better outcomes at lower cost.
For rehabilitation professionals—physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs)—this transition presents both a challenge and a tremendous opportunity. Our work inherently focuses on functionality, prevention and independence, which are the cornerstones of the new CMS vision. However, many rehabilitative care programs remain too fragmented, too reactive and disconnected from the broader care ecosystem, often in silos. This will not affect the next, more responsible phase of transformation.
New Mission: Prevention, Empowerment and Value Accountability
The new CMS innovation strategy is built on three pillars: promoting evidence-based prevention, helping people achieve their health goals, and driving choice and competition. For rehabilitation providers, these pillars translate directly into the need for rigorously constructed and measured care pathways.
The risks of ignoring this shift have never been higher. Future payment models, such as the recently proposed ambulatory specialty model (ASM), will expose specialists to the bidirectional financial risks of episode costs and quality outcomes associated with high-volume, high-cost conditions such as low back pain and heart failure. These models specifically penalize low-value care, which often means avoiding unnecessary advanced imaging, injections, and, crucially, non-evidence-based interventions that do not contribute to functional improvement.
The opportunity for rehabilitation is clear: By optimizing our care pathways, we can serve as a major cost-saving intervention, demonstrating that functional rehabilitation is an evidence-based alternative to unnecessary downstream utilization, including surgery.
Redefining rehabilitation care pathways
Essentially, a care pathway is the map we follow to move a patient from functional limitation to functional independence. Optimizing them requires a multifaceted approach centered on clinical effectiveness and operational efficiency. What this means for recovery performance:
1. Important standardization: based on clinical evidence
The basis of the optimization approach is standardization. This does not mean treating every patient the same, but rather developing common protocols for common conditions (such as total joint replacement rehabilitation, stroke rehabilitation, or chronic low back pain) that are based on objective outcome data and nationally recognized clinical practice guidelines (CPGs).
For example, in the area of low back pain, standardized pathways must prioritize early, evidence-based physical therapy while actively reducing reliance on passive modalities, excessive imaging (such as unnecessary MRI, a specific measure of ASM), and high-risk medications. This systematic insistence on low-cost, high-value sequences is key to managing event costs and achieving shared savings under the new CMMI arrangement.
2. Customization that counts: Leveraging functional expertise
While standardization sets the boundaries for high-value care, customization is where the unique expertise of rehabilitation professionals shines. Programs must still take into account the flexibility of the individual patient's circumstances, goals, comorbidities, and social determinants of health (SDOH).
The therapist's ability to provide personalized care within a structured framework is our unique value proposition. Customization is not an excuse for change; it is the thoughtful application of standardized interventions to achieve a patient's individual goals, often tracked using patient-reported outcome measures (PROMs).
3. Strategic sequencing: Embedding rehabilitation upstream
In a value-based era, rehabilitation must be proactively positioned. Strategic “prioritization” means proactively defining where we are in the comprehensive care journey:
- Upstream (prevention): Engage high-risk patients (such as those with prediabetes, early signs of frailty, or a history of falls) before an acute event occurs. This directly achieves the prevention goals of CMS and avoids high-cost institutional care.
- Period (episode management): Incorporate functional measures into each appropriate phase to track progress and justify next steps, ensuring interventions are timely and necessary.
- Downstream (conversion): Close coordination with primary care, specialists, and community resources ensures smooth transitions of care and reduces the risk of readmissions or exacerbations of chronic conditions. This enhanced collaboration is explicitly motivated by improvement activities in models such as ASM.
Call to action: Define our own success
This is where operational maturity meets clinical excellence. We can’t wait for CMS to provide us with the perfect blueprint for recovery. Now is the time for recovery leaders to define what optimized care looks like, build these pathways using evidence and outcomes data, and then proactively demonstrate that our services are the most effective way to align with new strategic directions in healthcare. By leading with measurable value, we ensure our significant role in value-based arrangements and clearly demonstrate that outcomes are strategy, not just scorecards.
Photo: Arturo Pena Romano Medina, Getty Images
Susan Lofton is a physiotherapist with 25 years of experience in clinical care, operations and senior management. Susan has worked in a variety of healthcare settings, including acute care, IRF, skilled nursing, home health, and ambulatory care, giving her unique insight into patient transition needs and the inner workings of the healthcare ecosystem. Susan is passionate about improving healthcare and has deep expertise in regulatory compliance and optimizing strategies for success. Susan serves as Vice President of Outcomes and Clinical Translation for WebPT and is the Executive Director of the Keet Outcomes Qualified Clinical Data Registry (QCDR) for participation in MIPS and other quality payment programs.
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