Care Redesign

Specialty Care for the Underserved

Case Study · March 28, 2018

Specialty musculoskeletal care for the safety-net population of Austin, Texas, was hampered by a number of challenges, including gaps in infrastructure and care coordination that led to long wait times, unhelpful MRIs ordered by primary care clinicians, and overuse of the emergency department. The opening of the new Dell Medical School and Dell Seton Medical Center at The University of Texas at Austin prompted a restructuring of the service to reduce its reliance on specialist office visits. By employing a combination of expertise in care coordination, technology, and collaboration with primary care providers, we improved overall musculoskeletal care and eliminated the waiting list to see a musculoskeletal specialist.

The Challenge

Otherwise uninsured patients in Austin are covered by the Medical Access Program (MAP) offered by Central Health, the public health district representing Travis County. MAP covers primary care, prescriptions, hospital care, and specialty care, which was being provided through clinics and the former University Medical Center–Brackenridge (operated by Seton Healthcare, part of Ascension).

In 2012, Travis County voters approved an initiative that raised property taxes in support of the health of Central Texans, including a $35 million annual investment in the medical school. In addition to the medical school, the new $250 million Dell Seton Medical Center was built with funding from Seton.

At the same time, the demand for musculoskeletal services among MAP patients was outstripping available resources, and there was a backlog of more than 1,400 patients waiting for musculoskeletal care, some for more than a year. They were referred by local urgent care centers and emergency departments, as well as the Central Health primary care network.

Optimal care was hampered by several factors, including:

Limited access to specialists. Musculoskeletal care for MAP patients had been provided by a small rotating group of community-minded orthopedic specialists, who staffed a limited number of appointment slots in a hospital-based safety net clinic. Given the typically high no-show rate for appointments at these clinics, the efficiency of care was further reduced by wasted slots.

Poor care coordination and access to documentation. Care was documented on paper records, and specialists had no reliable mechanism for accessing the primary care records or communicating with primary care providers.

Over-ordering of imaging. Orthopedists use MRIs sparingly and mostly to plan surgery. To “do something” while their patients waited to see a specialist, PCPs were routinely ordering MRIs for diagnosis and triage: most patients with shoulder or elbow problems had an MRI and some had two. The vast majority of these MRIs were unhelpful and many were misleading (for example, age-related defects were labeled as “tears,” leading patients to focus inappropriately on surgery for repair). More timely access to a musculoskeletal specialist could have eliminated these screening MRIs, quickly identified patients with large acute defects who would benefit from having an MRI to plan surgery, and helped patients with age-related rotator cuff tendinopathy or other minor defects receive appropriate education, reassurance, and exercises.

Unnecessary ED visits. People waiting for care would often get frustrated or worried and seek care in the Emergency Department — thereby receiving the costliest form of evaluation but without moving them up on the priority list. Frequently the ED visit would accidentally create a duplicate referral.

The Goal

When Dell Medical School joined the team providing musculoskeletal specialty care, the goals were:

  1. Improve triage and management of referrals, so that patients who would not benefit from surgery would receive appropriate non-surgical care, and patients who would benefit from surgery would receive it promptly.
  2. Improve communication with primary care providers to extend our expertise by giving “real-time” advice to facilitate care without referral, identifying patients for whom an in-person specialty visit would be useful, and addressing urgent problems to avert unnecessary ED visits.
  3. Reduce unhelpful use of resources (MRI, urgent care, injection, physical therapy, and surgery) while improving access and optimizing musculoskeletal health.

The Execution

Innovations adopted in restructuring the service included:

Team care. The nurse practitioner associated with our musculoskeletal service worked closely with PCPs to answer their questions and improve coordination. In the absence of a workable electronic medical record interface, we relied on mobile phones, texts, and emails. Secure email for e-consults in many cases obviated the need for in-person specialty referrals. Referral management software helped eliminate duplicates, improve communication and coordination, facilitate pre-visit triage, and schedule appointments more efficiently. The musculoskeletal service promoted the mantra, “If you think MRI, call us first” to avert “screening” MRIs.

