1. Spine Clinic Innovating and Spreading Better Care Andrew Friedman MD
AAPM&R Innovations in Spine Care Summit October 2, 2015

2. Strategic plan slide

4. Current State—The Problem Statement

5. Musculoskeletal Pain Costs

7. Spine Clinic Design

9. Goals of Spine Clinic Quick access for the patient
The ‘right’ care at the ‘right’ time
Evidenced based care
High patient satisfaction
Quick return to function
Win for patient, win for employer, win for payer and win for us

10. Patient Priorities 1. Reassurance no serious disease
2. Relief of symptoms
3. Rapid return to function
Patient priorities in complicated cases include management of disability claims, legal claims, ongoing symptoms, suffering

11. Evidence-based appropriate care

12. Spine Clinic Appointment Sorting
Series of questions asked of the patient
chief complaint
red flag symptoms
mechanism of injury
date of onset
previous evaluation
previous diagnostic studies
previous diagnosis
previous treatment
co-morbidities
referral for care
Each response is weighted based upon clinical relevance
Based upon the patient response as score is assigned that correlates to the clinic that the patient will be scheduled into.
0-15 Acute Spine Clinic – 60 minutes with PT and 20 minutes with MD
15+ Physical Medicine Consultation minutes with MD (no PT)

13. Next 20 minutes: PT begins treatment with Patient
Flow of visit
First 10 minutes: Flow Manager rooms patient, updates EMR. Exits and signals PT
Next 20 minutes: PT enters, completes musculoskeletal evaluation, set the agenda for the MD. Signals MD
Next 20 minutes: MD enters, PT presents to MD, MD does exam, reviews images, MD/PT/Patient come up with tx plan. MD exits and goes on to next patient
Next 20 minutes: PT begins treatment with Patient

16. Outcomes

17. The New Approach Back pain best practice Details
Same day access for patients
Concurrent visits with doctors and physical therapists
Over-the-counter pain medicine and structured follow-up
Downstream referral if red flag symptoms
Results
55% reduction in spend per episode of back pain
1/3 fewer diagnostic imaging procedures performed
67% fewer missed days of work
91% patient satisfaction
SOURCE: Fuhrmans, Vanessa. "A Novel Plan Helps Hospital Wean Itself Off Pricey Tests." The Wall Street Journal. N.p., 12 Jan Web. 04 Aug <

18. Evidence-based Imaging Lower Utilization Without Pre-authorization
Mistake-proofing
Implemented
Reduction in imaging
Headache: -23%
Low back pain: %
Sinusitis: -27%
J Am Coll Radiol 2011;8:

20. Disc Decompression 2007-2010 More Consistent Less Consistent
More Intense
Less Intense

21. The Bigger Picture

22. Stepped-Care Model
Step Two
ssssYour text here S
Step One
Step Three

23. Stepped Care
Step 1—most patients. Low-cost intervention which addresses fears and encourages return to normal function
Step 2—targets patients who need more than simple advice to resume activities. Brief structured interventions
Step 3—targets pts who require more intensive interventions including treatment of psychological illness before they can return to work/family activities

24. Stepped Care Model Requires accurate stratification
Relies on Patient Measurement
Captures greater value for complex patients
Key to population managment

25. End slide