This is just filler content
TDR® brings the patients providers together to hear the assessment of the IPCA health
psychologist, share information, and plan treatment in a team-based decision making
format. The IPCA medical provider who has evaluated the patient, the IPCA health
psychologist who has evaluated the patient, the primary care provider, mental health
providers treating the patient, specialists engaged in treating the painful condition,
and allied health providers from physical therapy, Chinese medicine, etc. attend in
person or telephonically. Transdisciplinary healthcare delivery is different from
interdisciplinary or multidisciplinary, as the linked slide set explains:
an integrative process which synthesizes and extends discipline-specific
theories/concepts/methods to create new models/language to address a common problem
(pain, in our case).
At TDR® the care-team creates a clear picture of the patient and devise a treatment plan that fits the patient’s circumstances. We clarify which members of the treatment team have responsibility for communicating the treatment plan and carrying out next steps. The goals can be summarized as follows:
- Create a customized community of care around each patient
- Engage this community in contextually appropriate, patient-centered care planning that includes clear and patient-specific outcomes measures
- Re-center treatment of disease around the patient’s goals
- Improve patient adherence to treatment plans
- Improve health care provider ability to execute treatment plans
- Help providers positively impact of outcomes of care without added risk or effort
- Reduce provider workload (more efficient use of ancillary health resources, less duplication of effort, clarity of roles)
- Forge new links among Southern Arizona health care providers and ancillary care/community health services.
- Educate the primary care community on using specialty and ancillary health services more efficiently and effectively, particularly behavioral health services, physical therapy services, and community/home health services.
- Reduce provider burnout
- Define a template for the management of quality and total cost of care that is scalable and transferable to other high impact chronic disease states.
Based on the literature12,13,14,15,16 and IPCA’s observations of service over-utilization related to treating pain in Southern Arizona, TDR® reduces:
- Complications and patient dissatisfaction due to poorly coordinated, redundant, or unnecessary care.
- Overuse or misuse of specialty referral services;
- Ineffective surgery;
- Unnecessary imaging and other costly laboratory services;
- Ineffective procedural services;
- Excessive or inappropriate medication prescribing;
- Hospital readmission rates for pain after surgery;
- Emergency room visits for pain complaints;
- Medical practice overhead for referral management, prior authorizations, etc. Bennet Davis 3
- Barnett ML, Song Z, & Landon BE. (2012). Trends in physician referrals in the United States, 1999-2009. Archives of Internal Medicine;172(2):163-170.
- Institute of Medicine Committee on Quality of Health Care in America. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.
- Bodenheimer T, M.D Coordinating Care — A Perilous Journey through the Health Care System N Engl J Med 2008; 358:1064-1071
- Binder L. (17 October 2012). What we can learn from Walmart: How our healthcare system can save lives and dollars. Forbes Magazine. Retrieved online March 11, 2013 from http://www.forbes.com/sites/leahbinder/2012/10/17/what-we-can-learn-from-walmart-how-our- healthcare-system-can-save-lives-and-dollars/.
- Klepper B. (18 October 2012). Walmart moves health care forward again. The Health Care Blog. Retrieved online March 11, 2013 from http://thehealthcareblog.com/blog/2012/10/18/walmart-moves-health-care-forward-again/.
- David M. Cutler, Ph.D., and Wendy Everett, Sc.D. Thinking Outside the Pillbox — Medication Adherence as a Priority for Health Care Reform N Engl J Med 2010; 362:1553-1555 April
- Diagnostic and Statistical Manual V American Psychiatric Association. 2012 http://www.dsm5.org/Pages/Default.aspx
- Turner JA, LeResche L, Von Korff M, & Ehrlich K. (1998). Back pain in primary care: Patient characteristics, content on initial visit, and short term outcomes. Spine; 23:463-469.
- Pham HH, O’Malley AS, Bach PB, Saiontz-Martinez C, et al. (2009). Primary care physicians’ links to other physicians through Medicare patients: The scope of care coordination. Annals of Internal Medicine;150(4):236-242.
- Tait D. Shanafelt, MD; Sonja Boone, MD; Litjen Tan, PhD; et al Burnout and Satisfaction With Work- Life Balance Among US Physicians Relative to the General US Population Arch Intern Med. 2012;172(18):1377-1385.
- Paul Griner, MD, The Power of Patient Stories: Learning Moments in Medicine
- Parker SL, Shau DN, Mendenhall SK, & McGirt MJ. (2012). Factors influencing 2-year health care costs in patients undergoing revision lumbar fusion procedures. Journal of Neurosurgery: Spine;16(4):323-8.
- Becker A, Held H, Redaelli M, Strauch K, et al. (2010). Low back pain in primary care: Costs of care and prediction of future health care utilization. Spine;35(18):1714-20.
