Building Seamless Care Transitions: Connecting Physical Therapy to Community Resources for Older Adults With Arthritis

Background and Purpose: Physical therapists struggle to ensure continuity of care for older adults with arthritis and other chronic conditions at the completion of episodes of care. With osteoarthritis affecting 25 million older adults and causing activity limitations in at least 50% of cases, there is a critical need for a systematic approach to bridge the community-clinical gap between physical therapy and community-based organizations (CBOs) that offer evidence-based programming and address health-related social needs. This administrative case report presents a technology-enabled model for supporting patients’ transition from physical therapy to community-based programs, transforming traditional siloed care into an integrated system through a coordinated community care hub (CCH). Case Description: A physical therapist, Sarah, completes treatment for a 68-year-old patient with bilateral knee osteoarthritis. While the patient has made significant progress, they would benefit from ongoing community-based exercise and falls prevention programming. The patient also faces social isolation and food insecurity, which could undermine therapy gains. Sarah lacks an efficient way to connect the patient with appropriate services and follow up on progress. To address this use case, we developed a model linking health care providers with CCHs. The CCHs are local entities that coordinate networks of CBOs addressing health-related social needs and connect patients to evidence-based programs. Outcomes: Our model, set to pilot in 2024, streamlines referrals from physical therapy to CBOs and programs through: Simplified electronic referral process to community programs and resources. Improved tracking of patient engagement in post-PT programs. Enhanced communication between PTs and community service providers. Enriched long-term monitoring of arthritis management, falls prevention, functional outcomes, and social support engagement. Discussion: This approach offers a practical solution to a common challenge faced by physical therapists in managing the long-term care of older adults with arthritis. By leveraging technology to facilitate these community-clinical connections, we reduce the administrative burden on clinicians while improving both health outcomes and social support for patients. This model has the potential to transform how physical therapists ensure continuity of care and could be adapted for other chronic conditions.