In his presentation at the 2018 Musculoskeletal Leadership Summit in Chicago, Dr. Jeff Masciopinto, Chairman, Department of Neurosurgery and Director of the Spine Program at SSM Health, describes the history of the spine program at SSM Health, including its successes, failures and goals for the future. The practice is in a 400-plus-physician multi-specialty group that covers a wide geographic catchment area, and also owns an HMO with 400,000 covered lives.
Not surprisingly, the program became more effective when they broadened the leadership group to include primary care physicians. This allowed them to consider and more accurately understand the entire patient experience in their decision-making. But it was when they finally started to acquire meaningful data that helped them to identify strengths and weaknesses in practice patterns that they were able to pivot and tighten the focus on best practice guidelines system wide.
When Dr. Masciopinto and his team initiated the change management process in the Spine Program at SSM Health, they began with some soul searching. “We had to figure out what we really wanted to be,” he says. This meant looking both nationally and regionally to determine if they wanted to be a full-scale spine center, and what exactly that would entail. “We started to develop this value-driven focus.”
Value is often looked at with a dollar sign, Dr. Masciopinto explains, but really it goes beyond that. The group at SSM Health defines value as guiding the patient to the right treatment team at the right time. This mantra continues to guide their philosophy as they continue to refine their triage process, surgical care pathway, and as they start to build an early access disease specific pathway in the near future.
The First Pivot: Step One
Dr. Masciopinto’s team moved to a new office space in Wisconsin, where they had on-site physical therapy and chiropractic care. “We wanted to engage more than just the usual surgical pathways,” he says. They looked at other spine centers and websites to gather ideas, while continuing to speak with other groups and consider the marketing involved.
The team brought in a nursing FTE to start collecting data. “One of my great crusades in this was to have some patient-reported outcome data,” he says. “It was probably the highest hurdle, but something I continued to loop back to as we worked to improve the patient experience.”
They created a custom algorithm in efforts to start collecting data from the patient immediately after the consult is requested. It was an expensive buy-in, but it gave them a foundation to build upon in improving communication, education and iterating on the process. “We also have a secondary evaluation where our mid-levels review imaging and the initial intake and now help with pointing people in the right direction, which has become our theme.”
Through the spine center patient navigation, they were able to move on to categorize areas such as: duration of symptoms, treatment prior to request for consultation, neurological deficits, and whether the patient had any high-end imaging. “We were seeing this huge uptake in MRIs being ordered, and this allowed us to look at whether they were being done at an appropriate time,” Dr. Masciopinto says.
The Results (Part One)
The data showed that of the 857 referrals for consultation, 828 patients completed the intake process. Of those patients, 17 (2%) had red flag symptoms and were referred for consultation urgently. From the remainder of patients initially triaged, 414 (50%) had less than six weeks of symptoms, 109 (13%) had less than six weeks of symptoms and an MRI, and 397 (48%) were scheduled for neurosurgical consultation.
Ultimately, with a maximum of 10 months of follow up, 535 (64%) of the group had abnormal MRIs and neurosurgical consults, and 80 (10%) had normal MRIs and were triaged to other providers. The data also demonstrated a 20% consult-to-surgery ratio.
The Second Pivot: The Fix
Now that they had the data, it was time to determine what they would do with it. They decided to create an EMR-based consult process with embedded best practice guidelines. If the patient continued to see symptoms after six weeks of care, then SSM Health would send them for an MRI and consultation.
“We got a lot of pushback, including angry calls from senior primary care colleagues who were frustrated that we were changing their long-standing practice,” says Dr. Masciopinto. “While it seemed like a great idea, it didn’t play out. We had implemented the fix based on our results, but we didn’t do a good enough job on the education side.”
This inspired the second pivot of the process, which is where the real change happened. They knew they had the data, but they had to engage their primary care doctors upfront. So the team nominated a primary care leader as co-director of the Spine Program. “Once we had her on board, not only did we have someone who’s in the realm and could tell us what’s frustrating from a primary care directive, but we could see the results and what behaviors they were creating as far as value.”
This was the big turning point; it was the point in which SSM Health was able to redirect from a screening process to a mantra of directing the patient to the right place at the right point of time in their pain problem.
The Results (Part Two)
As a result, the team at SSM Health was able to establish a more collaborative process. Primary care leaders not only had access to the data, but they had one of their leaders communicating to them. “They took it to heart,” says Dr. Masciopinto.
In addition to improving best practice adherence, they found patients understood, accepted and appreciated the process in which they were given their options upfront. This eliminates points of waste, both in regards to the patient’s time and pathway inefficiencies. “We’ve created more value, not only as described to the patients and providers, but we’ve reduced unnecessary MRIs by 100-plus a year (out of 800), leading to significant cost savings,” says Dr. Masciopinto. “We’ve also improved our surgery to consult rate to 40%, so we’ve doubled it and we’re nearing our goal of 50%.”
The Online Patient Surgical Pathway
The team at SSM Health felt like they had made significant improvements at this point, but they still wanted to move forward. They had yet to collect the outcomes data they were hoping for, and they still had more to do to enhance the patient experience once the patient came to see them for surgery.
The goal at this point was to get the patient more involved in their treatment. The team started an exploration for a more data-centered approach that would help them improve outcomes and reduce complications. Dr. Masciopinto began having discussions with Wellbe, noticing the improvements they were introducing to the total joint world could be readily applicable to the spine world. “We became the first Wellbe spine patient pathway,” says Dr. Masciopinto.
In addition to streamlining, vetting and unifying communication throughout the patient experience, they were able to implement physician practice uniformity with custom MD preferences. The team went on to construct three lumbar spine specific pathways, each one custom built with a focus on improving patient expectations, patient education and communication intervals throughout the experience.
“We’ve continued to modify this process,” explains Dr. Masciopinto. This has inspired a keen interest in rewinding the patient care pathway to the initial point of contact with the primary care provider. “We’re moving towards establishing a pathway that starts when they call their doctor.”
From here, they would enroll the patient in the pathway, which immediately initiates an education process that may involve some online coaching or online physical therapy. It also sets out expectation settings, which creates real value for the primary care doctors and for the health plan. “What we want to do,” says Dr. Masciopinto, “is continue with a really coordinated best care practice throughout the patient’s pain episode.”