A Videoconferencing Healthcare Delivery Model
The Integrative Pain Center of Arizona (IPCA) is participating in a demonstration project of an evidence-based, videoconferencing healthcare delivery model designed to maximize primary care physicians’ ability to care for complex chronic pain patients by linking them to pain medicine specialists. The original program, Project Extension for Community Healthcare Outcomes (Project ECHO™), was developed by the University of New Mexico to establish “communities of practice” and build primary care providers’ expertise, improve patients’ access to specialty care, and improve retention of primary care providers in isolated and/or underserved communities. Since its inception in 2004, Project ECHO™ has been demonstrated to be a low-cost, replicable intervention that has been expanded to address 11 different disease conditions, including chronic pain and headache management.
IPCA and its partner, Community Health Center, Inc. (CHC), will conduct the first Project ECHO™ replication project in Arizona and Connecticut. Our innovation is to provide e-consult and e-grand rounds consultations from a freestanding, unaffiliated, outpatient, interdisciplinary pain medicine clinic to primary care providers located in Tucson and throughout the state of Connecticut to make expert help more available and less costly. This model also benefits specialty practices by enlarging their scope of practice and adding a new source of income. Furthermore, while the clinical impact of Project ECHO™ has been documented for, less is known about the operational and financial impact of the program. Accordingly, the CHC-IPCA ECHO Arizona Pain Program will evaluate the impact of Project ECHO™ on healthcare costs and utilization, among other patient and provider outcomes. While the current project focuses on treatment of pain, it is part of a larger project designed to provide access to quality specialty care at lower cost for a variety of chronic or complex illnesses. The program aims to decrease the cost of care and improve the competitiveness of small- and medium-sized private practice primary care and specialty clinics. We have funding for the first six months of the project and we seek matching funds in order to conduct the project one full year.
In the existing model of care, the patient is referred by their primary care physician to a specialist for help with complex or chronic illness care. This system has a number of drawbacks that adversely affect cost of care, access to quality care, and the primary care physician’s ability to succeed in the medical home role, such as:
- Patients may not be able to physically get to the specialty office (e.g., travel distance, disability, insurance limitations on specialist consultations, etc.);
- Synergy among providers caring for the patient is very difficult to achieve without laborious and multiple phone conversations between individual providers because of poor communication infrastructure;
- Providers have little financial incentive to collaborate on treatment plans, leading to fragmented and sometimes contradictory care;
- There is little opportunity for primary care providers to improve their own knowledge and skills regarding management of complex and chronic conditions in the standard model; and
- Duplication of diagnostic efforts because of coordination and communication deficiencies, which increases costs to the patient and healthcare system.
Wide variations in care among primary care providers exist nationwide, challenging the notion that doctors and hospital provide consistently high quality care.# Despite the need for innovation in healthcare delivery, however, primary care and specialist providers face significant barriers to engage in quality improvement efforts. Smaller private practices may lack the resources to participate in quality-based initiatives that would allow them to participate in savings sharing agreements. Moreover, it is becoming increasingly difficult for specialists to fund private practices on the basis of clinical revenue from face-to-face encounters with patients. The CHC-IPCA ECHO Arizona Pain Program represents an opportunity to reduce variations in the quality of chronic pain treatment and facilitate meaningful integration of national specialty and primary care evidence-based guidelines and recommendations into daily practice.
Realizing that much of the actual care and care coordination can be delivered through the primary care provider office − provided expert input is available – the Project ECHO™ program implements a “virtual consultation with a panel of experts” model. In New Mexico, the program has demonstrated improved efficiencies, including improved care quality and decreased administrative overhead. While the program targets rural practices, it has also been shown to be effective in supporting urban practices as well. The CHC-IPCA ECHO Arizona Pain Program will replicate this model by connecting primary care providers in Tucson and Connecticut to chronic pain experts in Tucson, who will provide them with educational and consultative resources. These “back room” specialists will enable primary care providers to manage complex patients within their practices and stop the cycle of fragmented referrals and substandard care that so many chronic pain patients experience.
The CHC-IPCA ECHO Arizona pain program
The primary investigator of the CHC-IPCA ECHO Arizona Pain Program is Daren Anderson, MD, of CHC. This program, which is the first of its kind in Arizona, will set the foundation for negotiation with AHCCCS and other Arizona health plans for a larger, similar program that will reach out to private practices across the state of Arizona.
The CHC-IPCA ECHO Arizona Pain Program will run for one year, collecting outcomes data on a variety of domains on participating primary care clinics, with control primary care clinics included for comparison. The program consists of two levels of support for primary care providers: for simpler patients there is an e-consult with an expert arm. For more complex patients, e-grand rounds will be held during weekly two-hour conferences in which primary care providers will present complex or difficult pain cases through a web conference format to a panel of IPCA experts. Management advice will be given and follow up e-meetings or consults will be scheduled. The patients will be followed at intervals over the year at future web rounds or e-follow up with the same IPCA expert team to monitor progress and adjust management plans. In addition, a 15-minute didactic presentation will be provided at each e-grand rounds to instruct primary care providers on specific issues related to chronic pain, such as behavioral health and pharmacological options.
This program not intended to replace specialty consultation services.
Benefits of the CHC-IPCA ECHO Arizona Pain Program
Based on the literature and IPCA’s observations of service overutilization related to treating pain in Southern Arizona:
We anticipate a decrease in:
- Overuse or misuse of specialty referral services;
- Ineffective surgery;
- Unnecessary imaging and other 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 outright unnecessary care.
We anticipate an increase in:
- Contextually appropriate care planning (i.e., care plans that take the social and psychological context of the patient’s life into account);
- Appropriate specialty consultation (particularly in the area of behavioral health);
- Health plan coverage of behavioral health and coordination of care; and
- Patient satisfaction .
Patients will benefit from the CHC-IPCA ECHO Arizona Pain Program by having more timely access to better and cheaper care. Practitioners will benefit from better resource utilization, less unnecessary care, healthier and patients. These are improvements that a primary care practice or a specialty practice can leverage for cost savings sharing with a health plan. It also may increase the competitiveness of independent private practices and ensure long-term sustainability. Overall, the community will benefit by the proliferation of innovative programs such as the CHC-IPCA ECHO Arizona Pain Program that help cap the rise in healthcare costs.