A Novel, Clinic-Based Approach to Address Patients with Complex Back Pain in a Veterans Administration Hospital: The Back Pain Home

Jul 20, 2018, 16:25 PM by Peter Barelka, MD

Over the past several decades, we have witnessed the care of patients with spine-related pain growing in complexity. There is a tremendous expansion in the modalities available to the interventional pain, neurosurgical, physical medicine, and rehabilitation (PM&R), as well as psychological specialties for the treatment of chronic painful conditions of the spine. Although the additional resources are welcome developments, they have a significant downside. When commonly employed treatment plans are spread out concurrently over several specialties, we can see a wasteful overlap of resources. The multiple processing of initial intakes, imaging, electromyography (EMG), physical therapy (PT), and surgical or interventional pain procedures consume significant clinic capital. This problem becomes more pronounced in patients with complicated clinical pictures as they become disproportionate utilizers of care.

To address this problem and streamline care, involved providers at the Veterans Administration (VA) Hospital in Palo Alto, California, created a new clinical environment: the Spine Clinic. We staff our clinic with attending-level physicians from the pain medicine, neurosurgery, and PM&R specialties. We also have providers from PT and psychological specialties. During an evaluation at the Spine Clinic, the patient presents with all providers simultaneously. Prior to seeing the patient, clinicians review the patient's history, prior imaging, EMGs, physical exams, and psychological demeanor from prior documentation, when available.

“During an evaluation at the Spine Clinic, the patient presents with all providers simultaneously.”

In selecting patients for the Spine Clinic, we have centered on treating patients whose high degree of spinal pathology requires frequent provider input. We chose those patients for several reasons, one of which was to preserve the standard tiered system of managing spine-related pain. This system relies on primary care providers to spearhead the delivery of care through the consult process. We recognize the effectiveness of this system in managing most patient complaints and therefore chose not to alter it. Rather, Spine Clinic patients are selected by providers themselves from a cadre of pre-existing clinic patients. Participation in the Spine Clinic requires no litmus test, although typical Spine Clinic patients have had significant previous interactions with one of our involved services and failed to make meaningful progress with their condition. While there are no direct consultations available to outside providers, the Spine Clinic staff identify appropriate patients based on their knowledge of them and of other specialties. By avoiding compartmentalization of specialties, we enjoy a broader understanding of other involved professionals and gain an appreciation for the effectiveness and appropriateness of various plans of care. We feel that this cross-training has become invaluable in directing all our clinic patients into appropriate care.

The Spine Clinic uses the well-developed concept of a multidisciplinary care model. Significant data has shown that addressing the physical as well as the biopsychosocial pathologies of patients leads to better outcomes. Additionally, some patients who have completed all reasonable, validated conservative and interventional care have been deemed to be nonsurgical candidates and yet still suffer from chronic daily nonmalignant pain of spinal origin. The ubiquitous emotional pathology of such patients often remains unaddressed in solitary clinics. We have found the collaborative, multidisciplinary setting to be helpful because it allows us to address the patient's outstanding questions and emotional state in a comprehensive manner. It also sets up a unique support system for physicians, allowing us to collaboratively address a patient's consideration of more high-risk, expensive, and often-unproven treatment modalities. As such, the Spine Clinic practitioners are occasionally in the situation of having nothing else reasonable to offer. We believe that having this discussion with patients is important. In a traditional clinical construct, patients may leave a clinic or become lost to follow-up, only to matriculate to another clinical provider and repeat already disproven modalities. The Spine Clinic's cooperative construct allows providers the unique capability of telling a patient that there is likely nothing else to be done. This allows us to address outstanding questions and emotional issues that can assist the patient in adhering to a reasonably conservative plan of care.

Our Spine Clinic approach allows for a streamlined clinic experience for the patient. No longer are patients asked to complete up to five or more separate consultations and imaging appointments to determine a plan of care. Rather, we offer timely input from all the providers: a one-stop shop for patients that brings to bear all available resources of various specialties. The time a patient saves—although perhaps difficult to objectively assess—is subjectively clear to see. The typically larger catchment area of patients in the VA system may amplify this characteristic and result in more significant time savings. However, even patients from smaller regional hospitals and clinics may notice a significant time savings.

Another benefit to our Spine Clinic system is that it provides patients and caregivers with a cleaner line of communication. The traditional system of individual specialist consultation, although usually appropriate, can result in loss of valuable information. This is most often seen in complicated chronic pain patients. For instance, in the traditional consult system, a neurosurgical patient may be asked to return to the Pain Clinic to be evaluated for a series of selective nerve blocks to assist in determining pain location. However, even this seemingly innocuous plan has countless opportunities for failure: The patient could convey to the pain physician a different location or type of pain, or voice his or her desire to change the ultimate goals. The patient may simply fail to follow up on the visit. Either way, the result is the same: confusion on the part of the patient and provider alike. Patients and providers can quickly find themselves operating from very different starting points, seeking different outcomes. In the Spine Clinic, all providers who will render care discuss the plan of care with the patient. We significantly curtail possible confusion by simply having all providers in the same room discussing treatment options with the patient.

Initial feedback from our patients indicates the Spine Clinic has been well received. Patients enjoy the single visit construct in which they can get what they see as instantaneous feedback to their questions and concerns. Whether clinicians feel it is reasonable to consider what could be called customer satisfaction, its prominence in current and future medical care is certain. When we consider the current volatile political situation surrounding medical reform in this country, it will be necessary to implement novel, efficient delivery systems for care. All recently adopted and currently proposed legislation prominently features payment systems that emphasize efficiency and standardization of care. Future changes will likely see a continuation of the policies laid out in Medicare Access, the CHIP Reauthorization Act (MACRA), and other bundled payment plans with an overall trajectory that addresses redundant and inefficient processes. It seems reasonable that some coordination of care is necessary at the clinic level to efficiently address the further growth requirements of the field. At the VA Hospital in Palo Alto, California, involved providers have found that seeing certain patients simultaneously in a multidisciplinary setting helps address complex, spine-related pain in a way that improves patients' clinical experience and clinic efficiency.

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