A spine patient can wait months to see a surgeon only to learn at the appointment that surgery is not the next step.
They may need physical therapy first. They may need pain management or an injection. They may not have completed the conservative treatment required before an insurer will authorize a procedure.
For the patient, that can mean another referral, another specialist and another wait. For the surgeon, it means an appointment with someone they cannot yet help.
Burlington, Mass.-based Tufts Medicine is trying to eliminate that mismatch. The health system is building a more unified approach to spine care across specialties and locations, designed to get patients to the right clinician earlier instead of leaving them to navigate neurosurgery, interventional spine, pain management and rehabilitation largely on their own.
“We often find that patients just don’t land in the first spot that makes the most meaningful visit,” Caitlin Rivet, BSN, RN, director of clinical operations at Tufts Medicine’s Lawrence, Mass.-based New England Neurological Associates, told Becker’s.
The goal sounds simple: the right patient, the right care, the right location. Making that happen across a health system is harder.
The wrong 1st appointment
Tufts Medicine’s spine network spans three hospitals, an integrated network of practices and multiple specialties, including neurosurgery, interventional spine, rehabilitation and anesthesia-based pain management. Patients can enter that network from multiple points, and referring clinicians may have different levels of familiarity with what each specialty offers.
That creates an expensive problem in spine care: Access alone does not help much if the patient gets access to the wrong clinician. Ms. Rivet said a significant portion of patients referred to neurosurgery have not yet pursued conservative treatment. A patient may arrive after months of worsening pain expecting an answer, only to learn that physical therapy or another nonsurgical intervention should come first.
“You’ve used the patient’s time poorly, and it’s a poor use of the surgeon’s time,” she said.
The reverse happens, too. Patients can remain in pain management after conservative options have been exhausted when a surgical evaluation may be the more appropriate next step.
The goal is therefore not simply to move volume away from surgeons. “It’s supposed to be bidirectional,” Ms. Rivet said.
Better navigation could put more patients who need conservative treatment into pain management while preserving neurosurgical capacity for patients who are ready for a surgical evaluation.
For patients, that could eliminate unnecessary stops. For clinicians, it could mean spending more appointments with patients they are positioned to help.
“There’s nothing more disheartening to a provider than to be sitting across from a patient saying, ‘I don’t have a service to provide for you right now,’” Ms. Rivet said.
Making separate programs behave like 1
Solving that problem requires Tufts Medicine to understand how patients move through each part of the system. That has meant mapping workflows across locations that do not necessarily operate the same way.
“Each system location is doing things a little bit differently,” Maureen Cappola, executive director of anesthesia and perioperative medicine at Tufts Medicine, told Becker’s.
The system has brought together representatives from different specialties and locations and expanded the work to include front-line staff and nursing leaders. Teams are examining workflows and developing algorithms that could create a more centralized patient pathway without requiring every clinic to function identically.
Ms. Rivet described the work as a blend of clinical and operational expertise: Clinicians determine what care a patient needs, and operational teams help determine how to get the patient there.
The harder part is making those connections seamless for the patient. Instead of sending someone away with another referral, the teams can communicate directly, turning what might have been another stop in the process into a coordinated handoff.
“The patients feel that direct handoff,” Ms. Rivet said. “It’s not just one department to another or one specialist to another. It’s an interlinked journey.”
1 front door, multiple destinations
Tufts Medicine is also working to centralize parts of the referral process. The goal is to create a common access point that can direct patients based on their clinical needs and geography.
When a referral comes in, key team members could review the patient’s information, determine the appropriate specialty and identify the Tufts Medicine location that makes the most sense.
Ms. Rivet said the experience should feel almost “conciergey.” Instead of making care less personal, centralization could reduce how much navigating patients have to do themselves.
Prior authorization is part of that equation. Ms. Cappola said the system is examining whether parts of the process can also be handled more centrally. Getting patients to the appropriate care earlier could help avoid delays when insurers require conservative treatment before approving injections, procedures or surgery.
The longer-term vision goes beyond coordinating care across separate locations.
“For us the vision is to eventually have co-located clinics where a patient could walk right down the hall to see a different specialist,” Ms. Cappola said.
New England Neurological Associates already offers a smaller-scale example. Neurology, neurosurgery, rheumatology, interventional pain and psychiatry are located within the practice, giving the team a model for what deeper integration could look like across Tufts.
Scaling that experience across roughly 10 locations and several specialties is the harder task.
When success becomes invisible
For all the complexity behind the effort, Ms. Rivet’s definition of success is simple.
“If we do this well, then it should just feel seamless,” she said.
Patients should not have to carry imaging from one clinician to another. They should not wait months for an appointment only to discover they need to start again with another specialist. They should not have to understand the organizational boundaries separating the clinicians treating them.
Instead, Ms. Rivet said, patients should feel “fully enveloped in support from the initial point of contact.”
That is what makes the work more than a patient-experience initiative. Getting patients to the appropriate clinician earlier could reduce unnecessary specialist visits, make better use of procedural and surgical capacity and allow providers to spend more time with patients they are positioned to help. It could also shorten the path to treatment without assuming that faster care means faster surgery.
The goal is not to create one standardized treatment path but to build a system capable of directing different patients down different paths without asking them to navigate the intersections themselves.
Tufts Medicine is still working toward that model across its network. But Ms. Rivet said one of the most important pieces is already in place.
“Everybody is swimming in the same direction,” she said. “Which means it’s possible.”
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