Care Redesign

An Innovative Approach to Treating Complex Gynecologic Conditions

Case Study · January 9, 2019

Aware of the distress caused by complex gynecologic conditions, as well as a paucity of services for insured and uninsured women, we designed a new clinical program to provide comprehensive, team-based, and patient-centered care at the Women’s Health Institute at The University of Texas at Austin. We improved services and reduced costs by establishing integrated practice units, restructuring clinic visits, creating evidence-based care pathways, and enhancing care coordination.

Key Takeaways

  1. Complex gynecologic conditions such as incontinence, pelvic organ prolapse, chronic pelvic pain, and vulvar disorders require a multidisciplinary approach. Integrated care for these distressing conditions is hard to find.

  2. The Women’s Health Institute at The University of Texas at Austin designed our clinic to provide comprehensive, team-based, and patient-centered care for women with complex gynecologic conditions.

  3. Our initiative involved establishing integrated practice units, restructuring clinic visits, creating evidence-based care pathways, and improving care coordination.

  4. We reduced health care costs by increasing access to nonsurgical therapies, limiting inpatient surgery, optimizing physician time in clinic, and taking advantage of technology for patient-provider communication.

The Challenge

Comprehensive treatment for complex gynecologic conditions, such as urinary and anal incontinence, pelvic organ prolapse, chronic pelvic pain, and vulvar disorders, is hard to come by. These hidden problems rob women of dignity, hamper productivity, and lead to high health care consumption. Treatment is typically fragmented, requiring patients to travel to multiple providers before and after their diagnosis (if and/or when it is made), and the full spectrum of care is not always available — especially for women who are under- or uninsured. While surgical treatment is indicated for some, many patients are not offered the option of less-invasive care. Many women are uncomfortable discussing these painful and embarrassing problems with their primary care physicians (PCP) and partners, and suffer in silence.

Complex gynecologic disorders are highly influenced by general and psychological health. Treatment success requires attention to obesity, poor mental health, and other common conditions often ignored, or poorly managed, in subspecialty clinics. Subspecialist MD providers also have limited resources to perform complex care coordination, which, in turn, leads to narrowly focused treatment plans.

For the women of Austin, Texas, comprehensive care for complex gynecologic disorders was limited or nonexistent. Based on current prevalence data, over 300,000 women in Travis County suffer from these disorders. Within the safety-net system, these conditions were often undiagnosed, undertreated, and had long waiting times for specialty referral. For some conditions, no specialist care was available, and many women sought care through emergency rooms and urgent care centers, where they would receive pain medications and/or referral to a subspecialist, but no care plan. Care coordination was poor.

Although many women with complex gynecologic conditions improve with nonsurgical treatments, low-risk, low-cost, and effective treatments were not always available. Additionally, many women who received treatment and whose conditions had stabilized remained under the care of subspecialists due to lack of PCPs’ ability to manage these patients — further limiting access to subspecialty services.

The Women’s Health Institute launched an initiative to improve care and increase access to comprehensive services for complex gynecologic conditions. We established integrated practice units (IPUs), restructured clinic visits, provided quality care coordination, and created evidence-based care pathways that brought together advanced practice providers (nurse practitioners and physician assistants), physicians, social workers, dietitians, medical assistants, and pelvic floor physical therapists to provide wraparound services. These changes, which also reduced costs, were led by the Department of Women’s Health at the University’s Dell Medical School.

The Goals

We conveyed the following goals as we created the clinical pathways and implemented the clinical care model:

  • Develop standardized care pathways that offer evidence-based therapeutic interventions for complex gynecologic conditions.
  • Increase access to subspecialty services and colocate services for women in Travis County, providing integrated care within one clinic.
  • Engage and empower patients to set personal treatment goals and to self-assess for improvement.
  • Support community physicians in caring for women whose symptoms have improved or stabilized so that patients could return to their PCPs for ongoing care.

The Execution

Based on feedback from patients and providers within the community, we knew that access to complex gynecologic care within the community was fragmented and limited, especially for underserved women. To address this, our team researched evidenced-based models of care, determined the current cost of care and prevalence of these conditions in our community, developed care pathways and financial models, and solicited feedback from experts in the field and women who had experienced these conditions. We also worked with our local health care district and community partners to raise awareness of this need. The design phase took 3 years from concept development to execution, and we conduct ongoing process improvement.

Key innovations adopted:

Integrated practice units: The Women’s Health Institute designed three integrated practice units, one each for pelvic floor disorders, chronic pelvic pain, and vulvar disorders. We chose the IPU model because it surrounds a patient with the expertise to treat her condition and holistically meet her needs. Circling the providers around a woman in a single clinical setting also reduces inefficiencies in care coordination for the subspecialist, patient, and her family. We created value by reducing care costs when possible, having providers work at the top of their license, and colocating IPUs in a single location with shared infrastructure. For our safety-net population, we introduced a bundled payment mechanism that lowered barriers to low-cost interventions such as physical therapy.

odel for Complex Gynecologic Care Team at the Women's Health Institute

  Click To Enlarge.

