Evidence-based Care Plans for Chiropractic · PDF fileEvidence-based Care Plans for...
Transcript of Evidence-based Care Plans for Chiropractic · PDF fileEvidence-based Care Plans for...
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Evidence-based Care Plansfor Chiropractic
(that can’t be denied)
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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
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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.”
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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
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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
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Action Zone for: Dissemination Implementation Measurement Improvement
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BBP
Also: customersconsumerspolicymakers
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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……………
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Proper use of guidelines
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General Recommendations
Additional Care
Complicating factors and Co-morbidities
Bridging the Gap
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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
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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:
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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
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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
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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
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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
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• 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
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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
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• 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…
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The ChiroCode DeskBook is available at ChiroCode.com
This presentation is covered Chapter 4.5