Evidence-Based Prac/ce and Paent-Centered Careaskdrlehman.com/ub-ortho/ebp1.pdf · Evidence-Based...

Evidence-BasedPrac/ceand

Pa/ent-CenteredCareDr.JamesJ.Lehman

AssociateProfessorofClinicalSciencesUniversityofBridgeportCollegeofChiroprac/c

Whatdoesevidence-basedprac/cemeantoyou?

Areyouanevidence-basedprac//oner?

ACAEvidence-BasedPrac/cear/cle

Discussion

Whatispa/ent-centeredcare?

Pa/entcenteredcarerequiresmedicaldoctorsandchiropractorstoworkside-by-side.

MyMessage

•  Integra/onofevidence-basedchiroprac/cservicesintothehealthcaresystemenhancespa/entsafetyandqualityofcare.

•  TheAffordableCareActpermitschiropractorstofunc7onasmembersoftheprimarycareteam.Thelanguageinthebillensuresthatdoctorsofchiroprac7ccanbeincludedonthesepa7ent-centeredandholis7cteams.Thenon-discrimina7onprovisionli=ssomeoftheburdenimposedbyunfairlimita7onsofcertaininsurancecompanies.

PainCareinAmericaMustChange

•  Mostpeopleinpain,includingthosewithchronicsymptoms,gotoprimarycareproviderstogetrelief.Butcurrentsystemsofcaredonotadequatelytrainorsupportinternists,familyphysiciansandpediatricians,theotherhealthcareproviderswhoprovideprimarycareinmee7ngthechallengeoftrea7ngpainasachronicillness.Primarycareproviderso=enreceiveliDletrainingintheassessmentandtreatmentofcomplexchronicpaincondi7ons.

CurrentStatusofChiroprac/cPhysiciansinHealthCareSystem

1. Misunderstood2. Overtrained(Limitedscope)3.  Undertrained(Chiroprac/cspecialist)4.  Underpaid5.  Underu/lized

Pa/entcenteredcarerequiresmedicaldoctorsandchiropractorstoworkside-by-side.

KeystoIntegra/on

•  Competentandcaring•  Evidencebased• Holis/candkind•  Pa/entcentered• Willingtointroduceyourself

NewPainManagementModel

•  Healthcareteam•  Primarycarproviders– MD–  DO–  NP–  PA

•  Chiroprac/cfacultymembers,residentsandstudents

•  Behavioralhealth

Chiroprac/cServicesatCHCIMeridenpilotevalua/on

IanitaZlatevaDarenAnderson

ProjectSTEP-ingOut

“Integration of Chiropractic Services and Training into a Community Health Center”

RISK

STEP1

STEP2

STEP3

PCMHPrimaryCarePodsRou/nescreeningforpresence&intensityofpainComprehensivepainassessmentandfollowupManagementofcommonpainfulcondi/ons

StructuredfollowupassessmentNurseCarecoordina/on

Complexity

TreatmentRefractory

Comorbidi8es

RISK

OnsiteCo-managementOn-sitebehavioralhealthco-management

PainmanagementgroupsessionsStressreduc/onChiroprac/c

ProjectECHOconsulta/on

Ter/aryInterdisciplinaryPainCentersAdvanced diagnostics & interventions CARF accredited pain rehabilitation

Integrated chronic pain and SUD treatment

TheSteppedCareModelforPainManagementatCHC

0%

0%

0%

14%

7%

0%

7%

3%

16%

3%

0%

0%

0%

14%

9%

0%

6%

4%

20%

3%

0%

0%

0%

13%

12%

0%

6%

7%

25%

4%

Addic/onMedicine

Chiropractor

Acupuncturist

PhysicalTherapy

PainManagement

Physiotherapy

PhysicalMedandRehab

NeurologicalSurgery

OrthopedicSurgery

Rheumatology PainReferralsbycohort

ChronicOpioidCohort(n=1019)

OpioidCohort(n=3663)

PainCohort(n=6746)

Action plan

Lackofpaintraining/lowknowledgescores

Lackofpainspecialtysupport

Lowbehavioralhealthco-

management

LowuseofCAM

Poordocumenta/on

ofpainassessment

andtreatment

lowratesofpain

reassessment

Lowratesofopioid

agreement/u-toxmonitoring

NewCHCPolicy• Utoxq6month• Opioidagreementqyr• Documentedf/uq3mo• PainfollowupHPIfolder• Paindashboard

ProjectECHOOnlinepainCME

Chiroprac/cand(?)

acupuncturesvcatCHC

Behavioralhealthpainreferrals

CHCMeridenChiroprac/cPDSA

•  UniversityofBridgeportContractual•  Dr.JimLehman+3students•  4hrsessionsWed.andSat.•  InternalreferralinECW•  ECWHPIfolders•  Collabora/vemanagementforpain/musculoskeletalproblems

•  PreliminaryResults1/04-4/18/2012–  NumberofUniquePa8entsSeen–45–  NumberofPa8entVisits–152

<35

years

23.91%

36-50 years

50.0%

>50 years

26.09%

Age Range Distribution

Asian 2.2%

Black or African

American 6.5%

Caucasian 39.1%

Hispanic 52.2%

Race

Medicaid 21.7%

Medicaid Managed Care Fee

for Service 34.8%

Medicare 2.2%

Uninsured 13.0%

Unknown 28.3%

Last Medical Financial Class

Who are the Chiropractic Patients?

