John M. Ventura, DC, is a clinical instructor in family medicine at the University of Rochester School of Medicine. Ian Paskowski, DC, MBA, is the medical director of the Jordan Hospital Spine Program.
The patient centered medical home (PCMH) model is comprised of several key characteristics (1):
- The patient has a personal physician who can provide first contact and continuous comprehensive care
- The personal physician is the leader of a team of providers who care for the patient
- The focus is upon the whole person, caring for all their healthcare needs at all stages of life
- Care is coordinated and integrated across all areas of healthcare delivery and across the patient’s community utilizing HIT (health information technology) and delivered in a culturally and linguistically suitable format for the patient
- Quality and safety are of paramount importance
- Reimbursement commensurate with the added value provided by the medical home model, along the lines of a pay for performance program
The fundamental principal of the patient centered medical home is that episodic care is replaced by coordinated, integrated care in a manner which meets the patient's needs and establishes management and preventive strategies.
Spine care, predominately the evaluation and management of back and neck pain, presents an opportunity to utilize several of the key principles of a patient centered medical home in the evaluation and management of a very common condition. Back pain ranks within the top 5 reasons a patient presents to a primary care physician's office and represents 5 percent of all visits to a primary care physician (2). While mortality related to back and neck pain may be negligible, morbidity (lost productivity, suffering) and costs are enormous. Direct costs related to spine care have been estimated to be in the upwards of $100 million, with indirect costs (lost productivity) being X1 –X5 this amount (3). Of grave concern is that outcomes related to these massive expenditures, such as clinical status and self assessed health status, have not been improving (4).
By approaching spine care from an integrated, coordinated model, rather than the 'ala carte' often adversarial approach, costs can be managed while clinical outcomes are improved. In addition, a focus is placed upon self management strategies and preventive measures. We can approach spine care by looking at each of the key characteristics of the patient centered medical home and evaluating how this characteristic could be applied in an effective and efficient manner.
1. The patient has a personal physician who can provide first contact, continuous comprehensive care. In a spine center of quality, a triage clinician performs the initial history and examination of the patient. Prior to this initial visit support staff will gather necessary information such as prior diagnostic tests, consultations, procedures. A distinguishing feature of a triage clinician in a spine center of quality is that this provider has the necessary skill set to not only triage the patient to appropriate tests/specialists, but also to effectively classify and treat 80 percent of those patients who do not require high cost items such as surgery, MRI or pain management. The triage clinician needs to be trained in a clinical care pathway which is based in evidence based, patient centered principles.
2. The personal physician is the leader of a team of providers who care for the patient. For the triage clinician to function in the role of team leader, they must be trained in a diagnostic classification system which effectively parses the patient into the appropriate flow process. The goal is to get the right patient to the right provider at the right time. The clinical care pathway must rapidly sort out those patients who require more advanced approaches, such as surgery and pain management, while also having the management skills and strategies to effectively manage the larger pool of patients who require a more conservative approach.
3. The focus is upon the whole person, caring for all their healthcare needs at all stages of life. An effective (doing the right thing) and efficient (doing the thing right) spine center of quality will adopt a biopsychosocial approach to spine care, giving equal importance to the psychosocial component as they do the pathoanatomical. In developing prevention strategies, the job requirements, recreational interests and key motivators must all be included in the decision making process. The patient must be included within all aspects for goal setting and therefore treatment planning.
4. Care is coordinated and integrated across all areas of healthcare delivery and across the patient's community utilizing HIT (health information technology) and delivered in a culturally and linguistically suitable format for the patient. A spine center of quality will adopt health information technology which connects all the varying aspects of a community of healthcare delivery. Use of EHR (electronic health record) and HIE (health information exchange) provide the opportunity to coordinate and share information among all the providers involved within the care of the patient. In addition, direct access to educational information to the patient via the EHR and the HIE, delivered in a 'culturally and linguistically suitable format for the patient,' enhances the patient experience and opportunity for management and prevention.
5. Quality and safety are of paramount importance. Utilizing programs such as the National Committee for Quality Assurance Back Pain Recognition Program (NCQA BPRP) to provide a framework for clinical care, and Lean Six Sigma (LSS) to provide a framework for process management, the quality and safety of spine care are greatly enhanced. In addition, an algorithm which is based upon best available evidence to triage patients into appropriate 'treatment arms' will ensure clinically efficacious treatment while minimizing risk to the patient.
