Integrative Care Model Reduces Wait Times

Partnership at National Spine Centre streamlines triaging

Over the past several years in the city of Calgary, the number of referrals to dedicated spinal surgeons has grown exponentially.   

Six years ago, the University of Calgary, Faculty of Medicine, Division of Neurosurgery, had on file more than 4,000 faxed requests for spinal consultation spread out amongst seven overloaded surgeons.  This backlog had created a significant degree of frustration in patients, referring physicians, spinal surgeons, and the Calgary Health Region.  This was not a local phenomenon.  The prevalence of spinal complaints has overwhelmed the specialty of spinal surgery across the country.  In those offices accepting new patients, waiting times for pain-related complaints are commonly in excess of three years.

A PUBLIC/PRIVATE PARTNERSHIP
In January of 2002, the University of Calgary Spine Program moved on an initiative designed to improve both the efficiency and quality of spinal care in the Calgary Health Region.  Recognizing the fiscal restraints of a public health-care system and the predicted demand of over 70,000 new patients accessing spinal care per year for Southern Alberta alone, the program would create a public/private partnership between practitioners in a university-based practice with a number of spinal specialists from various health disciplines working in the community.

The partnership’s streamlined triage system aimed to provide rapid access to care for appropriately selected patients.  Best practices were to be followed in the clinical decision-making, and the use of objective clinical outcome tools would gauge the success or failure of treatment based on diagnostic category.  Public funding was not sought for the establishment of the community-based program. Today, fiscal independence remains a cornerstone in this initiative for two main reasons: to avoid competition with other important and expensive regional programs; and to allow the model to expand or contract in response to constraints of supply and demand.

In going forward, we carefully engaged the College of Physicians and Surgeons of Alberta, the College of Chiropractors of Alberta, Alberta Health and Wellness, the Alberta Medical Association, and the Calgary Health Region in discussions.  To date, we remain in close contact with these stakeholders to ensure that the interests of all Albertans are met or exceeded.

From November of 2002 through March of 2003, the project’s initial phase addressed the training and implementation of the triaging and assessment process.  A small team consisting of a chiropractor, a physiotherapist, a physiatrist and two neurosurgeons was assembled.  This group began working in the spinal neurosurgeons’ hospital clinics, which allowed for the chiropractor and physiotherapist to receive training on the assessment and decision-making tools used in the those practices.  Multidisciplinary care pathways for complex spinal problems were coordinated, which entailed drawing on the expertise of the physiatrist for management of the non-surgical or spinal cord injured patients.

In April of 2003, the project was expanded when three spinal surgeons and one physiatrist moved a portion of their weekly clinics from the hospital into a community-based clinic where they were shadowed by their chiropractic and physiotherapy colleagues.  Once confidence in both the process and core competencies of the team was established, the program evolved to permit chiropractors and physiotherapists to perform all of the initial intake assessments.  This transition occurred in June of that year, marking the birth of an integrated multidisciplinary spine clinic called National Spine Care (NSC).

HEIGHTENED EFFICIENCY
Following the initial patient assessment, currently performed by either a chiropractor or physiotherapist, appropriate care pathways are utilized, based on well-established best practices guidelines.  Other efficiencies in coordination of multidisciplinary care are achieved in a “rounds” format whereby the team meets on a regular basis, providing a forum to present cases and gain consensus opinion as to the most appropriate management for that patient.  Having the various health-care disciplines in close contact allows the lines of communication to remain open, which facilitates proper care.

The past several years have, as expected, seen increasing activity at NSC.  Patients who would otherwise be placed on lengthy to indefinite waiting lists through the usual referral processes are notified by telephone and in writing of the option of visiting the multidisciplinary clinic.  While the benefits of rapid access, multidisciplinary assessment, and a spectrum of medical and surgical treatments are immediately obvious, patients are advised that they might not see a physician at all during their encounter, and that not all of the costs are covered by Alberta Health and Wellness.  This is brought to their attention before the initial assessment, when patients are also informed that they may elect at any time to pursue regular referral routes.

The benefits of this partnership to the specialist have become readily apparent.  First, access for those patients truly requiring surgery has improved.  In this triage system, the number of patients receiving surgical consultation actually found to be surgical candidates approaches 90 per cent (as opposed to fewer than 20 per cent in the traditional system).  Second, a spine-focused history and physical has largely been completed by the primary physiotherapy or chiropractic assessment.  The surgeon, for example, needs only spend a dedicated half-hour with the patient, confirming the workup that has already occurred as well as going through risks and benefits of surgery, compared to the previous hour and a half formerly required to complete a history, physical examination and consent.  Accordingly, the efficiency of surgical consultation within this model shows a threefold increase.

COMPREHENSIVE SPINAL CARE
Whereas only 30 per cent of new patients presenting to NSC actually require a focused surgical consultation, 70 per cent present with spine-related health problems that are best-managed conservatively.

The scope of services available at NSC is wide. Typically, our focus is on active rehabilitation and instruction in home-based self-management strategies.  Various passive treatment modalities, including chiropractic, physiotherapy, acupuncture and massage therapy, can be effectively incorporated to improve mobility and reduce pain.  In keeping with the biopsychosocial model of care, psychology and dietary counselling services are offered to help with issues ranging from pain control, to smoking and obesity. While not offered “in-house,” partnership with Interventional Diagnostic Radiology for therapeutic and diagnostic spinal injections is ongoing.

PATIENT SATISFACTION MONITORED
Individuals receiving spinal care must have no question in their mind that they been given expert opinion and attention in a highly personalized, unrushed manner.  To this end, we continuously monitor the satisfaction of our patients.  On a 5-point scale (1 = strongly disagree, 5 = strongly agree), our patients score their satisfaction with care received at 4.4.  In addition, they mildly disagree that the cost of their assessment was a financial burden (2.5), and mildly disagree that their third-party insurance adequately offset the cost of their appointment.  Interestingly, patients remain neutral (3.0) on the time they had to wait for their appointment, which is presently averaging less than two months.
Since the inception of NSC, the efficiency of the wait lists for spinal surgery has been dramatically improved. Integrating the various health-care disciplines has streamlined the intake, diagnostic, triaging and treatment regime, effectively reducing the surgical wait list by over 70 per cent.

We anticipate that creative solutions, which call for the integration of health disciplines in a multidisciplinary setting such as NSC, will grow as an aging population places larger demands on the health-care system.