Physical, Occupational and Rehabilitation Therapy Case Studies
Healthcare5 Case StudiesUpdated Sep 2026
Therapy teams spend their days inside other people's decisions. A referral is accepted with incomplete information, a plan changes between shifts, a discharge date is set before the home question is answered, and a family asks for more detail than the patient has agreed to share. The five cases here follow those moments across outpatient, inpatient, and community settings. Work through each one by asking what each person knew when they acted, which protocol applied, and where the system could have made the right step easier. Discuss the questions with colleagues who work in similar services.
Case Study 1
Shoulder pain that stopped responding to care
Harbor View Rehabilitation Clinic, a single-site outpatient practice with two therapists per shift and a referral line to the regional primary care group.
The situation
Dariush, a physical therapist at Harbor View Rehabilitation Clinic, received a referral for a man in his late fifties with shoulder pain managed for six weeks in primary care. At the first visit he reported that the pain now woke him most nights and that he had lost some weight without trying. His range of motion was reduced, and the intake form recorded the pain as stable at the last review. The referring note suggested a routine plan. Two visits later, the night pain was more frequent and a new numbness had appeared in the arm. The clinic's escalation protocol lists that combination as needing same-day medical review.
The challenge
The main difficulty was that no single observation crossed a threshold on its own. The weight loss was self-reported and the night pain was described as intermittent at first. Dariush had to decide whether to continue the plan agreed with the referrer, contact the referrer directly, or use the protocol's escalation route, and she had to do this without a clear diagnosis in her own discipline. The referrer was on leave for part of that week.
Analysis
Start with what the patient needs from the encounter. He came for a shoulder problem and was given a plan, but the information he was now giving described symptoms that did not fit that plan. Clinical evidence in this setting is cumulative. A single report of night pain is weak evidence, while the same report across visits, combined with unexplained weight change and a new neurological symptom, forms a pattern that protocol language is designed to catch. Dariush recorded each change in the same terms at every visit, which made the trend visible to anyone reading the chart later.
Teams grounded in Physical, Occupational and Rehabilitation Therapy treat escalation as a coordination task rather than a judgment about who is right. The local protocol gave Dariush a named route: same-day contact with the medical team responsible for the referral, documented with the time and the person spoken to. She did not need certainty about the cause to use it. What she needed was a clear record of the findings and a message that could be acted on without a follow-up call. Her note to the referrer listed the changes in order, stated which protocol criterion was met, and asked for a named clinician to confirm receipt.
- First visitNight pain and weight loss reported; routine plan continued.
- Second visitNight pain more frequent; numbness described for the first time.
- Third visitProtocol criteria met; same-day escalation chosen.
- Same dayWritten message sent; receipt confirmed by referring clinician.
Actions taken
- Dariush wrote a same-day message to the referring clinician, attaching the three visit notes and the specific changes, and recorded the time it was sent and who acknowledged it.
- She paused the routine plan for the shoulder and told the patient plainly why, using the words from the protocol so that he heard the same explanation from the medical team later.
- The clinic added a standing field to its intake form asking whether night symptoms, weight change, or new numbness had occurred since the last review, so trends would surface early.
- The therapy lead reviewed the escalation log each month, looking at how long each referral took to receive a medical response and whether any patient returned to the clinic with a changed plan.
Results
The referrer acknowledged the message within the hour and arranged a same-day review. The medical assessment led to care outside the clinic's scope, and the patient was transferred with a written summary from Dariush. The routine plan was formally closed in the record. The patient later said he had felt dismissed at the first visit, which the team used when reviewing intake conversations. Over the following quarter, the clinic logged two more referrals escalated on the same criteria, and both were acknowledged the same day.
Questions for discussion
- What single change in a patient's report would have prompted you to contact the referrer earlier, and how would you have recorded it?
- How should a therapist balance a referrer's plan against a protocol criterion when the two appear to conflict?
- Which parts of an escalation message would you keep the same for every referral, and which should change with the patient's circumstances?
Case Study 2
A transfer plan lost between shifts
Cedar Fork Medical Center, a 240-bed regional hospital with a 22-bed inpatient rehabilitation unit.
