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Journal of Neuroscience Nursing:
doi: 10.1097/JNN.0b013e3181aaaaf5
Article

Software-Assisted Spine Registered Nurse Care Coordination and Patient Triage-One Organization's Approach

Crossley, Leslie; Mueller, Lori; Horstman, Patricia

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Author Information

Lori Mueller, RN BSN CRRN, is a nurse clinician at the West Virginia University Spine Center, West Virginia University Hospitals, Morgantown, WV.

Patricia Horstman, RN MSN NEA-BC, is the director of clinical program development and the administrator at the West Virginia University Spine Center, West Virginia University Hospitals, Morgantown, WV.

Questions or comments about this article may be directed to Leslie Crossley, RN BSN, at crossleyl@wvuh.com. She is a nurse clinician at the West Virginia University Spine Center, West Virginia University Hospitals, Morgantown, WV.

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Abstract

Back disorders encompass a spectrum of conditions, from those of acute onset and short duration to lifelong disorders. The use of a traditional spine center model of patient flow, in which the patient is scheduled the first available appointment without an initial assessment of spine-related symptoms at West Virginia University Spine Center, Morgantown, West Virginia, resulted in frustration and delays for the spine patient and referring physician dissatisfaction. Today, the use of a software-assisted spine patient triage and registered nurse care coordinator patient navigation system in this multidiscipline, multimodality comprehensive spine program provides quick and efficient patient triage to the appropriate level of spine care (surgeon vs. nonsurgeon). The model consists of five major steps, which are explored in this article: medical history intake; films or studies retrieval; rapid review of the patient's medical condition and diagnostics by a spine specialist preappointment and subsequent triage to the appropriate level of spine care; registered nurse care coordinator patient education and guided navigation through the patient's preferred treatment plan; and last, diagnostic study, pain injection, and provider scheduling. Patient satisfaction scores, referring physician satisfaction scores, and resultant impact on referral volumes, ancillary utilization, workload productivity, and surgical yield demonstrate that this new approach to patient triage has made significant improvements in efficiency, productivity, and service.

Over 80% of adults experience one or more episodes of back pain in their lifetime (Sg2 Health Care Intelligence, 2007). Physician visits for back pain rose 94% from 1994 to 2004 and will increase by 15% over the next 10 years (Sg2 Health Care Intelligence, 2007). Medical Expenditure Panel Survey data from 1997 to 2005 reflect that the average expenditure for respondents reporting spine problems was 73% greater than that of those without spine problems (Martin et al., 2008). Multiplying the mean incremental expenditures for spine problems in 2005 ($2,850; 95% confidence interval) by the estimated number of persons with spine problems in 2005 yields $85.9 billion (95% confidence interval) in additional health expenditures among those with spine problems. This represents 9% of the total national expenditure estimated from Medical Expenditure Panel Survey (Martin et al., 2008). These data suggest that spine problems are expensive, due both to large numbers of affected persons and to high costs per person.

The cause of back pain is often unclear, and patient needs differ according to the presenting symptoms, diagnosis, psychosocial factors, and goals for recovery. Approximately 90% of back pain cases have no identifiable cause and are designated as nonspecific (Manek & MacGregor, 2005). Van den Bosch, Hollingworth, Kinmonth, and Dixon (2004) reported that the probability that a particular case of back pain has a specific cause (spinal fractures, cancers, infections, and cauda equine syndrome) identified on back radiographs is less than 1%. Diagnostic triage of low back pain is useful in screening for red flags, those warning signs that should lead the clinician to investigate for a serious pathology in need of immediate diagnosis and treatment, and in weighing the urgency of medicosurgical treatment (Poitras et al., 2008).

Treatment of back pain should begin with conservative, nonoperative treatment, especially when the source of pain cannot be identified. Surgical treatments should be explored when indicated by diagnostic tests and imaging findings and in consideration of patient comorbidities and psychological status.

