Complexities of shared decision-making in home-care physical therapy: a mixed methods study

Shared decision-making (SDM) appears underutilized in physical therapy despite its potential benefits. Information regarding how SDM occurs in home-care physical therapy is limited.

The objective was to describe SDM as experienced by physical therapists during in-home initial evaluation visits with older adults (age 65+) and to recommend SDM improvement strategies.

A convergent mixed methods design integrated findings from an anonymous survey and from volunteer interviews.

The setting was United States home care.

Surveys were completed by 220 home care therapists working in 44 states. Twenty therapists completed interviews.

Participants' SDM-related experiences were examined.

The main outcomes were descriptions of SDM contained within 1 theme and practice dilemmas within a second theme.

The theme SDM as a Suite of Decisions emerged from 6 subthemes relating to goal setting, treatment planning, and service administration: discovering patients' goals, translating patients' goals into therapy goals, selecting the type of treatment, determining treatment frequency and duration, delineating delivery specifics, and SDM after the evaluation. The theme Balancing Patients', Therapists', and Employers' Needs emerged from 2 subthemes: patient advocacy versus organizational duty and coping with professional distress. Data described SDM actions and actors varying by decision type and therapy allotment decisions shifted from the patient-therapist dyad to include additional actors. Practice dilemmas surfaced related to reimbursement allocations, locus of authority to determine treatment frequency, and care continuity.

Home-care physical therapy SDM is complex and affected by setting-specific contextual factors including competing loyalties that may cause ethical distress. Strategies for improving SDM are provided.

Knowledge of shared decision-making's complexities can inform strategies for improving its use, potentially increasing patient engagement and patient and therapist satisfaction.