6. Reimbursement commensurate with the added value provided by the medical home model, along the lines of a pay for performance program. The advent of Accountable Care Organizations, partially driven by healthcare reform, are being established to reward quality and hold all involved parties accountable for the care being delivered. Whether hospital based, a component of a large physician organization or the operation of a small rural practice, every provider will be asked to measure the quality of their clinical processes and the quality of their clinical outcomes while also managing their costs in a responsible fashion. By utilizing a spine center of quality, the hospital, physician organization or individual practitioner, will demonstrate to industry and third party payors that they are operating in a fashion consistent with a patient centered medical home model. And reimbursement can reflect the level of quality rendered.
While the patient centered medical home does not specifically address spine care, the development of a spine center of quality can implement many of the same key characteristics of a PCMH and also address some additional challenges facing primary care. One notable challenge is appropriate evaluation and management of patients with spine related pain. A 2009 survey done by Consumer Reports indicates that of all provider groups (primary care, medical specialists, physical therapists, chiropractors and acupuncturists), primary care physicians received the lowest patient satisfaction scores for management of back pain (5). In addition, imaging for back pain may be over utilized by primary care physicians with not so innocuous results. One randomized controlled trial looked at plain film imaging for back pain versus no imaging and another looked at MRI for back pain versus no imaging. The group of patients randomized to receive imaging had no better outcomes, and in fact scored lower on self-perceived health status, demonstrated a higher likelihood of persistent pain and utilized higher number of office visits than those not receiving imaging (6,7). Given the high prevalence of back/neck pain, the exponentially rising costs associated with the care and the high morbidity of spine pain, the choice of implementation of a spine center of quality becomes an easy decision.
Learn more about Spine Care Partners.
Notes:
1. www.ncqa.org
2. Cote P, Cassidy JD, Carroll L. The treatment of neck and low back pain: who seeks care? who goes where? Med Care 2001;39:956–67.
3. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 2008;8:8–20.
4. Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingsworth W, Sullivan SD. Expenditures and Health Status among adults with back and neck problems. JAMA 2008; 299(6):656-64.
5. Consumer Reports 2009: http://www.consumerreports.org/health/conditions-and-treatments/back-pain/overview/back-pain.htm
6. Chou R, Fu R, Carrino JA, Deyo RA.Imaging strategies for low back pain: systematic review and mand meta analysis.
7. Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: randomized controlled trial. BMJ 2001; 322(7283):400-05.
Patient centered medical home
The patient centered medical home (PCMH) model is comprised of several key characteristics (1):
- The patient has a personal physician who can provide first contact and continuous comprehensive care
- The personal physician is the leader of a team of providers who care for the patient
- The focus is upon the whole person, caring for all their healthcare needs at all stages of life
- Care is coordinated and integrated across all areas of healthcare delivery and across the patient’s community utilizing HIT (health information technology) and delivered in a culturally and linguistically suitable format for the patient
- Quality and safety are of paramount importance
- Reimbursement commensurate with the added value provided by the medical home model, along the lines of a pay for performance program
The fundamental principal of the patient centered medical home is that episodic care is replaced by coordinated, integrated care in a manner which meets the patient's needs and establishes management and preventive strategies.
Integrating spine care
Spine care, predominately the evaluation and management of back and neck pain, presents an opportunity to utilize several of the key principles of a patient centered medical home in the evaluation and management of a very common condition. Back pain ranks within the top 5 reasons a patient presents to a primary care physician's office and represents 5 percent of all visits to a primary care physician (2). While mortality related to back and neck pain may be negligible, morbidity (lost productivity, suffering) and costs are enormous. Direct costs related to spine care have been estimated to be in the upwards of $100 million, with indirect costs (lost productivity) being X1 –X5 this amount (3). Of grave concern is that outcomes related to these massive expenditures, such as clinical status and self assessed health status, have not been improving (4).
By approaching spine care from an integrated, coordinated model, rather than the 'ala carte' often adversarial approach, costs can be managed while clinical outcomes are improved. In addition, a focus is placed upon self management strategies and preventive measures. We can approach spine care by looking at each of the key characteristics of the patient centered medical home and evaluating how this characteristic could be applied in an effective and efficient manner.
1. The patient has a personal physician who can provide first contact, continuous comprehensive care. In a spine center of quality, a triage clinician performs the initial history and examination of the patient. Prior to this initial visit support staff will gather necessary information such as prior diagnostic tests, consultations, procedures. A distinguishing feature of a triage clinician in a spine center of quality is that this provider has the necessary skill set to not only triage the patient to appropriate tests/specialists, but also to effectively classify and treat 80 percent of those patients who do not require high cost items such as surgery, MRI or pain management. The triage clinician needs to be trained in a clinical care pathway which is based in evidence based, patient centered principles.
