Integrative Pain Center of Arizona’s (IPCA’s) Multidisciplinary Rounds (MDR) Program leverages existing medical resources to address six critical shortcomings in our health care system; shortcomings which drive high cost of care and which lead to lower quality of health care in Southern Arizona and across America:
- Lack of coordination among providers: Fragmentation of medical evaluations and services is a well-known deficiency of the American health care system.,, Overutilization and poor adherence to treatment are but two of the consequences. The core of MDR is careplan coordination among providers and with the patient and family.
- Overutilization of diagnostic, medical, and procedural services: MDR 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 care.
- 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.”
- Misdiagnosis of psychological conditions that drive unhealthy behavior and cause pain: IPCA’s experience with MDR 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 MDR rounds are aware of the DSM V diagnostic category that describes the psychological states that drive pain complaints: the Somatic Symptom Disorders. Patients with psychological pain are usually misdiagnosed with non-existent physical ailments and are referred for inappropriate, ineffective, and costly medical treatments. The IPCA MDR 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 MDR.
- Failure to prevent progression to chronic illness: Because primary care providers rarely use measures of patient function to assess disease, 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.” MDR 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 survey 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 at 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.” MDR programs provide a vehicle for combating burnout by restoring control to primary care providers, by hassle reduction, and by increasing provider engagement and learning.
There are many times when care coordination models currently in use, such as e-referral and one-on-one care coordination (for example, a nurse phone call with a patient), will not suffice. These methods do not support optimal decision making, prioritization of care, patient engagement or assignment of roles to caregivers. We believe that the MDR process is worthy of study because it addresses the shortcomings of existing models and it is a scalable, transferrable, efficient, and low cost solution to control health care costs and provide high quality care for chronic illness. Outcomes data on the MDR process are needed to motivate payment reformers to find a means of funding the MDR process; the MDR process and MDR capable programs are rare and will remain so unless our reimbursement system changes to fund care management of this type. Painful chronic illness provides a good starting point for study of the MDR/team conference model. Because IPCA operates a mature MDR program for painful chronic illness, we are well-positioned to develop outcomes data. Because IPCA is committed to positive health care system change, we seek to develop the data: we seek grant funding to support feasibility testing of MDR for a two-year period to assess MDR’s impact on patient outcomes, patient and provider satisfaction and compliance, and total cost of care.
Through MDR, IPCA seeks to:
- Create a customized community of care around each patient, including the patient
- Engage the community in contextually appropriate, patient-centered care planning that includes clear and patient-specific outcomes measures
- Re-center treatment of chronic disease around the patient’s goals
- Improve patient adherence to treatment plans
- Improve health care provider adherence to treatment plans
- Hold providers accountable for outcomes of care
- 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 transferrable to other high impact chronic disease states.
MDR aligns with the Institute of Medicine’s call for a “new professionalism,” which “applies throughout health care and wellness and…emphasizes cross-disciplinary responsibilities and accountability to achieve improved outcomes.” The MDR program is a behavioral health augmented team conference that can be described as “transdisciplinary health care,” an approach which seeks to bridge the gaps among disciplines and reduce fragmentation to achieve positive health outcomes through provider collaboration. MDR has evolved since 2002 from IPCA’s integrative, patient-centered, evidence-based, multidisciplinary team-based approach to diagnosis and treatment of subacute and chronic pain and sports injuries. MDR convenes patients’ IPCA, external medical, and allied health providers to develop treatment plans through shared decision-making centered around the patient’s goals. Through this collaboration, treatment plans become truly patient-centered, thorough, and less fragmented. Furthermore, it permits the care team to apportion management to the most advantageous provider and location (e.g., IPCA, the primary care practice, or a physical therapist). This approach enables IPCA to optimize treatment and minimize cost of care by addressing patients’ medical, physical, psychosocial, and vocational needs. Since its inception, many external providers have expressed appreciation and excitement after participating in MDR and state that it was a valuable – and often, novel – experience.
Patients discussed at MDR are people in the community who have been evaluated as patients at IPCA. Patients are recommended for the multidisciplinary rounds by an IPCA provider when the patient’s IPCA medical intake, an outside provider, or a poor response to initial treatment suggests the need for behavioral pain medicine evaluation and/or for better coordination of care. A behavioral pain medicine evaluation usually precedes MDR presentation, and the behavioral medicine is evaluation is accomplished before the first team conference. This evaluation includes the use of validated testing and interview protocols to assess mental health, personality, cognitive, cultural, and environmental factors plus patient expectations and goals for treatment. This is crucial information because all these factors influence a patient’s response to illness and engagement in pursuing better health. The MDR team conference gives patients’ multiple providers the opportunity to hear different perspectives on the patient’s condition, to clarify and align the patient’s goals with careteam goals, and to plan treatment together. Often, medications (especially opioids), behavioral pain management treatments (e.g., cognitive behavioral therapy), surgical procedures, or physical rehabilitation are not initiated until MDR occurs. This underscores the value IPCA places on its MDR program.
