INTEGRATIVE CARE ADDRESSES THE PATIENT’S BODY, MIND AND SPIRIT
— the biopsychosocial model. Health care organizations, administrators, insurance companies, government agencies and even patients have multiple definitions and interpretations for integrated care. Common terms in this health care space include collaborative, coordinated, comprehensive, interprofessional, multidisciplinary, continuity, evidence-based, patient-centered and value.
For Jesse Cooper, DC, and member of UNC Regional Physicians Physical Medicine and Rehab in High Point, N.C., integrated care means that all providers — among them primary care, neurology, cardiology, orthopedics, physiatry, chiropractic, occupational therapy and physical therapy — practice to the height of their evidence-based scope in a coordinated, supportive way, ensuring the best delivery of cost-effective, patient-centered care. “This means that medical errors are minimized, unnecessary tests avoided, prescription painkillers reduced and patients ultimately will receive the most complete care,” indicates Dr. Cooper.
The components of integrated care are most efficiently delivered within a system where providers are co-located and utilize the same electronic health record (EHR). Having a shared health record allows all providers to see the big picture of what care is being provided. “This ensures that we do not have duplication of services or conflicting care,” says William E. Morgan, DC, at Walter Reed National Military Medical Center in Bethesda, Md. “For complicated cases, the use of a case manager with treatment algorithms will ensure that the patient is guided to the most appropriate treatment plan.”
DCs tend to be an independent lot. In most cases, they are not required to be on-site at another health care setting to be part of an integrated unit; options include keeping a separate office, maintaining a contractual shared savings arrangement or moving into one integrated setting. Having all providers in the same space, however, typically improves communication among providers, speeds up decision-making and makes it more convenient for the patients — providing a seamless care experience.
PPACA and Integration
With the Patient Protection and Affordable Care Act (PPACA) in place, there is less emphasis on fee-for-service and more on reimbursement for improved patient outcomes. As a result, health care systems are eager to keep patients out of high-cost settings and to manage their chronic illnesses, which become very costly over time. Therefore, they are increasingly interested in adding DCs to their systems, who also serve as portal-of-entry providers, bringing in new patients. DCs can also play critical roles in disease-management programs, thereby reducing long-term health care costs.
“As part of an integrated staff team, DCs can conduct wellness visits, disease management for chronic illnesses like obesity and type 2 diabetes and advise patients on dietary and lifestyle changes,” says David C. Radford, DC, director of the Chiropractic Clinic of Solon in Solon, Ohio. Dr. Radford is on the Preferred Provider Panel (PPO) of the Cleveland Clinic and treats Cleveland Clinic staff. He has a strong working relationship with University Hospitals Regional Hospitals and St. Vincent Charity Hospital. “Hospitals also understand the value of loyal providers who can refer patients into their systems,” he says.
Even with the obvious advantages of working with DCs, the addition of chiropractic physicians into what PPACA has termed integrated practice units (IPUs) has been slow. IPUs, such as patient-centered medical homes (PCMHs) and accountable care organizations (ACOs), are the cornerstone of PPACA. “The good news is the antidiscrimination language in Section 2706 of PPACA guarantees that services provided by DCs should not be singled out and excluded as non-essential from state exchanges or the essential minimum benefits,” says Dr. Cooper. “While doctors of chiropractic currently cannot independently establish an ACO or PCMH, they can partner with other providers and share in savings demonstrated by the ACO or PCMH.”
DCs can provide a wide range of care in a coordinated integrated practice. Federally qualified health centers and the large chronic pain population treated by the Department of Veterans Affairs (VA) are among the groups that have benefited the most from the inclusion of chiropractic. “The trend is for more integration of DCs into medical clinics and hospitals, and for more MDs and DOs to work within chiropractic offices,” says Dr. Morgan. “The Department of Defense (DOD) and the VA are both following directives to find safe alternatives to opiates and pain procedures. As a result, they are gradually expanding the chiropractic benefit.”
