1/26/2017

1

Evidence-based Care Plansfor Chiropractic

(that can’t be denied)

1

Presented by Evan M. Gwilliam, DC MBA BS

CPC CCPC NCICS CCCPC CPC-I MCS-P CPMA

Vice President

• Use evidence to bridge the gap from general recommendations to additional care

• Document care plans that make it easy for auditors to agree with you

• Maximize insurance reimbursement

Takeaway

1/26/2017

2

What is a Treatment Plan?

“A care plan is an ordered assembly of expected or planned activities, including observation goals, services, appointments and procedures, usually organized in phases or sessions, which have an objective of organizing and managing health care activity for the patient.”

3

What is a Treatment Plan?

1. A list of each complaint, with its relevant diagnoses

2. Treatments and modalities selected

3. Duration and frequency of care

4. Treatment goals

5. Objective measures to show progress

1/26/2017

3

Clinical Practice Guideline: Chiropractic Care for Low Back Pain

(J Manipulative Physiol Ther. 2016; 39, by Globe G,

Farabaugh RJ, Hawk C, Morris CE, Baker G, Whalen

WM, Walters S, Kaeser M, Dehen M, Augat T.)

Three places you can learn more:

• http://clinicalcompass.org/ccgpp/new-for-2016

• http://www.jmptonline.org/article/S0161-4754(15)00184-0/abstract

• ChiroCode DeskBook, chapter 4.5 Treatment Plans

Patient’s Values and Expectations Best Research

Evidence

Individual Clinical Expertise

Best Practices

‘Best’ Best Practices

BP

BP

BPBBP

Action Zone for: Dissemination Implementation Measurement Improvement

BP

BBP

Also: customersconsumerspolicymakers

1/26/2017

4

1. Care foundation includes: Research, clinical decision-making, patient values.

2. They are “guidelines”, not cookbooks for care.

3. They are NOT caps in care.

4. They are NOT rigid recommendations.

5. One must consider the “uniqueness” of each pt.

6. If denied, challenge the claim reviewer to produce the page, paragraph, and sentence demonstrating where you exceeded the guideline. If he/she cannot……………

7

Proper use of guidelines

8

General Recommendations

Additional Care

Complicating factors and Co-morbidities

Bridging the Gap

1/26/2017

5

Patient Characteristics• Older age

• Pregnancy

• Psychosocial factors

• Delay treatment >7 days

• Non-compliance

• Lifestyle habits

• Obesity

• Type of work activities

Complicating Factors

Injury Characteristics• Severe initial injury

• > 3 previous episodes

• Severe signs and symptoms

• Number/severity of previous exacerbations

• Treatment withdrawal fails to sustain MTI

Complicating Factors

1/26/2017

6

History• Pre-existing pathology/surgery

• History of lost time

• History of prior treatment

• Congenital anomalies

• Symptoms persist despite previous

treatment

Complicating Factors

Algorithm for the Chiropractic Management of Low Back Pain

• Dictate or recommend the modality of treatment• Guide the management of non-painful functional

or structural spinal care (subluxation correction, posture correction, scoliosis management, etc)

• Apply to wellness care/health promotion

The scope of this algorithm is for the

chiropractic management of spine related

pain.

It does not:

1/26/2017

7

This is a new

patient

Patient presents with low

back pain

This is an established patient with

a new condition or a moderate-

severe exacerbation of a pre-

existing condition

This is an established patient with

a mild episode of a previously

treated (usually chronic)

condition.

Perform New Patient

Evaluation

Perform Established

Patient EvaluationPerform Evaluation1 (Often

Condition Focused)

Go to Acute Care

Algorithm

Go to Chronic

Care Algorithm

1

2 3

4

5 6

Pain ≥ 3 mo.

duration

Pain < 3 mo.

duration 7 8

Patient presents with acute spine related pain.

Is ConditionOutside of Scope of

Practice or Skill Set

Refer to appropriate provider/ facility

Is co-management required?

Refer to appropriate provider/facility

Yes No Yes

Yes or No

Begin therapeutic trial of up to 12 visits within 4 weeks.

Assess for improvement at mid-point of trial using any

of the accepted measurement tools

Improvement Evident at Midpoint?

