Description of the Integrative Pain Center of Arizona’s TDR® program:
Why healthcare providers should attend
Introduction:TDR® is IPCA’s unique clinical care coordination program. TDR® is the primary reason that IPCA has been awarded Center of Excellence status by the American Pain Society, and is now in its second decade of operation. We have been quietly achieving success in preventing and eliminating chronic pain, patient by patient, operating in the shadow of the volume driven procedurally based programs as we await the change to value-based health care. TDR® brings our patients’ providers together to hear the assessment of the IPCA health psychologist, share information, plan treatment in a team-based decision making format, and assign tasks related to careplan execution to the members of the careteam likely to have the most impact on patient adherence. 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. The process is called transdisciplinary healthcare, the goals of which are summarized below. A sense of shared accountability to best outcomes is the most important result. At IPCA, patients are screened at their medical intake consultation and triaged to the TDR® program when psychosocial factors, medical complexity, and/or treatment team factors (eg: multiple poorly integrated providers, polypharmacy, overprescribing) predict failure of siloed, monodisciplinary care.
The goals of the program can be summarized as follows:
- Help providers positively impact of outcomes of care without added risk or effort
- Reduce provider, especially PCP, workload (more efficient use of ancillary health resources, less duplication of effort, clarity of roles)
- Create a customized community of care around each patient
- Engage this community in
- Care planning that is contextually appropriate and patient-centered
- Developing clear and patient-specific outcomes measures
- Assigning/accepting accountability for achieving the outcomes
- Create transparency in decision making
- Re-center treatment of disease around the patient’s goals
- Improve patient adherence to treatment plans
- Improve health care provider ability to execute
- 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.
- Improve care outcomes, through all of the above
Based on the literature, 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.
Details: 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., 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.
- 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 care. As Walmart recently discovered, the likelihood of surgical intervention declines significantly if a patient receives a second opinion from a third-party provider.3,
- 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.” 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 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 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 are not yet using measures of patient function to assess disease, and because it is unusual in primary care to assess psychological risk factors predictive of progression to chronicity, primary care clinics 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 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.” 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.