CIS - Pam Duncan Nov12 aWhen it comes to improving the American healthcare system to provide higher quality care at lower cost, we must be mindful of how we are currently failing the patient, and how to remedy that, not place all of our focus on system failure. By improving the care given to the patient, improvement in the system will follow. So says Pam Duncan, PhD, PT, FAPTA, FAHA, Wake Forest Baptist Health, who addressed the group of attendees this morning at the 2014 Kindred Clinical Impact Symposium: Clinical Excellence in the Care of the Stroke Patient Across the Continuum.


Duncan started her presentation with a personal story of her own mother’s stroke in 1985 – a massive stroke which deprived her of any potential for regain of function. Duncan’s mother stayed in the hospital for three weeks, and then the family transitioned her to a nursing home for her final days of life. At that nursing home, in 1985, a physical therapist appeared with an order to get Duncan’s mother up. Duncan protested; a trained physical therapist herself, Duncan felt this intervention was inappropriate in her mother’s case. She told the PT that she could do passive range of motion exercises with her mother, and that was it. Within 24 hours, Duncan’s mother had died. Weeks later, a bill for the physical therapy came – for $150. When Duncan expressed disbelief at the cost for what was done, for a woman who was close to death, she was told, “what do you care, Medicare paid for it.”

This, Duncan said, is a good example of the kind of experience that set stage for the current state of the United States healthcare system, which currently has the highest GDP for healthcare in the world, exceeding any other civilized country. But in order to fix the failing system, we must focus on not failing the patient, Duncan said.

CIS - Pam Duncan Nov12 bHow do we do that? 


  • Partnerships between acute and post-acute providers, based not on “marketing” but on the nuts and bolts of how systems can truly work together to integrate care 
  • Listening to the voices of the patient and family 
  • Measuring outcomes for each patient 
  • Bundled payments for care cycles 
  • Asking ourselves, did we improve the patient’s functional status and make rational decisions about palliative care? 
  • Providing care at home when possible, because patients treated at home seem to fare particularly well at lower cost 
  • Focus on patient’s functional status, not age, when considering therapy and treatment options 
  • Create a comprehensive post-acute stroke service model 
  • Systematically assessing the patient and incorporating that into the medical record 
  • Take patient’s goals and preferences into consideration 
  • Have the guts to share probability of good and bad outcomes, with objectivity, but also with the personal touch to say, “if this were my family member, this is what I do.”

Said Duncan, “We can all deliver care with expertise, humility and passion.”

*In her presentation, Duncan referenced Ezekiel Emanuel’s recent article in The Atlantic, Why I Hope to Die at 75. The article muses on the functional limitation that plagues many people over that age.