Case Study 1 Specialty Care Dartmouth Hitchcock Spine Center

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We needed a language to work with our patients. The value compass provides the language that helps our multidisciplinary team work with our patients to get them back to work, back to play, one back at a time.

James Weinstein, spine center founder

A Typical Illness Episode: Health Outcomes Tracking and More

A patient comes for his first visit to the Dartmouth-Hitchcock Spine Center in Lebanon, New Hampshire. He is greeted by the receptionist, given a touch-screen computer, and asked to use the computer to answer a set of important questions about his health before seeing the physician. He takes less than twenty minutes to answer questions about his back problem, functional status, expectations for treatment, and working status. When the patient finishes, he hands the computer back to the receptionist. The receptionist transfers the survey data to the reception desk computer, which has a custom-designed database application for processing and printing a patient value compass (PVC) in the form of a one-page summary report (Figure 9.1). The PVC provides a balanced view of clinical and functional status, patient expectations for and satisfactions with her or his clinical care management, and other data on work status and costs of care. The PVC is used to enhance communication between the provider and patient to better meet the patient's needs. It is placed on the front of the medical record, and when the patient sees the physician for an initial assessment, they review the PVC, which describes the patient's health status specific to the spine and also related areas, such as bodily pain, physical health, mental health, and role performance compared to an average person of her or his age and sex.

The sample PVC in Figure 9.1 shows not only that the patient is suffering from acute back pain but also that he has an extreme sleeping problem, is possibly suffering from depression, has been unable to work at his job for three weeks because of his back problem, and has had chronic back pain for more than three years. The patient and physician discuss these results, and after gathering additional data through history taking and physical examination, they develop a care plan that is based on the patient's preferences and health needs and that blends behavioral medicine, physical therapy, and occupational therapy.

On each subsequent visit to the Spine Center during the next two months, the patient uses the touch-screen computer to record his current health status; this updates the changes in such health outcomes as back pain, physical functioning, and mental health that he has achieved. After six months the patient is back on the job, is free from depression, and has pain that is only slightly worse than that of the average adult (Weinstein, Brown, Hanscom, Walsh, & Nelson, 2000).

Other Facts About the Spine Center

• The Spine Center uses a data wall to display important indicators of clinical outcomes, patient satisfaction, and business performance. (A data wall displays key measures for use by the clinical team; these measures show current performance and trends over time.) The various data displays create a story about practice performance, which can be viewed by the entire practice staff.

• The Spine Center views statistical process control charts and measures of processes and outcomes as essential keys to practice management and improvement.

FIGURE 9.1. PATIENT VALUE COMPASS FOR A TYPICAL SPINE PATIENT.

Patient:

Patient A-Number: Date of Birth: Visit Type: Initial Visit Clinician: Thom Walsh, PT

DHMC

10/10/01

Initial Visit Summary

Age: 20 Gender: male Race: White Weight: 190 Height: 5'11"

HISTORY

Age: 20 Gender: male Race: White Weight: 190 Height: 5'11"

Current Problem Areas: shoulder, neck, middle back, lower back and knee

Had spine-related problems for: more than 3 years

Most recent episode began: 9/4/01

Previous Providers: none of the listed care providers

Previous Treatments: medication

Daily Physical Requirements prior to problems: moderately strenuous

Reason for visit: for a second opinion and because another doctor recommended it

FUNCTIONAL STATUS

Pain and Daily Activities

Activity: Impact of pain

Dressing:

Lifting:

Walking:

Sitting:

Standing:

Sleeping:

Social life:

Traveling:

Sex life:

slight slight severe

- severe

- extreme

- substantial

- moderate

- moderate Oswestry Disability Index (0-100)

SF-36

] Scores

-Norms

] Scores

-Norms

——■—*-*---

47

60

63

40

40

[231

General Health

Mental Health

Physical Role Functioning Emotional

Role Physical

Social Functioning

Vitality

Bodily Pain

General Health

Mental Health

Physical Role Functioning Emotional

Role Physical

Social Functioning

Vitality

Work Status: on leave of absence

(not due to ill health) Hours/Week Before: 40 or more Hours/Week Now: does not apply Stopped Work: 9/16/01 Back to Work: Date Back:

Summary Scores (mean 50 SD 10)

100 75 50 25 0 NR

Summary Scores (mean 50 SD 10)

100 75 50 25 0 NR

severe

CLINICAL STATUS

Comorbidities: Depression and Back Pain

Smoking: Never smoked Duration: no response Frequency: no response Symptoms:

MODEMS Scores

80 60 40 20

NR ^ Neuro Neuro Pain Pain Cervical Lumbar Cervical Lumbar

Medications:

Current Medications over-the-counter

Freq. in past week not at all Effect of Meds: no response

EXPECTATIONS

Expect from treatment:

Symptom Relief: not sure More Activities: not sure Sleep Better: probably yes Return to Job: not sure Exercise and Recreation: not sure

Satisfaction:

If rest of life with current symptoms: somewhat dissatisfied

COSTS

Work Lost:

Missed: 3 weeks

Financial Assistance:

SocSecur: (not applicable) Disability: (not applicable) Work comp: (not applicable)

Provider Signature:

• The Spine Center creates an outcomes-based annual report and uses it as a key document during the center's all-staff annual retreat, where staff review improvements made and set up small teams to work on needed improvements for the coming year.

• The Spine Center contributes data to the National Spine Network, twenty-eight independent clinics that share outcomes data, enabling cross-site comparisons.

• The Spine Center is the lead organization for a $15 million, eleven-site, National Institutes of Health-sponsored, randomized clinical trial on the value of spine surgery for the three most common diagnoses for which spine surgery is performed.

• Many patients are delighted with the care they receive, but the Spine Center still has important improvements to make.

• The Spine Center has embraced the IOM's call for making quality data transparent and has started posting its outcomes and quality and cost data on the Dartmouth-Hitchcock Medical Center Web site (http://www.dhmc.org/ qualityreports).

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