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Comprehensive Spine Programs

A comprehensive spine program can serve as a model of cost-effective, patient-centered care within an academic medical center (Chen & Yang, 2008). The ideal spine center would serve back or spine pain patients expeditiously, providing a comprehensive range of imaging and physiological testing; offer timely surgical or nonsurgical treatment options; and include professionals who are good communicators and can provide patients with appropriate explanation of the cause of their symptoms, take into account the patient preferences, and encourage patients to become more actively involved in treatment of their back pain (Chen & Yang, 2008).

Through multidisciplinary collaboration, comprehensive spine programs allow patients to receive seamless care across multiple locations and provide a strong communication link to all stakeholders, including referring physicians, patients, payors, and employers. Patient access to spine care, specific scheduling with the appropriate spine specialist for his or her specific spinal issue, collection of previous relevant spine studies and tests, and obtainment of the necessary authorizations can result in miscommunications, delays in treatment, patient and referring physician frustration, and loss of subsequent referrals. To be successful, a spine program must enhance continuity of care for the patient, provide two-way communication with the patient's referring and primary physicians, and schedule visits and procedures quickly.

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Multidisciplinary Collaboration

Although many spine programs focus solely on surgical spinal care, the West Virginia University (WVU) Spine Center recognized that diagnostics and nonoperative treatments also play critical roles in spine care. Nationwide, fewer than 10% of back pain patients require surgical intervention (Sg2 Health Care Intelligence, 2007). At WVU, prior to June 2005, a newly referred patient was scheduled the first available appointment with a spine surgeon without initial assessment of presenting spine-related symptoms. The registered nurse (RN) played no role in this process.

As a result, it was not unusual to have a spine surgeon's clinic overbooked and patient wait times to range from 2 to 6 months. Many patients came to their initial appointment without attempting conservative treatment or completing appropriate testing, leaving the initial patient appointment with the need for additional diagnostic testing and a subsequent return appointment. Under this traditional approach, the WVU spine surgeon medically managed the patient's nonsurgical spine issues, often impeding access for those patients whose conditions did require surgical intervention. More specifically, surgical yield per clinic for at least one spine surgeon at WVU was one surgery per 67 scheduled clinic visits or one surgery per clinic day. Patients who required surgery waited in line with patients who did not require surgery. Both referring physicians and patients verbalized frustration with the delays in care.

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Integrated Systems

At WVU, the hiring of a neurology-neurorehabilitation spine specialist and use of other existing nonsurgical spine specialists (occupational medicine, osteopathic medicine, and pain specialists) provides additional avenues for conservative treatment of spine-related issues. A central point of access, elimination of service duplication, utilization of nonsurgical treatments such as physical therapy and pain management, and the use of nurse navigators as care coordinators were incorporated in the WVU Spine Center program to promote continuity and to ensure triage to the appropriate spine specialist on the first patient visit. The RN care coordinators use clinical algorithms and policies and procedures to assure standardization of care and to guide appropriate patient migration through the spine care delivery system.

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Patient Triage

In consultation with the Mayfield Clinic & Spine Institute in Cincinnati, the WVU Spine Center implemented the Priority Consult™ spine patient triage process on June 1, 2005. An innovative program, Priority Consult™ is a software application used by the spine center staff and physicians to assist patients with spine problems to access appropriate treatment quickly, efficiently, and easily (Gilligan, 2006).

This software system was selected by the WVU Spine Center because it would not only allow for electronic capturing of each patient encounter but also support paperless care coordination and patient navigation across the full continuum of sites and services preappointment. This system also allowed for data reporting of volume indexes such as treatment utilization, noncompliance rates, and spine specialist practice patterns and electronic capturing of a rapid review of the patient's medical condition and diagnostics by a spine specialist, preappointment, and subsequent triage to the appropriate spine specialist (Fig 1). A typical patient prior to this approach might have spent up to 6 months awaiting treatment to obtain resolution of symptoms, whereas now patient treatment begins, in collaboration with the referring physician, pre-spine specialist appointment (Table 1) within 1 week of films or studies receipt and spine specialist case review and triage.

