The first step toward building a successful musculoskeletal care delivery system is creating a structure upon which to divide the most important symptoms, conditions or patient segments (i.e., creating IPUs). This can be a challenge because being too inclusive in a single IPU will dilute the team’s ability to provide focused, high-value care for that condition, and picking conditions that are too rare or narrow makes it difficult to justify the upfront investment in resources.
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Explore This IssueDecember 2020
A base condition should have a high prevalence, burden of disease and cost of care across the patient population to maximize the opportunity for value improvement. In our institute, we created multidisciplinary teams dedicated to chronic conditions of upper extremity, lower extremity, back/neck and inflammatory/autoimmune disease (i.e., arms, legs, backs or all of those). These buckets are designed from the patient’s perspective and understanding rather than specific medical diagnoses to make it easier for them to be placed with the appropriate team.
We then created the multidisciplinary team that would be held accountable for managing the condition. The team included clinical and non-clinical members: orthopedic surgeons, rheumatologists, physiatrists, advanced practice providers, social workers, registered dieticians, physical therapists, chiropractors, registered nurses and medical assistants.
It is becoming more common for orthopedic surgeons and rheumatologists to co-locate in outpatient group practice settings, although this remains a somewhat new concept. The Integrative Rheumatology and Orthopedics Center at the Hospital for Special Surgery, New York, is one such model that exemplifies perioperative co-management of patients by rheumatologists and orthopedists.4 The center has several research projects underway, focusing on such topics as perioperative flares in rheumatoid arthritis.5 However, outcomes data for this collaborative approach is wanting and needed.
In a climate in which the medical and surgical worlds often remain separate and mired by long referral waitlists, we have intentionally broken down traditional silos by bringing rheumatology, physiatry and orthopedics together into a single clinical entity. From the provider perspective, it is a pleasure to work in an environment where interactions between medical and surgical providers are not only expedient, but collegial.
In more traditional settings, the co-management of patients like Ms. K. meant long hold times attempting to contact providers, unreturned pages and endless games of phone tag. Clinic notes with plans of care were often faxed to the wrong place, or not at all. Coordination of care was so challenging as to be nonexistent.
At the Musculoskeletal Institute at UT Health Austin, perioperative communication is easy, timely and enjoyable. We safely manage medications and transitions of care via face-to-face interactions or secure electronic communication. We provide the help of physical therapists and social workers to address patients’ social and financial challenges before and after surgery. In short, we provide patient-centered care.
Ms. K. was extremely grateful to both me and Dr. Koenig for allowing her to walk again. Our team is proud of what she achieved, and with joy in our hearts, we have all watched the video of her doing leg presses just weeks after surgery.
We entered this profession to be good doctors who provide great care to patients regardless of the circumstances. This case demonstrates what can happen when we put good doctors into a system that it is built to foster frequent and true collaboration. In reality, intelligent design deserves more credit for her success than her care team. Isn’t it time to start designing our care teams around the success of the patient from the patient’s perspective?