Consider• Modifying treatment methods• Additional diagnostic procedures• Referral or co-management

Refer to appropriate provider/facility

Continue TrialSymptoms Resolved?

Perform Reassessment

Evaluation

Yes

Yes

No

No

Acute Care Algorithm

1

23

4

5

6

7

8

910

11

12

1/26/2017

8

MTB Achieved?

Continue up to 12 visits within

4 weeks

Yes

No

Acute Care Algorithm

Do Significant

Symptoms and/orFunctional deficits

Remain?

Is conditionStable or resolved?

Release with home care instructions or

transition to wellness care

Trial withdrawal desired?

Functional/symptom improvements?

Has condition deteriorated

Consider co-management

Provide home care instructions and initiate trial

withdrawal.

Reassess condition status

Refer

Yes Go to Chronic

Care Algorithm

OtherTreatment

Options availableIn this

facility?

Additional improvement

likely?

Refer

Yes

Yes

No

No

No

No

Yes

1314

17

1516

19

18

2021

22

23

24

25

26

27

Yes No Yes

No/Not Sure YesNo/Not Sure

Complicating factors that may document the necessity of

ongoing care for chronic conditions.

• Severity of symptoms and objective findings

• Patient compliance and/or non-compliance factors

• Factors related to age

• Severity of initial mechanism of injury

• Number of previous injuries (N3 episodes)

• Number and/or severity of exacerbations

• Psycho-social factors (pre-existing or arising during care)

• Pre-existing pathology or surgical alteration

• Waiting >7 days before seeking some form of treatment

• Ongoing symptoms despite prior treatment

• Nature of employment / work activities or ergonomics

• History of lost time

• History of prior treatment

• Lifestyle habits

• Congenital anomalies

• Treatment withdrawal fails to sustain MTB

Chronic Care Algorithm

1/26/2017

9

• Minimize lost time on the job

• Support patient’s current level of function/ADL

• Pain control/relief to tolerance

• Minimize further disability

• Minimize exacerbation frequency and severity

• Maximize patient satisfaction

Chronic Care Goals

Chronic Care Algorithm

Patient presents with chronic/recurrent spine related pain.

Do the benefits of chronicpain management

outweigh therisks?

Refer to appropriate provider/facility or

provide home management instructions.

Red flags present? Refer to appropriate provider/facility

This visit follows a trial withdrawal and there

is a recurrence or worsening of

symptoms

This is a symptom flare for a known chronic

condition or recurrence of acute

condition

This is a scheduled visit for ongoing/recurrent care for a

patient expected to progressively deteriorate based

on previous treatment withdrawals.

Traumatic cause of exacerbation?

Treat according to ongoing/recurrent care

plan (1-4 visits permonth). Re-evaluate

every 12 visits at minimum.

Consider imaging

Mild Exacerbation?Moderate to severe exacerbations follow

Acute Care Algorithm.

Continue

No Yes Yes

No or yes but appropriately managed.

Yes

No

No

Yes

Chronic Care Algorithm

12

34

7

6

5 8

9

10

1112

1/26/2017

10

Treat for up to

6 visits.

Has patient

returned to pre-

episode status?

Consider further

diagnostic testing

DoesCondition

Worsen upon repeatedattempts to

withdrawcare?

No Yes

Release patientProvide home management

recommendations if appropriate

Consider ongoing/Recurrent care plan of 1 – 4

visits per month. Re-evaluate at least every 12 visits.

Red Flagspresent or other

conditions outside of scope or skill

set?

Refer to appropriate

provider/facility

SymptomsImproved?/Are Chronic

Care goals beingMet?

MTB/Pre-EpisodeStatus

OtherTreatment options

Available at thisfacility?

Discontinue care and refer to appropriate provider/facility for

opinion/management

Treat for up to 6 visits. Consider multimodal, multidisciplinary care.

Chronic Care Algorithm

No

Yes

Yes

YesYes

No

NoNo

Yes

No

13

1415

1617

18

1920

21

22

2523

24

• This is only for spine related pain

• All decisions should take into account provider experience and patient preference.

• Care is appropriate provided improvement is demonstrated and/or expected.

Remember…

1/26/2017

11

The ChiroCode DeskBook is available at ChiroCode.com

This presentation is covered Chapter 4.5