As Walmart recently discovered, the likelihood of surgical intervention declines significantly if a patient receives a second opinion from a third-party provider.3, The MDR program helps to reduce overutilization by involving the entire care team and the patient in a unified treatment plan that yields the most benefit for the patient and by holding participants accountable to the team for good outcomes. Within MDR, providers discuss the results of IPCA’s behavioral medicine evaluation, identifying patients whose pain is not primarily due to a medical condition as well as those at risk for developing chronic pain due to coexisting medical/psychological conditions. MDR unites the care team around the need to treat these behavioral and mental health diagnoses appropriately. Finally, MDR teaches participating external providers the principles of functional evaluation and screening patients for psychological risk factors for chronicity.
Patients may be re-presented at intervals of 2-6 months to track outcomes and to adjust the treatment plan accordingly. Following initial MDR, a lead provider is assigned to the task of communicating MDR discussion to the patient/family and on serving as the link between careteam and patient/family, and this is crucial to engaging the patient. The role of link may be assigned to a physical therapist, social worker, primary care provider, or complimentary/alternative medicine provider – and often this role will shift to providers in the wellness industry (personal trainers, massage therapists, chiropractors, etc) as a patient leaves the “sick care system” for the wellness system.
Recruitment of Providers and Participation to Date
Currently, MDR is held twice a month. Six patients are discussed for ten to 15 minutes each during the hour and a half-long session. Patients’ providers are contacted and invited to join IPCA in the discussion and determination of patients’ treatment plans about one month in advance of the session. The participation of the primary care provider is mandatory in most cases because patient compliance with the treatment plan depends on primary care understanding, buy-in, and support. All external providers are encouraged to participate, and all are sent a summary of their patients’ care for the painful illness. The summary may include a high-level behavioral evaluation and description of available imaging, physical therapy, and other relevant information. Following MDR, providers are faxed a summary of the careplan generated at MDR for their records. Participating providers are also asked to take a short internet-based survey of their experiences with MDR to help IPCA improve the program. In March 2013, IPCA began piloting the effects of offering a small compensation on provider survey participation rates.
We began tracking participation data for the external providers who were invited to MDR in August 2012, when we hired a part-time project coordinator for MDR to do this work. . The table below illustrates the level of external provider participation in MDR from August 24, 2012 to February 8, 2013. “Participation” is defined as “external provider attending the rounds presentation of the provider’s patient (typically 5-10 min total time commitment) by telephone or in person”.
Barriers to Successful Program Implementation
IPCA has integrated MDR into its practice since 2002. While MDR is a priority at IPCA, the program faces significant challenges to full implementation, as well as its ability to assess its impact on patient outcomes and total cost of care. These include:
Barriers of program implementation and management
- External providers’ schedules (particularly among primary care providers) are often very tight and scheduled far in advance, so they are not free on the suggested particular day and/or time. Note that overall, 60% of external providers invited to participate decline.
- Project coordination costs are not reimbursed and must be covered fully by IPCA.
- External providers’ participation is not reimbursed by insurance, and IPCA’s providers’ time for MDR is also often not covered. Subsequently, at IPCA, MDR is subsidized by patient revenue.
- With the current limitations, IPCA is only able to allocate three hours per month to MDR. Delaying or rescheduling MDR can defer the development of patients’ pain treatment plans, which burdens patients and risks their leaving IPCA.
- Patient records from external providers are incomplete and/or missing, making it difficult to assess patients’ treatment as a result of MDR, and calculate costs/savings and outcomes.
- Many providers do not understand that MDR is the focal point of team-based care. They are unaccustomed to team-based health care and many do not understand the purpose of MDR or their role in the discussion.
- Few external providers understand that a behavioral health evaluation is crucial to understanding their patients well enough to design an appropriate treatment and wellness plan.
Based on the literature,,,, and IPCA’s observations of service over-utilization related to treating pain in Southern Arizona, we anticipate a decrease in:
- overuse or misuse of specialty referral services;
- neffective 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;
- office overhead for referral management, prior authorizations, etc.; and
- complications and patient dissatisfaction due to poorly coordinated, redundant, or unnecessary care.
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