Insights / Quality Improvement / Uncategorized

A Musculoskeletal Integrated Practice Unit Improves Access and Outcomes in an Underserved Patient Population

Tiffany Liu and Karl Koenig

In today’s health care system, patients must struggle through a dizzying array of obstacles to receive their care, with little opportunity or support to become effective advocates in their own care. As a result, patients see multiple specialists before an effective treatment plan is implemented and often undergo duplicative and unnecessary testing.  Moreover, as the transition from volume to value continues, practicing in the current volume-based care delivery models will become unsustainable – it is already nearly impossible for a surgeon to see more patients, achieve better outcomes, ensure patient satisfaction, all at lower costs than ever before….  all while reporting innumerable metrics for quality assurance.

The idea of an integrated practice unit (IPU) has been described previously by Michael Porter and associates. As a co-located multidisciplinary team of specialists providing care for a condition rather than in siloed specialty groups, an IPU team assumes joint accountability for outcomes across the entire care continuum and seeks to increase the value of care provided. Well-known IPUs in the United States have been established for certain conditions at MD Anderson Cancer Center and Cleveland Clinic’s Neurological Institute, with recent additions such as Union Square Family Health (Massachusetts).

Dell Medical School recently opened the doors of its Musculoskeletal Institute, a group of IPUs for musculoskeletal conditions with an emphasis on providing care to underserved patients in the local community who historically had limited access. In one office visit, a patient with hip or knee pain might learn a home exercise program from a physical therapist, optimize their nutrition plan with a dietician, receive behavioral health support from a social worker, discuss the risks and benefits of arthroplasty with a surgeon, and learn how to finance their health care by speaking with a financial counselor. This type of patient-centric care requires support and dedication from an interdisciplinary team of musculoskeletal specialists as well as collaborative services. Providers must be fluid and accept that each patient might have very different needs, and be able to pivot accordingly. Similar to the “flipped classroom”, our providers to hold a team huddle prior to the start of clinic, where a patient’s history, imaging, and socioeconomic issues are discussed. This allows each visit to begin with full background established and creates more time to be spent on shared decision-making with the patient.

Our retrospective pre/post study sought to characterize the impact of the musculoskeletal IPU on access to care and patient outcomes. In terms of access, the IPU’s timely triage of musculoskeletal referrals was of paramount importance. Prior to the IPU, only 2% of referrals were addressed within 30 days; under the IPU, 19% of new referrals were addressed within 30 days. While referral triage is not a novel concept, our experience demonstrates that simple process improvements can significantly benefit patient care. This degree of impact is especially relevant and important in low resource care settings.

This study also demonstrated that the IPU care design was associated with significantly better outcomes among surgical patients. We attribute this to improved patient selection – by broadening the perioperative discussion to include a patient’s goals, beliefs, values, and other sociodemographic factors, our practitioners are better able to identify appropriate surgical candidates and tailor their perioperative counseling. Moreover, experts in a variety of disciplines are on hand to provide psychosocial support and help with preoperative optimization. When modifiable risk factors were identified, the team was in a position to work with patients in order to improve them prior to surgery.  This is reflected in decreased length of stay (2.9 days to 1.4 days) with no associated change in readmission rates or percent of patients discharged home.

We recognize that Dell Medical School operates in a unique environment, and that other organizations and practices may not have the ability or resources to completely redesign their care delivery. While we tout the IPU model and its patient-centered approach, it seems clear that that even small changes, such as using experts to triage referrals on a wait list, can lead to improved access to health care when resources are limited.  These types of changes can be made in almost any system. Most importantly, we advocate for a continuous, iterative improvement mindset. We look forward to delivering more data in the future that can help identify the most useful aspects of the IPU approach, measure outcomes on both non-operative and operative patients, and provide insight into the long-term effects on value.

Read the full article published in Healthcare: The Journal of Delivery Science and Innovation at https://doi.org/10.1016/j.hjdsi.2018.10.001

Tiffany Liu, MD is an orthopaedic surgery resident at UCSF

Karl Koenig, MD MS is an orthopaedic surgeon and Medical Director of the Musculoskeletal Institute at UT Health Austin/Dell Medical School

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