How Clinical Navigation Can Make Spine Care Better

Spine

This article is written by Patrick Vega, M.S., a principle at Vega Healthcare, and was originally published to the Vega Healthcare blog on September 1, 2011.

Preface
The topic of "clinical navigation" has gained a wider audience, both within the healthcare community as well as in popular media.  On August 16, 2011, the Wall Street Journal published an article, "When a Doctor Isn't Enough; Nurse Navigators Help Patients Through Maze of Cancer-Treatment Decisions, Fears," by Laura Landro, Assistant Managing Editor and author of "The Informed Patient" column. While health systems, hospitals and physician practices are preparing for more integrated, patient-centered care that emphasizes ease of access, quality and satisfying experiences, care providers of back and neck pain treatment (often a dismal experience, fraught with long waits and confusion) have also benefitted from navigation that is advantageous not only for the patient but also the range of medical providers themselves.

Incidentally, spine navigation grew out of the models first originated in cancer care. Many feel that navigation is applicable to any medical condition/treatment that is longer in duration, has multiple symptoms and diagnoses, multiple providers and locations, or is often poorly coordinated.

The article below provides an overview of the key elements of navigation for spine care, now considered best practice for hospitals and spine specialists.

Nurse navigation in spine surgery
It is not uncommon that patients seeking care for back and neck pain will report a lengthy and often frustrating process of getting relief. Adult conditions are typically caused by degenerative conditions; arthritis, disc disease, misalignment or may result from acute trauma. Many will have been referred to a spine specialist by a primary care physician (PCP).  One of the challenges for PCPs is making a referral to the most clinically appropriate specialist. With exhausting caseloads and the fact that many PCPs, with the advent of hospitalists, rarely encounter spine specialists. This disconnection can result in PCPs not being current with technology and treatment options, whether surgical and non-surgical.  

When referral is required, PCPs often seek treatment options based on three criteria: access to the specialist practice within an acceptable timeline, real-time communication about the specialist's treatment plan and an acceptable level of customer service. While it is the PCP that determines the timing of referral, it is often handed to a nurse to explore options and facilitate the referral. Again, access, communication and service are the fundamental determinants of establishing a reliable specialist referral relationship.

In nearly every community the current system of intake resides exclusively in the respective spine specialist offices and is frequently dysfunctional and inefficient.  Each has their own protocols and procedures for accepting and treating referrals from medical professionals and self-referred patients. Physicians often characterize the coordination of access, evaluation and treatment as "haphazard" and poorly coordinated. It is encouraging that many medical staff and spine specialists recognize both the need and opportunities to improve service to medical professionals and self-referred patients.   

Access to spine care has long been a challenge for both the self-referred patient and professional referral source. Frequently, the first referral is made to a surgeon for consultation. It is not uncommon that scheduling an initial consult will require a wait between four to eight weeks. With greater than 85 percent of patients needing non-surgical care, patients and consulting surgeons are frequently frustrated that the patient is referred again for non-surgical care and must endure the attendant wait for another specialist. This is particularly acute in geographies where patients must wait for extended periods of time and make long drives for specialist consults only to be told that they are not a surgical candidate.  

Because of the often urgent nature of seeking pain relief (acute pain, disability, loss of function) consumers will seek the most visible, accessible and responsive provider, regardless of provider outcomes and clinical appropriateness of treatments. This predictable behavior is cautionary for both patient and spine specialist; patients may engage in treatments that are not the most effective and providers may be referred patients better served by a colleague in another spine subspecialty. The proactive spine specialist will ensure access to care is rapid and triage to treatment is expedited.

Due to the often disabling nature of back pain and its impact on social and professional life, psychosocial co-morbidities are much more prevalent in spine (depression, anxiety, chronic pain, high dose narcotic use) than joint care. Additionally, estimates are that between 5-10 percent of spine care patients have filed Worker's Compensation claims. Such claims can add administrative complexity to the challenges of clinical care.  

One of the best ways to address these deficiencies is to develop and deploy a comprehensive intake, triage and navigation (ITN) care management system. The value in care coordination lies in improving the level of access to the most clinically appropriate spine specialist in an expedited timeframe, communicating treatment paths to the patient and referring professional, and providing a truly differentiated patient experience instead of a typically dissatisfying experience filled with confusing treatment options, long waits, contradictory diagnosis and too often, re-referral to other spine specialists.

Hospital Spine Program- Access
Managing inquiries at most hospitals remains rudimentary — the process is typically just one of offering contact information (sometimes in a live call, often in a call back) for an associated spine practice with little discrimination. Often, an ill-prepared staff consults a list of specialists, provides the referral and disengages from the caller. With such a loose system, customer service, treatment revenues and the opportunity to engage with callers are, at a minimum compromised and potentially even damaged.