The situation
The inpatient rehabilitation unit at Cedar Fork Medical Center runs therapy across two shifts, with a written handover at the change of shift and a verbal update at the nurses' station. A woman in her seventies was recovering from a hip-related admission and had been assessed in the afternoon by Mateo, a physical therapist, who set a transfer plan that required two staff and a specific piece of equipment. The plan was entered in the therapy notes but not in the nursing care plan. At handover, the outgoing therapist gave a brief verbal summary that mentioned progress but not the equipment requirement. The evening nurse assumed the usual single-person transfer.
The challenge
The gap surfaced when the patient attempted to get up from the bed unaided with a nursing assistant absent for a moment. Nothing had gone wrong yet, but the near miss showed that the safeguard depended on one person remembering a detail. The team had to find out how the information moved, which entries were authoritative, and how to fix the handover without adding a long form to every shift change.
Analysis
The patient's needs were specific and changing. She had made measurable progress in the afternoon, which was exactly why the plan had been updated, and that same progress meant her risk was shifting from day to day. The most reliable evidence about her safe level of help was the therapist's assessment note, written after direct observation. The nursing care plan still reflected an earlier assessment from before the change. Clinical evidence is only useful at the point of care if the people acting on it can see the same version of it.
Handover is where a plan either becomes shared or stays with its author. The unit's handover standard asks for changes in mobility status to be stated aloud and written on the bedside board, and the therapy notes were not linked to either. A structured format helps only if every element is filled in. Here the verbal summary covered progress and omitted the requirement, which suggests the format was used as a memory aid rather than a checklist. Strong safeguards in this setting include read-back of the safe level of help and a single source that both disciplines update.
Actions taken
- Mateo, who had set the plan, called the evening nurse before leaving and asked her to read the transfer requirement back, so the change was confirmed by two people.
- The unit added a required field to the therapy handover sheet for any change in safe level of help, initialed by the receiving clinician before the shift closed.
- Each therapy note that changes a mobility restriction now generates a flag on the bedside board, and the flag stays until a nurse has acknowledged it in the electronic record.
- The quality lead will audit a monthly sample of mobility changes, tracing each from therapy note to bedside board to nursing plan, aiming for full agreement in nine of ten.
Results
Over the next full quarter, the unit audited forty mobility changes. Agreement across the three records rose from about six in ten at the start to nine in ten by the end. No further near misses linked to handover were reported in that period, though the team recognized that the sample was small. The most useful change was the initialed field, which made the receiving clinician a visible owner of the plan rather than a passive listener. The audit continues each month, and the results are reviewed at the joint therapy and nursing meeting.
Questions for discussion
- Which element of your own verbal handover is most likely to be dropped under time pressure, and what would make it harder to drop?
- When a therapy note and a nursing plan disagree, which record should a receiving clinician trust, and how would the unit know?
- How small can an audit sample be before its results stop being useful for deciding whether a change worked?
Case Study 3
Waiting lists and a shrinking loan store
Brightwater Community Therapy Service, a mixed home and clinic team of nine therapists serving older adults across a rural and town catchment.
The situation
Brightwater Community Therapy Service provides home-based and clinic-based physical and occupational therapy to older adults, with nine therapists and a loan store of adaptive equipment kept at the main clinic. Over one season the referral count rose sharply after two local hospitals began discharging patients earlier. Two therapists were off for planned leave in the same month, and the loan store was short of several commonly requested items because a batch had been held for repair. The waiting list reached a length that the intake coordinator, Yolanda, considered unsafe for people already at home with a worsening mobility problem. Demand was real, not inflated.
The challenge
The service could not add staff within the quarter, and the equipment could not be replaced in time. Every option moved risk somewhere else. Faster triage would leave some stable referrals waiting longer. Block booking home visits would reduce travel but might leave urgent cases in a queue behind routine reviews. The team had to choose an allocation method it could explain to referrers and defend in a complaint review.
Analysis
Triage in a service like this should follow the patient's functional need rather than the order of arrival. The intake form already records the reason for referral, recent changes in walking or transfers, and whether the person is alone at home. Those fields are the team's best early evidence, and they point in different directions for different referrals. A person whose function is falling week by week needs a timely assessment even if an earlier referral has been waiting longer. A stable person waiting for a routine review gains little from being moved up, and the team should be able to say why in each case.
