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 such as arthritis, disc disease, or misalignment, or may result from acute trauma. Many will have been referred to a spine specialist by a primary care physician (PCP). However, one of the challenges for PCPs is making a referral to the most clinically appropriate specialist. With exhausting caseloads and with the advent of hospitalists, many PCPs rarely encounter spine specialists. This disconnection can result in PCPs not being current with technology and treatment options, whether surgical or non-surgical, which can unfortunately compromise the care ultimately received by the patient.
When referral is required, PCPs often seek treatment options based on three criteria:
1. Access to the specialist practice within an acceptable timeline
2. Real-time communication about the specialist’s treatment plan
3. An high level of customer service
While it is the PCP who determines the timing of referral, this task is often handed-off 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, current systems of intake reside exclusively in the respective spine specialist offices and are frequently dysfunctional and inefficient. Each has their own protocols for accepting and treating referrals from medical professionals and self-referred patients. Referring 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 the need to improve service to medical professionals and self-referred patients. Corazon believes that opportunities for spine program improvements can begin here – before the patient even walks into the office.
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 lengthy wait between 4 – 8 weeks. With greater than 85% of patients needing non-surgical care, patients and consulting surgeons are frequently frustrated that the patient is re-referred for non-surgical care and must endure another wait for a specialist. This is particularly acute in geographies where patients must wait for extended periods and make long drives for initial 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. Corazon’s national experience reveals that this predictable behavior is instructive for both patient and spine specialist -- patients may commit to treatments that are not the most effective and providers may be referred patients better served by a colleague in another spine subspecialty. Only the best and most proactive spine specialists will ensure rapid access to care and triage to treatment by the right specialist at the right time...which may mean referring the patient elsewhere, though this approach can become a dissatisfier.
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, for example. Additionally, estimates are that between 5-10% of spine care patients have filed Worker’s Compensation claims, which can add administrative complexity to the challenges of clinical care.
Corazon believes that one of the most effective approaches to address these common barriers is to develop and deploy a comprehensive intake, triage, and navigation (ITN) care management system. Indeed, the greatest 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 remarkable 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 follow up. Often, an ill-prepared staff consults a list of specialists, provides the referral, and disengages from the caller. With such an uncoordinated system customer service, treatment and patient engagement are 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 the surgeon)
• Lack of coordinated care once patient is in treatment
• Poor communication about current and prospective interventions
• Patients and PCPs will follow the path of fast access (even if not the most clinically-appropriate or effective)
• Spine out-migration / leakage from the hospital system
Triage & Navigation
As the most effective antidote to these challenges, Corazon often recommends 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), imaging, Chiropractic or pain management. The goal of an effective ITN program is to bring hospital and spine specialist ownership and sequential management of a typically inefficient, fragmented, or non-existent system 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
ITN also provides a care coordination function, ensuring thorough communication to referring and treating physician or to the patient. 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 defined process and link them to services that match their needs. A vanity phone number (i.e., 1 800-BACK PAIN) can add an element of increased identity and will be easily remembered.
The fundamental value of 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.
Additionally, the most sophisticated ITN systems also capture surgical and non-surgical outcomes data, an emerging requirement and clear differentiator. This data can increasingly be used to substantiate quality of care, improve contract pricing, and communicate value directly to patients and referring physicians.
Nurse Navigation & Medical Triage
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 through:
• Collection of treatment information
• Coordination of physician review of the medical history
• Providing patient education
• Facilitating triage and scheduling with spine specialists
• Supporting the provider team by previewing treatments and answering patient questions
• Communicating patient status in real time with referring physicians
The function of medical triage is most often performed by a physician (spine surgeon, physiatrist) or, by agreement, a Chiropractor, Nurse Practitioner or Physician Assistant. The selection of which licensed staff to deploy 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 consensus criteria developed by all participating spine specialists.
In some cases, when non-surgical options have not proven 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 potentially damage 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. With the advent of at-risk models such as mandatory bundled payment, (Comprehensive Care for Joint Replacement [CJR]), highly-coordinated care becomes even more important to ensure ease of access, effectiveness, efficiency, and to achieve improved outcomes. Intake, triage, and navigation provides immediate access, response, and guidance through coordinated and specialized spine care, generating significant clinical and customer service benefits to both patients and medical professionals. And while improved care and outcomes is the goal of any service enhancement, the benefits to this effort can have far-reaching and positive implications clinically, operationally, and financially. As the healthcare industry continues to evolve, improvements to varied elements of the service continuum can only better-positon a program for the future.
Patrick Vega is a Vice President at Corazon, Inc., a national leader in strategic program development for the heart, vascular, neuro, and orthopedic specialties. Corazon offers a full continuum of consulting, software solution, recruitment, and interim management services for hospitals, health systems, and practices of all sizes across the country and in Canada. To learn more, visit www.corazoninc.com or call 412-364-8200. To reach the author, email pvega@corazoninc.com.
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