Institutions with all faculty staff may be more amenable to implementing ITN systems because competitive pressures can be less intense.  For the all private-practice staff, challenges in developing and deploying centralized ITN often occur because their respective interests are not fully aligned. The typical challenges for hospitals and physician practices associated with access and care include:

•    Patients enduring long waits, ill-defined paths of care, successive dissatisfying experiences and continued pain and disability
•    High levels of patient non-compliance and appointment no-shows
•    Inappropriate utilization of spine resources; i.e.- non-operative patients being evaluated and managed by surgeon
•    Lack of coordinated care once patient is in treatment
•    Poor communication about current and prospective interventions
•    Patients and primary medical professionals will follow the path of fast access (even if not the most clinically appropriate or effective)
•    Spine out-migration / leakage from the hospital system

The most effective antidote to these challenges is a patient-centered model of ITN that ensures patients are quickly directed to the most effective care modalities, and to spine specialists most qualified to treat their unique symptoms, whether it be surgery, physical therapy, Physiatry (PM&R) or pain management. The goal of an effective ITN program is to bring hospital and spine specialist ownership and sequential management of typically inefficient, fragmented or non-existent systems of intake.  

An operational ITN system supports and promotes the patient experience, spine specialists, referring physicians and professional referral sources (Worker's Compensation, employer and payors). Specifically, an effective ITN process:
•    Places a priority on customer service to the patient and referring professional
•    Provides expedited evaluation and treatment by the most clinically appropriate spine specialist
•    Maximizes quality of face-to-face time with spine specialists
•    Results in better clinical outcomes
•    Positions the hospital to capture incremental ancillary services

Any specific marketing and educational initiative for spine programming or services should be accompanied by a well-conceived centralized system of ITN, characterized by rapid access to staff that can readily engage callers into a process of recording symptoms and history and linking them to services that match the caller's needs. A vanity phone number- 1 800-BACK PAIN, can add an element of increased identity and be easily remembered.  

In a fully-developed ITN system, the first stage is the referral from primary care, patient self-referral and conceivably other spine specialists to a hospital or outpatient based ITN system. The ITN system's advantages include: immediate response to callers, a centralized collection of clinical and demographic information, and administrative support for referring offices and self-referred patients. The fundamental value of the intake and medical triage lies in the evaluation of the patient's presenting symptoms by a spine expert, matching the patient with the most clinically appropriate spine specialist and expediting the scheduling. ITN also provides a care coordination function, ensuring thorough communication to referring and treating physicians or to the patient.

Additionally, the most sophisticated ITN systems also capture surgical and non-surgical outcomes data, an emerging requirement and differentiator.  This data will increasingly be used to demonstrate quality of care, improve contract pricing and communicate value directly to patients and referring physicians.

Nurse Navigation & Medical Triage
Like cancer care, spine nurse navigation is the "glue" of care coordination over a complete episode of care. The role of the nurse navigator is to manage the patient experience: collection of treatment information, coordinate physician review of the medical history, provide patient education, facilitate triage and scheduling with spine specialists and supporting the provider team by previewing treatments and answering questions with the patient and communicating the patient status in real time with the referring physician.  In essence, the nurse navigator, as a patient advocate, creates and maintains critical linkages between the clinical, administrative and customer service elements of care, adding value to each step in the process and enhancing the effectiveness of each treatment and spine specialist.

The function of medical triage is most often performed by a physician (spine surgeon, physiatrist) or by mutual agreement, a nurse practitioner or physician assistant. The selection of which licensed staff to use in the role is dependent on the organization's needs. The triage staff must be competent in evaluation and selection of an initial course of care. In the circumstance of using a non-physician staff it is critical that the staff use criteria developed by all participating spine specialists.

In some cases, when non-surgical options have proven not adequately effective, referral of the patient for surgical care is indicated. Those patients ultimately appropriate for surgical care are carefully evaluated before a surgical procedure occurs. Execution of the comprehensive ITN system ensures that those patients likely to respond to non-surgical care are referred to such.  

A Caveat, before promoting
One caution — promotion of spine services will drive inquiries. Hospitals should avoid marketing activities until an accessible, comprehensive and highly functional system for managing customer response is established and fully operational. It is not uncommon that a hospital will squander marketing dollars, disappoint and frustrate professional and consumer callers and actually hurt the reputation of the hospital and affiliated physicians by being ill-prepared. The attractions of an easy to use intake, triage and navigation system for those seeking care for back and neck pain are so compelling that the system must be carefully developed, implemented and maintained.

Summary
Clinical navigation is a powerful and effective tool, applicable to a wide variety of medical conditions that engages both the patient and their medical providers. Intake, triage and navigation provides immediate access, response and guidance through coordinated and specialized spine care, generating significant clinical and customer service benefits to patients and medical professionals.

© Vega Healthcare 2011

Patrick Vega, M.S., is Principal for Vega Healthcare, a consulting firm supporting hospitals and healthcare organizations in Spine, Neurosciences, Musculoskeletal services and Orthopedics, in the areas of:

•    Assessment, Strategic Planning
•    Business Development
•    Center of Excellence Development

Contact:  
pvega@vegahealthcare.com

301 730-2595
vegahealthcare.com


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