In 2018, with increasing and burdensome workloads for referring and primary care providers, the neuroscience service line at Penn Medicine sought a more unified approach to treating patients with spine needs.
Four different departments involved in spine — orthopedic surgery and neurosurgery, physical medicine and rehabilitation and anesthesia/management — all had different processes to manage patients referred for spine care, which contributed to the workload of referring and primary care physicians. Additionally, patients seeking spine care within the four departments were treated in siloes.
Discussions with primary care providers revealed the barriers preventing streamlined patient navigation: six consult orders in the Epic EMR system pointed to various departments for spine care, but few were being reviewed. Referring providers were often unsure whether to send patients to a surgical or nonsurgical spine provider and patients were bouncing between the four spine departments with little continuity of care.
Thus, a pilot initiative was established at Philadelphia-based Penn Medicine, which created one consolidated Epic consult order for spine care and directed all internally referred patients through a single channel — the newly created spine access center.
"A lot of patients want to be seen by a spine specialist but aren't really interested in surgery," said William Welch, MD, chairman of the department of neurosurgery at Pennsylvania Hospital and medical director of the spine center at Pennsylvania Hospital in Philadelphia. "The spine access center is able to screen the patient appropriately, utilizing clinical triage protocols established by the providers, to get the patient sent to the next available physician quickly."
"So, when patients call, they're screened by a Penn Medicine nurse and her team and directed to the most appropriate physician and location, based on their diagnosis," Dr. Welch added. "This triage process gets nonsurgical patients to the appropriate provider, and as a result helps the surgical practices to be able to see more surgically appropriate patients."
Now, primary care providers refer patients for spine care by placing one Epic order, which is managed by the spine access center. The team reviews the information and connects with the patient within 48 hours to schedule with the appropriate spine provider across all four spine departments, which encompasses more than 50 providers and 16 locations.
In establishing this new process, there were concerns that needed to be mitigated amongst internal spine providers, particularly around referral patterns. If a provider refers their patient to a specific spine surgeon, they automatically are sent to that physician, eliminating referral concerns of some surgeons at Penn Medicine.
However, if there is no designation and the spine access center feel surgery is required, the patient is scheduled with the first available surgeon — giving the patient choice of location based on their geographic preference — creating incentive for physicians to open their schedules.
"Each quarter the nurse manager publishes to the entire group the number of patient consults, the number of patients that went to nonoperative care such as rehab or anesthesia, and the number of patients that went to the surgical side," said Sean Grady, MD, chair of the department of neurosurgery and medical director of the neuroscience service line at Penn Medicine. "Everybody sees where every patient is going."
"When everything's transparent, everyone can see that they are getting a fair shake," Dr. Grady said. "Our referring physicians are incredibly happy and believe this is the best initiative that they've seen in the health system. Our patients are happy as well. We’re able to quickly get them scheduled for top-notch, integrated care. It's been wildly successful."
The program has been in place for more than 18 months, receiving more than 13,000 spine consult orders and scheduling over 12,000 spine appointments. Due to its success, Penn Medicine — which features a collaboration of employed and private practice physicians — has officially adopted the spine access center as a permanent offering across the four spine departments.