To create pathways, start by redefining diagnosis
To create pathways, start by redefining diagnosis
By Arthur Runyon-Hass, MD, PhD
Diplomate, American Board of Anesthesiology
Medical Director of Pathway Healthcare
A consulting and medical management company
Brentwood, TN
The creation of a pathway for pain treatment must start at the beginning, with the patient’s diagnosis. Here’s how we develop treatment pathways for workers with chronic pain (see pathway, p. 19):
r Redefine the diagnosis.
The first and possibly most important step in pathway development for the chronic pain patient is making the diagnosis. Frequently, pain patients have been passed around the medical care system with a mixed bag of diagnoses. By the time patients are referred to us, the clinical frustration becomes evident. It is not uncommon to see referring diagnoses such as leg pain, back pain, or even whole body pain. Needless to say, you can’t design a treatment pathway around a diagnosis that does not even appear in the ICD-9 terminology.
You must redefine the diagnosis. This will provide an important triaging and channeling function for the patient and case manager. Occasionally, the diagnosis will be inappropriate for treatment at our center, and those patients are referred out. To aid in making the diagnosis, we have developed a set of frequently identified diagnoses to act as a sort of menu for the clinician.
We also have developed extensive lists of diagnostic indicators. These criteria help to more clearly delineate the primary or secondary diagnoses in potentially complicated patients. Once the primary diagnosis is identified, concomitant problems are more easily treated.
r Determine key treatment modalities.
Most physicians, nurses, and case managers are familiar with the concepts of the treatment pathway, algorithms, and care paths. These often are represented in complicated branching and re-branching formats. One of the major goals of these diagrams is to depict the logical sequence of thought or action involved in diagnosing or caring for a patient with a particular problem. These algorithms are mostly designed to include all of the possible clinical presentations that may exist. The end result often is highly complicated.
In contrast, our pathways were developed utilizing only those therapies that have proven efficacy based upon the literature or upon our own retrospective population survey. In general, we have found that treatment modalities based upon anecdotal success provide little additional improvements when applied to a large population of pain patients. While we realize some patients may benefit from the more invasive or controversial treatments, these options should not be considered until proven technologies are exhausted.
r Determine the appropriate treatment durations.
The duration of treatment is the final key factor to incorporate into the treatment algorithm. For the payer, time is cost. For the patient, time in treatment may mean additional physical or emotional pain. We developed our treatment time courses based upon literature references, community standards, and our own performance. Not only is the total duration of treatment critical, but so are the various milestones depicted within the pathway.
Both payers and patients are keenly aware of the passage of these milestones. The patients use the time points as a gauge to treatment success or failure. The payers monitor the milestones because they often are called upon to certify additional funding based upon data collected at each milestone evaluation.
One of the unanticipated benefits of the standardized treatment plan is a dramatic reduction in the duration of treatment often with enhanced patient acceptance. Feedback from payers, patients, and even referring physicians has motivated us to resist prolonged treatments based upon hopes for successful outcomes.
r Develop the case management tracking tool.
Our outpatient pathway/algorithm encompasses interventions by all team members from the scheduling clerk to the physician. In order to coordinate, monitor, and track the patient’s progress through the pathway, a customized tracking form was developed for each diagnostic clinical pathway. (See tracking sheet, p. 20.) This tracking form has been one of the most valuable aspects of our outpatient case management approach. In one quick glance, the case manager can review all aspects of treatment for a particular patient. It provides a list of the key interventions and a time frame for each diagnosis and patient. The tracking form further outlines the milestones of treatment to be reached. Examples of particular milestones may include patient education, duration of treatment, procedures performed, and reduction of pain from the baseline.
Most importantly for the practice-based case manager, the initiation of the tracking form "starts the clock ticking." The various tests, therapies, and milestones are measured in the context of weeks. In our practice, the time course is one of the more closely monitored outcomes of our treatment. This ongoing appraisal allows rapid identification of additional or underlying problems that may or may not be related to the primary diagnosis. These concurrent problems often will create the potential of significantly prolonging treatment. The tracking component helps to keep the various team members, and the patient, focused on the anticipated goals. It also promotes improved communication between the patient, team members, and payers.
r Sell the whole thing to the physicians.
One of the most tangible aspects of developing and using a case management model for pain patients has been the evolution of the attitudes of the physicians involved. As expected, the use of objective outcomes data has assisted the most in this transformation. Many of our clinicians initially resisted the concept of standardizing pain treatments for two primary reasons:
Each physician tended to believe his or her treatments were superior to those undertaken by other clinicians.
Physicians felt this population required a clinical approach that was too complicated to easily track.
The first misconception, concerning clinical superiority, was easily addressed by utilizing universally agreed upon outcome measurements. It quickly became apparent that, with few exceptions, Dr. Smith wasn’t significantly better than Dr. Jones. Once this initial misconception was cleared away, it became simple to identify those key aspects of patient care that made a critical difference. The rather complicated treatment plan, initially felt essential, had rather quickly become abbreviated.
The second major stage of physician buy-in involved the time course of treatment. Our efforts to appropriately abbreviate the treatment duration were most significantly aided by our patient education efforts. Historically, the patient with chronic pain had little clue as to what treatments to expect. Once we began providing treatment road maps, most patients became quite adept at facilitating their treatment plan as well as addressing when to discontinue treatment. With few exceptions, the patients preferred not to prolong treatment if they didn’t continue to improve. With time, our clinicians began to accept the basic treatment plan as well as the prescribed treatment duration. They similarly became quite helpful at outlining goals and time courses of adjuvant treatments if indicated.
The third phase of physician acceptance is what we call "comfortable dependence." Occasionally patients are not accepting of the caregiver’s recommendation to discontinue care. The physician often is placed in that difficult position of not doing "whatever you can do for me, doc." In these situations, our staff have found our outcome data helpful.
With the data in hand, the clinician feels less obligated to move on to the next treatment modality. Using the real-time tracking form helps clinicians make these decisions on a daily basis. Similarly, the physician now can give realistic success and failure rates of a planned treatment to patients, based on a larger population base and not simply his or her own anecdotal results.
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