- Hendee WR. Becker GJ, Borgstede JP, Bosma J, et al. (2010). Addressing overutilization in medical imaging. Radiology;257(1):240-5.
- White LA, Robinson RL, Yu AP, Kaltenboeck A, et al. (2009). Comparison of health care use and costs in newly diagnosed and established patients with fibromyalgia. Journal of Pain;10(9):976-83. 16Hawkins K, Wang S, & Rupnow M. (2008). Direct cost burden among insured US employees with migraine. Headache;48(4):553-63.
TDR® efficiently addresses 10 critical breakdowns in our healthcare system
- Lack of coordination among providers: Fragmentation of medical evaluations and services is a well-known deficiency of the American health care system.1,2,3
- Overutilization and poor adherence to treatment are but two of the consequences. The core of TDR® is careplan coordination among providers and with the patient and family. Bennet Davis 12 Overutilization of diagnostic, medical, and procedural services: TDR® promotes timely information exchange among primary care, specialist providers, and the patient; clarity of treatment goals; role coordination among a patient’s multiple providers; and accountability of each provider to agreed-upon outcomes. This in turn reduces duplication of effort, prevents conflicting treatment efforts, and also improves provider adherence to evidence based, patient centered principles of care4 . As Walmart recently discovered, the likelihood of surgical intervention declines significantly if a patient receives a second opinion from a third-party provider.3,5
- Poor patient adherence to treatment plans: Coordination of care improves patient adherence: “The existing movements toward deployment of HIT, improved coordination of care, and payment reform together create a desire and an infrastructure for improving health outcomes through improved adherence.”6 After TDR® team conferences patients understand that the careplan is the product of a team effort, they are more likely to hear a consistent message from their entire care team along with better reasons why the careplan will benefit them and they – all three are key factors in gaining buy in and compliance.
- Lack of transparency of medical decision making: Team based decision making forces articulation of medical reasoning and we make sure to capture this in a format that is accessible to health plans, patients, and employers.
- Lack of “patient-centered” decision making: team based decision-making introduces multiple perspectives on the patient into the decision making process, including the input of the behavioral health evaluator who leads the TDR® rounds and who has evaluated the patient for the purpose of providing the careteam with a details understanding of who the patient is and what the patient wants. Furthermore, team based decision making opens medical decision making to the scrutiny of team members and this helps to keep the patient’s interests at the center of the careplan.
- Misdiagnosis of psychological conditions that drive unhealthy behavior and cause pain: IPCA’s experience with TDR® has demonstrated that many primary care providers and specialists are often unable to discern when unhealthy behavior and pain complaints are driven by psychosocial factors. For example, few primary care providers attending TDR® rounds are aware of the DSM V diagnostic category that describes the psychological states that drive pain complaints: the Somatic Symptom Disorders7 . Patients with psychological pain are usually misdiagnosed with non-existent physical ailments and are referred for inappropriate, ineffective, and costly medical treatments. The IPCA TDR® program includes behavioral health assessment to define for the care team any psychosocial drivers of illness. This assessment is used to guide treatment planning in TDR®.
- Failure to prevent progression to chronic illness: Because primary care providers rarely use measures of patient function to assess disease8,9 and because they rarely assess psychological risk factors predictive of progression to chronicity, primary care providers often under-diagnose the severity of the condition and fail to initiate treatment that might prevent the patient from becoming a “chronically ill patient.” TDR® programs re-focus healthcare on patient physical and psychological function. This is crucial to early intervention and prevention of chronicity.
- Provider burnout: A 2012 national survey10 showed that 45.8% of physicians were experiencing at least 1 symptom of burnout: loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment; and concluded that “Burnout is more common among physicians than among other US workers. Physicians in specialties Bennet Davis 2at the front line of care access (this includes primary care providers) seem to be at greatest risk.” Physicians are advised to “participate actively in health reforms that will return a greater level of control to physicians and their patients. Reorganizing primary care practices to allow more time for complex patients and recognition by insurers that excessive hassle is bad for patients and physician are also vital.”11 TDR® programs provide a vehicle for combating burnout by restoring control to primary care providers, by hassle reduction, and by increasing provider engagement and learning.
- Knowledge stagnation: TDR® provides a problem based learning format that exposes participants to new medical information and new problem solving methods as PCPs interact with expert specialists. For example, current medical providers are not trained in assessing severity of illness using measures of function – even though this is the standard of the world over. TDR® demonstrates and models the function base medicine concept, as input from physical therapists and behavioral specialists on a patient’s level of function is introduced into the discussion.
- Underutilization of ancillary health providers: Physical therapists and other ‘Allied health providers” have intimate knowledge of patients functional limits in progress or lack thereof if this really find its way into medical decision-making in the medical specialist or primary care world. TDR® provides a forum to correct this.