Each option is best judged by what it protects. Strict triage protects the most time-sensitive people but needs a named owner and a weekly review, or the queue drifts back to first come, first served. Block scheduling of home visits recovers travel time, but it should not be used to hide delays from referrers. Prioritizing the loan store by functional need is quick and visible to the team. Telehealth check-ins for stable patients could free assessment slots, provided the protocol says when a patient must be seen in person. The allocation protocol requires a weekly huddle with the service manager, where these trade-offs should be settled and recorded.
- Assess Score new referrals against the functional priority bands.
- Allocate Assign home, telehealth, or clinic slots against reserved capacity.
- Review Count displaced slots and waits that exceeded the target.
- Adjust Change bands or reserves only after two consecutive weeks of pressure.
Actions taken
- Yolanda set three written priority bands for home referrals, each tied to a functional change that the intake form captures, and published them to referring teams.
- The service reserved two home-visit slots each day for urgent reassessments, and the weekly huddle reviewed how many were used, how many were displaced, and why.
- Routine reviews for stable patients moved to a telehealth check-in where the record showed no change in function, with a rule that any reported decline returned the patient to the in-person queue.
- The loan store restocked the most requested items first, using the repair backlog list, and the service manager reported stock levels to the huddle every week.
Results
Waiting time for urgent home referrals fell to within the service's target over the following two months, and routine patients were told their expected wait at intake. Two complaints were raised about the new bands, both from referrers who had expected their own patient to be ranked higher. The review of both showed the band criteria had been applied correctly, and the team changed the referral form to show the reason for each band. The loan store returned to full stock for the common items in the second month. The displaced slot count stayed low but was still recorded, as the earliest sign of pressure.
Questions for discussion
- Which functional change on an intake form would you trust most to move a referral up the queue, and which would you want checked by a clinician first?
- How should a service explain a placement decision to a referrer who believes their patient was ranked too low?
- What would tell you that a reserved slot policy has become a way of avoiding routine demand?
Case Study 4
Uneven goal attainment across two clinic sites
Larkspur Outpatient Therapy Group, a four-site network providing physical and occupational therapy to adults after orthopedic and neurological conditions.
The situation
Larkspur Outpatient Therapy Group runs four sites and reports a small set of anonymized indicators each quarter to its clinical governance committee. Over the last reporting period, the share of patients who reached their agreed functional goals at discharge ranged widely between sites. At the northern clinic, a little under three in four patients met their goals. At the river site, the figure was closer to one in two. Attendance and referral wait times were broadly similar across the sites, so the gap was not explained by access alone. The governance committee asked the clinical lead, Priya, to find out where the difference came from.
The challenge
The indicators could not say why the difference existed. Goal attainment is shaped by case mix, by how goals were written, by how often patients attended, and by whether the record shows what was agreed. Priya had to separate a real difference in care from a difference in how care was recorded, and she had to do this without identifying individual patients beyond what the audit team needed.
Analysis
A goal attainment figure is only as meaningful as the goal it measures. Patients at both sites described similar aims in interviews, such as returning to a job that needed lifting or managing stairs at home. The difference lay in how those aims were written down. At the river site, many goals were phrased as general improvements that were hard to mark as met or not met. At the northern clinic, goals tended to name the task, the level of independence, and the setting. Good evidence here means checking the written goal, the discharge note, and the patient's own account as separate sources rather than assuming they agree.
The river site uses a shared template that opens with a free-text goal field, while the northern clinic uses a structured form with a prompt for the task and setting. Goals are set at different points: the northern clinic agrees them with the patient at the first visit and revisits them at the midpoint, while the river site often revisits only at discharge. The group's protocol requires measurable goals and at least one review, but neither site audits against it. A monitored cycle should change one process at a time, track goal wording and midpoint review, and watch for a rise in documentation time as an unintended cost.
Actions taken
- Priya asked both sites to write goals using a common format that names the task, the level of independence, and the setting, and sampled twenty recent charts from each site to check agreement.
- The group added a midpoint goal review to the scheduling template, so that the review appears as a visit prompt rather than relying on memory at the end of the episode.
- Each site ran a fortnight-long test of the structured form with one caseload, and the therapists recorded how long goal setting took at the first visit.