2. The personal physician is the leader of a team of providers who care for the patient. For the triage clinician to function in the role of team leader, they must be trained in a diagnostic classification system which effectively parses the patient into the appropriate flow process. The goal is to get the right patient to the right provider at the right time. The clinical care pathway must rapidly sort out those patients who require more advanced approaches, such as surgery and pain management, while also having the management skills and strategies to effectively manage the larger pool of patients who require a more conservative approach.
3. The focus is upon the whole person, caring for all their healthcare needs at all stages of life. An effective (doing the right thing) and efficient (doing the thing right) spine center of quality will adopt a biopsychosocial approach to spine care, giving equal importance to the psychosocial component as they do the pathoanatomical. In developing prevention strategies, the job requirements, recreational interests and key motivators must all be included in the decision making process. The patient must be included within all aspects for goal setting and therefore treatment planning.
4. Care is coordinated and integrated across all areas of healthcare delivery and across the patient's community utilizing HIT (health information technology) and delivered in a culturally and linguistically suitable format for the patient. A spine center of quality will adopt health information technology which connects all the varying aspects of a community of healthcare delivery. Use of EHR (electronic health record) and HIE (health information exchange) provide the opportunity to coordinate and share information among all the providers involved within the care of the patient. In addition, direct access to educational information to the patient via the EHR and the HIE, delivered in a 'culturally and linguistically suitable format for the patient,' enhances the patient experience and opportunity for management and prevention.
5. Quality and safety are of paramount importance. Utilizing programs such as the National Committee for Quality Assurance Back Pain Recognition Program (NCQA BPRP) to provide a framework for clinical care, and Lean Six Sigma (LSS) to provide a framework for process management, the quality and safety of spine care are greatly enhanced. In addition, an algorithm which is based upon best available evidence to triage patients into appropriate 'treatment arms' will ensure clinically efficacious treatment while minimizing risk to the patient.
6. Reimbursement commensurate with the added value provided by the medical home model, along the lines of a pay for performance program. The advent of Accountable Care Organizations, partially driven by healthcare reform, are being established to reward quality and hold all involved parties accountable for the care being delivered. Whether hospital based, a component of a large physician organization or the operation of a small rural practice, every provider will be asked to measure the quality of their clinical processes and the quality of their clinical outcomes while also managing their costs in a responsible fashion. By utilizing a spine center of quality, the hospital, physician organization or individual practitioner, will demonstrate to industry and third party payors that they are operating in a fashion consistent with a patient centered medical home model. And reimbursement can reflect the level of quality rendered.
While the patient centered medical home does not specifically address spine care, the development of a spine center of quality can implement many of the same key characteristics of a PCMH and also address some additional challenges facing primary care. One notable challenge is appropriate evaluation and management of patients with spine related pain. A 2009 survey done by Consumer Reports indicates that of all provider groups (primary care, medical specialists, physical therapists, chiropractors and acupuncturists), primary care physicians received the lowest patient satisfaction scores for management of back pain (5). In addition, imaging for back pain may be over utilized by primary care physicians with not so innocuous results. One randomized controlled trial looked at plain film imaging for back pain versus no imaging and another looked at MRI for back pain versus no imaging. The group of patients randomized to receive imaging had no better outcomes, and in fact scored lower on self-perceived health status, demonstrated a higher likelihood of persistent pain and utilized higher number of office visits than those not receiving imaging (6,7). Given the high prevalence of back/neck pain, the exponentially rising costs associated with the care and the high morbidity of spine pain, the choice of implementation of a spine center of quality becomes an easy decision.
Learn more about Spine Care Partners.
Notes:
1. www.ncqa.org
2. Cote P, Cassidy JD, Carroll L. The treatment of neck and low back pain: who seeks care? who goes where? Med Care 2001;39:956–67.
3. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 2008;8:8–20.
4. Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingsworth W, Sullivan SD. Expenditures and Health Status among adults with back and neck problems. JAMA 2008; 299(6):656-64.
5. Consumer Reports 2009: http://www.consumerreports.org/health/conditions-and-treatments/back-pain/overview/back-pain.htm
6. Chou R, Fu R, Carrino JA, Deyo RA.Imaging strategies for low back pain: systematic review and mand meta analysis.
7. Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: randomized controlled trial. BMJ 2001; 322(7283):400-05.