Evidence-based Care Plans for Chiropractic (that can t be denied) Presented by Evan M. Gwilliam, DC MBA BS CPC CCPC NCICS CCCPC CPC-I MCS-P CPMA Vice President 1 Takeaway 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 1
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 2
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 BP Best Practices Patient s Values and Expectations Also: customers consumers policymakers BP Individual Clinical Expertise BBP BP BP Best Research Evidence BBP Best Best Practices Action Zone for: Dissemination Implementation Measurement Improvement 3
Proper use of guidelines 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 Bridging the Gap Complicating factors and Co-morbidities General Recommendations Additional Care 8 4
Complicating Factors Patient Characteristics Older age Pregnancy Psychosocial factors Delay treatment >7 days n-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 5
Complicating Factors History Pre-existing pathology/surgery History of lost time History of prior treatment Congenital anomalies Symptoms persist despite previous treatment Algorithm for the Chiropractic Management of Low Back Pain The scope of this algorithm is for the chiropractic management of spine related pain. It does not: 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 6
Patient presents with low back pain This is a new patient 1 This is an established patient with a new condition or a moderatesevere exacerbation of a preexisting condition 2 This is an established patient with a mild episode of a previously treated (usually chronic) condition. 3 Perform New Patient Evaluation 4 Perform Established Patient Evaluation Perform Evaluation 1 (Often 5 Condition Focused) 6 Pain 3 mo. duration 7 Pain < 3 mo. 8 duration Go to Acute Care Algorithm Go to Chronic Care Algorithm Acute Care Algorithm Patient presents with acute spine related pain. Refer to appropriate provider/ facility Assess for improvement at midpoint of trial using any of the accepted measurement tools Is Condition Outside of Scope of Is co-management Practice or 1 required? Skill Set 6 2 or Begin therapeutic trial of up to 12 visits within 4 weeks. 3 5 Refer to appropriate provider/facility 4 Improvement Evident at Midpoint? 7 Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management 9 Refer to appropriate provider/facility 10 Symptoms Resolved? 8 Continue Trial 11 Perform Reassessment Evaluation 12 7
Acute Care Algorithm Do MTB Achieved? Significant Symptoms and/or Is condition Functional deficits Stable or resolved? Remain? 15 13 14 /t Sure /t Sure Release with home care instructions or transition to wellness care 16 Functional/symptom improvements? Trial withdrawal desired? Consider comanagement 24 Other Treatment Options available In this facility? 18 17 Refer 19 Refer 23 22 Provide home care instructions and initiate trial withdrawal. Reassess condition status 25 26 Continue up to 12 visits within 4 weeks 20 Additional improvement likely? 21 Has condition deteriorated 27 Go to Chronic Care Algorithm Chronic Care Algorithm 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 8
Chronic Care Algorithm Chronic Care Goals 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 Algorithm Patient presents with chronic/recurrent spine related pain. Refer to appropriate provider/facility or provide home management instructions. Do the benefits of chronic pain management Red flags present? Refer to appropriate provider/facility outweigh the 2 risks? 4 3 1 or yes but appropriately managed. This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. 5 This is a symptom flare for a known chronic condition or recurrence of acute condition 7 This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms 8 Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. 6 Consider imaging 10 Traumatic cause of exacerbation? 9 Mild Exacerbation? 11 Continue Moderate to severe exacerbations follow Acute Care Algorithm. 12 9
Chronic Care Algorithm Treat for up to 6 visits. 13 Consider further diagnostic testing 15 Has patient returned to preepisode status? 14 Does Condition Worsen upon repeated attempts to withdraw care? 23 Release patient Provide home management recommendations if appropriate 25 Red Flags present or other conditions outside of scope or skill set? 16 Refer to appropriate provider/facility 17 Consider ongoing/ Recurrent care plan of 1 4 visits per month. Re-evaluate at least every 12 visits. 24 Symptoms Improved?/Are Chronic Care goals being Met? 18 MTB/Pre-Episode Status 22 Other Treatment options Available at this facility? 19 Discontinue care and refer to appropriate provider/facility for opinion/management 20 Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21 Remember 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. 10
The ChiroCode DeskBook is available at ChiroCode.com This presentation is covered Chapter 4.5 11