male

41.3

% female

58.7%

Gender

CHCMeridenChiroprac/cPDSA

CHCMeridenChiroprac/cPDSA

CHCMeridenChiroprac/cPDSA

CHCMeridenChiroprac/cPa/ents

Period:Jan.4-April18Average/4hrsession TOTALS–N(%)

Booked 8.90 267

ShowTotal 5.07 152(57%)

Show-Ini8al 1.50 45(30%)

Show-Established 3.53 107(70%)

CancelTotal 1.97 59(22%)

Cancel-Ini8al 1.10 32(54%)

Cancel-Established 0.90 27(46%)

NOshow 1.90 56(21%)

NOShow-Ini8al 0.90 24(43%)

NOShow-Established 1.07 32(57%)

CHCMeridenChiroprac/cPDSA:Results

92.1%

50.0%

21.1% 18.4% 18.4%

13.2% 7.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Back Neck Leg Arm Hand/ Wrist Other Foot/ Ankle

Perc

enta

ge

of

Pat

ients

CHCI Chiropractic Services General Area of Treatment

34.1%

22.7%

15.9%

9.1%

4.5% 4.5% 4.5%0%

5%

10%

15%

20%

25%

30%

35%

40%

724.50 724.20 338.40 V82.9 723.10 723.90 728.85

Perc

enta

ge

of

Pat

ients

CHCIChiroprac8cServices

ReferralICD-9Codes

724.50 Backpain(chronic)724.20 LOWBACKPAIN338.40 Chronicpainsyndrome

V82.9 SCREENFORCONDITIONNOS

723.10 CERVICALGIA

723.90 NECKDISORDER/SYMPTNOS

728.85 MUSCLESPASM

CHCMeridenChiroprac/cPDSA:Study

•  Painfunc/onalassessmenttool:veryuseful,assessedimpactofpainonavarietyoffactors

•  Ptsa/sfac/onwithchiroprac/cassessmenttool:highlysa/sfied

2.5

2.5

2.5

2.5

5.3

5.3

2.6

13.2

2.5

7.5

7.5

7.5

7.9

10.5

13.2

7.9

12.5

10.0

22.5

15.0

13.2

21.1

13.2

13.2

35.0

45.0

37.5

40.0

50.0

36.8

39.5

39.5

42.5

30.0

25.0

30.0

23.7

26.3

31.6

26.3

0.0 20.0 40.0 60.0 80.0 100.0 120.0

day to day activities

work around the home

ability participate in

social activities

your enjoyment of life

things you usually do for

fun

enjoyment of social activities

your household chores

your family life

How much did pain interfere with:

Percent of Patients

Pain functional assessment tool - Chiropractor Patients - time 1

Not at all A little bit Somewhat Quite a bit Very much

2.7

2.7

2.7

2.7

5.4

14.6

14.6

2.7

13.5

5.4

5.4

10.8

10.8

20.6

20.6

18.9

83.8

91.9

91.9

86.5

83.8

64.7

64.7

78.4

0 20 40 60 80 100 120

spent enough time with me

thoroughly explains the

treatment(s) I receive

treats me respectfully

listens to my concerns

answered all my questions

advises me on ways to avoid

future problems

gives me detailed instructions

regarding my home program

Overall, I am completely

satisfied with the services I receive

Percent of Patients

My chiropractor:

Pt satisfaction with chiropractic services assessment tool: highly satisfied

Disagree Agree Strongly Agree

Howmuchdidpaininterferewith:

Time1(Pre-Treatment)Mean(N=40)

Time2(Post-Treatment)Mean(N=8)

yourdaytodayac8vi8es 4.20 2.87

workaroundthehome 4.00 2.37

yourabilitytopar8cipateinsocialac8vi8es

3.80 2.75

yourenjoymentoflife 3.90 2.75

thethingsyouusuallydoforfun

3.77 3.00

yourenjoymentofsocialac8vi8es

3.67 2.87

yourhouseholdchores 3.87 3.00

yourfamilylife 3.6 2.75

PainFunc8onalAssessmentTool

Note:PainInterferenceScale.Scoresonpaininterferenceitemsrangefrom1(notatall)to5(verymuch).

Pa/ents’CommentsfromtheSurveys•  Dr.Lehmanandhisstaffof4thyr.internswereabsolutelygreat.Iwasveryimpressedandwouldrecommendthemtoanyone.

•  Youareawesome.Ifeelgreat:-)•  Iwouldrecommendyourservicestoanybody.Thankyouvery,verymuch!

•  Allareashavebeenaddressed,Iamimproving100%.•  IwanttoappreciatethetreatmentsIreceivedwithmychiropractorwhenIcameinthefirst/meIwasinalotofpainandIwasn'tabletofunc/onatallandtodayI'mfeelingwonderful.ThankstoyouallandIwishandpraythattheseservicesstaywithus.GoodLuck!

CommunityHealthCarePilotStudyStudentComments

•  Thankyouforallowingmetopar7cipate…•  Theone-on-onetrainingwasfantas7c…•  Seeingpa7entswithseriouspainrespondtochiroprac7ccarewasveryvaluable…

•  Excellentclinicaltraining…•  Ilearnedmorein6weeksthantheprioryear…

CommunityHealthCenter,Inc.

SiteofthefirstUBCC/CHCchiroprac/cservice

CommunityHealthCenter,Inc.Middletown

CommunityHealthCenterInc.NewsiteswithChiroprac/cServices

•  Bristol•  Danbury•  Norwalk•  Meriden•  Middletown•  NewBritain•  NewLondon•  Stamford•  Waterbury

Thankyou

Ques/ons?