Care pathways: We established standardized care pathways based on best-practice evidence for the treatment of complex gynecologic conditions, such as stress urinary incontinence and persistent vulvar pain, and measured provider adherence. Standardization ensures that our approach to disorders is uniform. Care pathways are assigned based on patient symptoms, physical exam, goals for treatment, and completed patient-reported outcome measures (PROs), and patient cases are reviewed by a provider team. All women are offered nonsurgical management, if medically appropriate, which reduces unnecessary surgical interventions.

Provider adherence: Although we are still developing a systematic way to measure pathway adherence, we discuss this during case conferences with all providers.

Patient goals: Before beginning treatment, women discuss their treatment goals with their provider/s. This allows the care team to determine whether treatments are aligned with patient values and effective. We assess patients’ perceptions of their improvement at each visit and reassess PROs every 6 months.

Flipped clinic: We “flipped” the clinic structure. Before a patient’s first visit, the care team convenes to discuss the patient’s goals, PROs, symptoms, prior treatments, and general health, and identifies a care plan. Care pathways are modified once the patient is evaluated in person. The flipped clinic ensures that the patient is scheduled with the appropriate provider, and that the required team members are available. Many patients can be seen by a nurse practitioner (NP) or physician assistant (PA), whom we call associate providers, and this reduces both MD clinic time and costs.

Surgery: We moved the majority of our surgeries to an outpatient setting. By optimizing the appropriate care setting for procedures, we decreased costs. With added support through phone calls, women feel safe enough to recuperate at home, knowing they can reach a provider if/when needed.

Follow-ups: By communicating with patients through the electronic health record and phone calls, we reduced routine in-person follow-ups. This eliminated unnecessary and costly “just-in-case” visits.

Building capacity with our community partners: To enable patients to return to their primary care settings, we conducted training for simple procedures (such as vaginal pessary ring cleaning) and management of recurrent urinary tract infections for providers at other locations. In addition, we established clear avenues of communication with outside providers through direct interactions and consult letters.

The Team

Currently, our complex gynecologic care team consists of four full-time advanced practitioners (NPs and PAs), two pelvic floor physical therapists, one dietitian, a part-time nurse manager, five medical assistants, one social worker, and an equivalent of 1.2 FTE physicians. We have MD specialists in gynecology, urogynecology, and dermatology, with more planned. We contain costs by limiting physician clinic time while simultaneously involving them in care plans and execution.

Results

  1. We have established care pathways for complex gynecologic conditions that incorporate all evidenced-based treatments for these disorders. This ensures that all patients have access to the full spectrum of treatments for their disorders.
  2. We began measuring PROs and patient progress, and 70% of patients seen in the three IPUs indicate that their conditions have improved at 6 months after the start of treatment.
  3. For our safety-net population, we shortened wait times for treatment of pelvic organ prolapse and incontinence from 55 days to next-day appointments (this took 1–2 months), and access to comprehensive treatment for chronic pelvic pain and vulvar disorders is now available. For insured patients, wait times have also decreased, and services are colocated so that women don’t have to travel to see additional specialists.
  4. We increased the use of nonsurgical therapies for pelvic floor dysfunction. For example, leading professional societies recommend pelvic floor physical therapy as first-line treatment for urinary incontinence, but it was not available for Travis County patients and required referrals to outside providers in the insured population. Since October 2017, we have seen over 300 women in our PT clinic who are comanaged by our gynecologic subspecialists. The availability of low-risk, lower-cost options for care has further decreased costs.
  5. Our flipped clinic care model, with input from the team before and after the start of care pathways, demonstrates that we can deliver high-quality care utilizing NPs and PAs and optimizing the role of MD subspecialists. Personalized treatment goals have helped clinicians tailor care plans and improve communication with patients.
  6. Immediate access to social work and nutrition counseling ensures that these important disciplines are considered when constructing treatment plans. We have found that incorporating general health and psychological concerns is critical to the successful treatment of these women.

In summary, our care model is patient-centered, focuses on outcomes important to patients, and allows providers to work at the top of their abilities. These efforts have added value in the care of women with complex gynecologic conditions.

Next Steps

  • Design a support system for community providers to care for patients with stabilized complex gynecologic disorders through telehealth services such as Project ECHO.
  • Continue to refine and improve care pathways to enhance patients’ health based on responses to PROs.
  • Expand specialty services, including developing our Sexuality and Menopause program.

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