Occasionally, chiropractors work with primary care providers in order to complement the spectrum of services being offered. “Working with primary family practice providers offers several convenient pathways for the care of musculoskeletal anomalies,” says Leo J. Bronston, DC, MAppSc, vice president of ACA’s Council of Delegates, president of ACA’s Integrative Practice Council and owner of six chiropractic clinics in Wisconsin. “Other chiropractors work in the hospitals and/or clinics in disciplines such as neurology, pain management and physical medicine.”
Advantages of an Integrated Setting
The top advantage of an integrated setting is patient care, which improves tremendously when specialists work together to treat the complex health needs of today’s patients. Other advantages are an increase in patient referrals; the ability to provide a safe alternative to drugs, injections and surgery; reduced overhead costs; and improved personal growth and learning.
“Physician collaboration forces a higher level of competence among health care providers due to the necessity of communication,” says Dr. Cooper. “This is a form of healthy professional competition. It is very easy for solo practitioners to lose sight of the ever-changing health care landscape such as best practice guidelines, but if they are being held accountable by an organization that depends on them, they are typically motivated to go the extra mile and become a more complete doctor.”
Being part of a comprehensive care team does, however, require more time and effort to communicate with other doctors and surgeons of various specialties, both verbally and through the shared EHR. “While this may seem like a time-consuming effort, the rewards can be quite incredible,” says Dr. Radford. “It is very rewarding to be part of a team.” He notes that Cleveland Clinic provides access to patients’ electronic health records vi the EPIC electronic medical record (EMR) system, while University Hospitals Regional Hospitals and St. Vincent Charity Hospital provide access to their patients’ electronic health records via the GE Centricity EMR.
Dr. Bronston works in an integrated health care system that includes advanced nurse practitioners, physical therapists and support staff to complement each of the services he offers. For example, a patient may present with lower back pain and have burning upon urination. If the laboratory test delivered by staff indicates a urinary tract infection (UTI), the patient is then channeled to the allopathic professional who can best deal with the clinical condition. “Back pain is also evaluated to determine whether or not a chiropractic care session and/or physical therapy is needed,” says Dr. Bronston. “Likewise, patients who require more coaching to deliver an exercise component to their care plan may benefit from the alternative suggestion of visiting with the physical therapist.”
Dr. Morgan, who has worked in hospitals for the past 20 years, is currently practicing in a physical medicine department in a large medical center. In his experience, the presence of a chiropractic clinic in a hospital allows for an expansion of care and promotes the concept of natural healing methods, with less reliance on drugs. “The biggest benefit I have found in working in a hospital is the proximity of other resources,” says Dr. Morgan. “If I am concerned about a particular finding in a patient, I just walk down the hallway and ask a medical colleague for an opinion. More times than not, the doctor will come in the room and examine the patient.”
Making It Happen
The best way to join an integrated care team is by invitation. The easiest approach is becoming known in the community and developing working relationships with other health care providers. For example, nearly every patient has a primary care doctor (PCP). “When you see new patients, simply ask them if you can communicate your findings and treatment plan to their PCP,” says Dr. Radford. “The vast majority will say yes, which is your opportunity to make a good first impression. You can also communicate directly with the referring physicians. Make it a point to send these doctors your progress notes or an interim report, and at the end of treatment send them a discharge note. Also avoid any chiropractic terms that may be confusing, such as subluxation.”
DCs who wish to participate in an IPU program and be part of the Medicare Shared Savings Program need to partner with MDs or DOs who are established in an ACO or PCMH. As a first step, DCs need to identify MDs/DOs in their state who are currently involved in an IPU. “When approaching other provider types to discuss the value you bring to the table, be prepared and be succinct,” advises Dr. Cooper. “The triple aim of health care reform must be at the core of your argument: cost, satisfaction, outcomes. The triple aim also happens to be chiropractic’s strongest and most well-researched asset. Talk with your state organization. Have that organization reach out and make connections. Talk with your patients, and ask them to establish a dialogue between you and their PCP.”
Geographical regions in the United States or other countries often have different factors that influence how collaborative-type practices operate. In some areas, chiropractic services are used regularly by the patient population and chiropractors are sought out as a portal of entry into the health care delivery system. Recognizing this economic advantage, some health care groups have embraced chiropractic as part of their health care team. However, it can be challenging to find and describe the exact domain of each provider type, or how chiropractic fits into a coordinated effort to deliver the necessary care.