Optimizing care settings. We sought to deliver care in the least intensive setting. For patients having hips or knees replaced, we improved preoperative education and discharge planning to minimize inpatient stays and discharge patients to their homes. Rather than assuming a discharge to a post-acute facility, we identified caregivers at home, educated both caregivers and patients on the recovery process, and prepared the home environment. For example, some patients required temporary relocation to first floor apartments and others needed to secure transportation in advance for PT appointments. We worked closely with social workers and the perioperative surgical home staff to accomplish these tasks ahead of surgery. We are making increasing use of virtual visits, as well. The advice of a musculoskeletal specialist can be obtained by phone, text, email, or video chat (e-consult or virtual consult), as well as in person.

The vast majority of hand surgeries are now performed in the surgeon’s office, using local anesthetic with epinephrine, greatly improving access and reducing costs. Patients like the more intimate setting and the convenience. We estimate that approximately 80% of the surgeries performed by a hand surgeon can be completed in the office, including flexor tendon repair, tendon transfer, and Dupuytren fasciectomy, in addition to the simpler and more common carpal tunnel and trigger finger release.

Winnowing the wait list. Duplicates were removed, acuity was prioritized, and patients were triaged by musculoskeletal specialists and efficiently referred to the right provider for their condition. By addressing the most severe and urgent problems first, we could deploy specialist resources to areas where they could do the most good. New referrals now have in-person appointments within days to weeks, and can sometimes get a preliminary virtual visit in a matter of hours.

Talking with patients. We began calling patients directly prior to their specialist visits to better understand them and their conditions, as well as to review the options for addressing their condition. Because many patients already had a diagnosis and imaging in the system, we could discuss the results and their options without venturing into diagnosis and treatment. For example, we helped them understand when their problem was an age-related tendinopathy rather than an injury, or begin to consider the options for a wrist ganglion cyst. This incremental care allowed for gentle and gradual correction of common misconceptions, and provided time for people to reflect on their values and which option fit best. During in-person consultations, we emphasized independence and self-care, answered questions, and taught patients appropriate home-based exercise programs.

Adopting video visits. Passage of Texas’ new rules on telehealth at the end of May 2017, allowing an initial virtual visit without an in-person visit, has been a tremendous help in increasing the efficiency and effectiveness of our care. Even prior to the new law, we used web-based video visits with patients in prison in conjunction with the prison doctor, greatly reducing transportation costs for patients and guards. We also offered video visits for all patients for routine follow-up and post-operative care. After the law was passed, we offered virtual visits to new patients. Many patients prefer the convenience of virtual care. Using text messages, emails, phone calls, and video consultations results in fewer routine return appointments and opens up access for more new in-person patient visits. These electronic communications can also serve as “instant triage”: When it becomes clear that the patient should speak with a specialist, we can set up the visit at that time.

The Team

Our initial team consisted of one full-time nurse practitioner, one part-time nurse practitioner, and two part-time orthopedic surgeons (one lower extremity specialist and one upper extremity specialist). We worked closely with the staff and clinicians in both the community primary care clinics and the specialty clinics operated by Seton. Our current team includes a physical therapist, social worker, and dietician in a new office space.

Results

Through these efforts, the wait list was eliminated in roughly 7 months; the wait for MAP patients to see a musculoskeletal specialist, which had been more than a year, is now no more than 2 weeks, with many patients getting next- or same-day appointments.

Over a 6-month span, preoperative optimization and discharge planning for patients having hip or knee arthroplasty reduced the length of hospital stays from 3.5 days to less than 2 days without increasing readmission rates. At this point, over 90% of our primary TKA and THA patients are discharged to home after leaving the hospital.

We are not ready to quantify many of the effects of these changes because we are still building out systems to collect and analyze data. For the hundreds of people on the waiting list, those who needed surgery got it, and many others took advantage of the options, information, and support we provided to embrace courses of treatment that better reflected their needs and lives.

Further, we can connect people seeking care with specialty expertise via self-care tools, such as web-based materials for patients and PCPs to diagnose and self-manage many common musculoskeletal problems (backed up by ready access to specialty care). We can expand access to better health and high-value care through virtual appointments and decision aids that help people prepare to make important decisions between diagnostic or treatment options.

In-person visits with specialists are always available and often necessary. But we are demonstrating that technology and care coordination among partners can help provide the same level of care, or better, and remove the bottlenecks associated with waiting for one of those visits.

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