- The quality lead reviews attainment, midpoint review rates, and documentation time monthly, keeping a change only if attainment improves without documentation time rising beyond ten minutes per episode.
Results
After three monthly reviews, the gap between the two sites narrowed. The river site's goal attainment rose by a margin that the committee described as meaningful, though the team noted that small numbers made month-to-month variation large. Midpoint reviews were recorded for most new episodes at both sites. Documentation time increased by a few minutes at the river site, which the team accepted within the agreed limit. The northern clinic's rate held steady. The committee decided to keep the template change and to extend the audit to a second quarter before making any further claims about the cause.
Questions for discussion
- How would you separate a true difference in functional outcome from a difference in how goals were recorded when you only have anonymized indicators?
- Which process measure would you trust least as evidence of improvement, and why?
- What would a team need to agree on before changing goal wording at one site and not the other?
Case Study 5
Family pressure and a patient's home decision
Marlow Crest Rehabilitation Hospital, a 90-bed inpatient unit attached to a regional acute hospital, with a shared ethics consultation service.
The situation
Marlow Crest Rehabilitation Hospital has an ethics consultation service that unit staff can request during a complex episode. Ruth, a woman in her eighties, was admitted for rehabilitation after a fall that reduced her walking and her ability to manage stairs. The team assessed her as having capacity for her own decisions. She wanted to return to her apartment with support, and she said so clearly at each review. Her daughter, Anita, attended most sessions and asked the occupational therapist for a full written copy of the home assessment, including comments Ruth had asked the team to keep private. Anita also wanted a residential placement arranged before discharge.
The challenge
Ruth's confidentiality and her right to decide about her home were not in doubt, yet Anita's concern about safety was real and the home assessment did record a risk that needed attention. What Anita was entitled to know, what Ruth had agreed to share, and when the ethics service should be brought in rather than handled inside the unit were all open.
Analysis
Ruth's needs and the evidence about her home are two separate questions, and the team needed to keep them apart. The capacity assessment was decision-specific, and it had been carried out for the decision to return home with support. The home assessment documented real risks, including the stairs and the bathroom layout, and Ruth had been told about them. Being told is not the same as understanding, so the team checked that she could explain the risks back in her own words before treating her choice as informed. Her wishes do not change because her daughter disagrees, though they can be revisited if new evidence appears.
Communication choices in this case were about consent and sequence. Sharing the risk findings with Anita was possible only with Ruth's agreement, so the first step was to ask Ruth which parts she was willing to share and with whom. A family meeting with Ruth present allowed the risks to be discussed without anyone speaking for her. Escalation was appropriate once the request conflicted with a documented decision, and hospital policy names the ethics consultation service for that conflict. Social work should be involved, since a residential placement is a discharge planning question with its own assessment and funding steps, not something the therapy team can arrange alone.
Actions taken
- Caroline met Ruth alone and asked which parts of the home assessment she was willing to share with her daughter, and recorded the answer in her own words.
- The team offered a family meeting with Ruth present, using an agenda that covered safety concerns, Ruth's stated choice, and the options for support, so that Anita heard the same information Ruth did.
- The social work lead was asked to begin discharge planning in parallel, so that a residential option was assessed and explained to Ruth as one possibility, rather than arranged on her behalf.
- Because Anita's request conflicted with a documented decision, the therapy lead referred the case to the ethics consultation service with a one-page summary of the decision, the disagreement, and the open questions.
Results
Ruth agreed to share the stairs and bathroom findings with Anita, and to keep the rest private. The family meeting took place in the second week, and Anita said afterward that she had not understood the risks until she heard them from the team. The ethics service reviewed the summary and advised documenting Ruth's decision and its basis, which the team did. Ruth returned home with a support plan she had helped to write, and the social work lead closed the residential referral with her written agreement. Anita remained involved, and the team noted that her concern had shifted from the placement to the day-to-day arrangements.
Questions for discussion
- At what point would you have stopped sharing Ruth's home findings with Anita, and what would have changed your answer?
- How should a team record a patient's decision when a family member disagrees with it, and who should be able to read that record?
- What would you need to know about an ethics service before deciding that a conflict was too minor to refer?
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