“Because collaboration between medical and chiropractic physicians is relatively new, it is important to understand how these two groups work together successfully, and there is a need to examine the characteristics of current integrated approaches to identify features that can be assessed, modeled and/or implemented in other settings,” says Dr. Bronston. [For more information, he recommends reading “The Future of Chiropractic Revisited, 2005-2015” at www.altfutures.com
An Integrated Future
With shifting needs in health care reform, and increased emphasis on cost reduction and improved outcomes, Dr. Morgan believes there will be a steady increase in the integration of chiropractic into medical practices, medical centers and hospitals.
“I work in the DOD system of health care,” says Dr. Morgan. “Well over 70 percent of the medical doctors in the United States receive training in the DOD or VA systems of health care at some point in their education. Since there are hundreds of chiropractors dispersed throughout these systems, the next generation of medical doctors will likely mature with a greater appreciation for chiropractic being integrated into the care of patients.”
Dr. Bronston is also optimistic about the future of chiropractic in integrated settings. He believes the most cost-efficient approaches will reward improved patient outcomes, not fee-for-service. “The future reimbursement system will encourage selection of doctors based on several performance benchmarks, which have yet to be fully determined,” he says. “Given the huge dollar amount spent on neuromusculoskeletal conditions, chiropractors are poised to deliver on health care needs within integrated model settings.”
“I see the private solo practitioner becoming a model of the past,” adds Dr. Cooper. “Global health care data is being collected at a rate never seen before in history. Health care data is becoming seamless with the expansion of EHR. Hospital systems are growing. Physician group practices and small community hospitals are being engulfed by larger entities each day. Federal health care regulation and insurance regulation are here to stay and gaining power. Fee-for-service is on the way out. Soon, all physicians will be compensated by the outcomes they produce, not how many times they render a service. In five years, integration will be ubiquitous.”
Finally, working in integrated settings is a fantastic way to show the health care profession what DCs can do. More DCs need to reach out and become part of an integrated, multidisciplinary team. Not only will it expand the reputation of chiropractic and help it gain wider acceptance by the public and the greater medical community, it will also sharpen the DC’s game.
The best part about integration “is treating patients who would have otherwise never in their wildest dreams sought care from a chiropractor and seeing them improve,” says Dr. Cooper. “Chiropractic results speak for themselves. No doubt it takes time, hard work, sacrifice and a little luck to earn a reputation of trust and integrity from your medical colleagues. Be confident. Nobody does conservative evidence-based functional restoration of the musculoskeletal system like we do. Nobody understands movement like we do, particularly spinal biomechanics. Do not be intimidated, but be humble. A fine balance is required, but it is worth it — integration is ultimately a very rewarding experience.”
Statistics on Integrated Practices
The National Board of Chiropractic Examiners (NBCE) recently released its Practice Analysis of Chiropractic 2015, which is a project report, survey analysis and summary of the practice of chiropractic in the United States. It is available online at www.nbce.org/practiceanalysis
According to NBCE’s report, in hospital and military practice, a small portion (3.6 percent) of practicing chiropractors reported that they hold staff privileges at a hospital. This group had been growing steadily since 1991 – with 4.9 percent in 1991, 5.2 percent in 1998, 6 percent in 2003 and 6.9 percent in 2009 – but the share was lower in the new survey. The report finds 6.7 percent of chiropractic physicians are currently employed under contract to provide chiropractic care to active or retired military personnel. This group has grown by 50 percent since the question was first asked in 2009.
According to the results of the survey, 90.8 percent of the respondents work in achiropractic office, while 7.8 percent work in an integrated health care facility:
Chiropractic office-90.8 percent
Integrated health care facility-7.8 percent
Spinal surgical center-0.1 percent
Community health center-0.1 percent
Source: National Board of Chiropractic Examiners (NBCE) Practice Analysis of Chiropractic 2015
DCs in Integrative Settings
To learn more about chiropractic physicians in the integrated setting, go to www.acatoday.org/integrativepractice