Table 1
Table 1
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Figure 1
Figure 1
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It is important to note that this approach is solely used for preappointment patient triage and care coordination and is offered at no charge to the patient. Once a patient's appointment is scheduled with a spine specialist, all subsequent care, including referring MD communication, is managed through the respective spine specialists' clinic and administrative department (WVU Orthopedic Clinic, WVU Department of Neurosurgery Clinic, Medical Specialties Clinic, and WVU Pain Center).

The use of this approach allows for a seamless stream of data between spine specialist physicians and the Spine Center office and is viewed as an invaluable component of the spine care system at WVU. Communication surrounding the patient's care is electronically recorded including the medical history, treatment modalities completed, arrival and current location of films or studies, initial spine specialist impression and recommendations for treatment, RN care coordination notes, referring physician written communications, all patient telephone encounters, and scheduling discussions providing fingertip access to important patient care information and eliminating the perception of fragmented care across the continuum.

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RN Care Coordination

Once a new spine patient referral is received by fax or by telephone, the staff assistant completes demographic data entry in the software system, thus creating a new electronic patient record. After data entry, the RN care coordinator screens all new patient referral documents (studies or films radiographic reports and clinic notes) to identify red flags that might warrant the need to bypass the spine specialist review. In addition, the RN care coordinator may designate which spine specialist is most appropriate for the case based on specific spine specialty, patient diagnoses, presenting symptoms information found in the referring physician's clinic examination notes (if available), and preestablished spine specialist scheduling guidelines.

For those patients whom the RN care coordinator deems not meeting the established scheduling guidelines for bypass of the triage process, a referral specialist (individual with managed care orthopedic or neurosurgery background and extensive training in medical terminology and advanced training in telephone communications) contacts the patient via the telephone and obtains a detailed spine health history following a preset questionnaire of patient data elements specifically designed to capture the patient's current history of illness, work history, medications, previous treatment options explored, and diagnostic tests completed. Those referred patients who are not accessible by telephone to complete the medical history intake, for example, an incarcerated patient or a patient in a nursing home, are scheduled the first available appointment in the nonsurgeon spine specialist clinic.

If during the history intake process the referral specialist has questions regarding patient information obtained, the RN care coordinator reviews the patient's history and intervenes or directs care as appropriate. If the patient has had recent spine studies (within the past 6 to 12 months), the patient is asked to send the actual films and reports to the Spine Center. Once received, the RN care coordinator validates the relevant studies available and logs the films or studies arrival in the software system. This allows the software system to flag the patient as ready for spine specialist review. The spine specialist then reviews the patient's history and studies (typically within 1 week of receipt) prior to an appointment. New patient referrals in 2007 averaged 16 referrals per day. WVU currently has six spine surgeons and one nonsurgeon spine specialist who perform preappointment, software-enhanced patient triage. Dependent upon the individual spine specialist's practice, case reviews can range from 10 to 40 patients per spine specialist per week.

After review of the available studies, the spine specialist documents his or her initial impression and recommended treatment plan. He or she may request the patient be scheduled the first available appointment, recommend another specialist see the patient (surgeon, interventional radiologist, pain clinic, occupational medicine, physical therapy, chiropractor, massage therapist, neurology, or other specialist), and request further diagnostic testing or that the patient start a specific medication (e.g., neurogenic pain medicine). In addition, he or she will determine the urgency of the appointment scheduling. If nonsurgical treatment is requested before an appointment, the RN care coordinator calls the patient directly and discusses the treatment plan recommendations (i.e., physical therapy, steroid injection, and medication initiation) with the patient.

The telephone is not generally considered to be a primary tool in the delivery of nursing care; however, the telephone provides a vital link to patients. It is via the telephone that the RN care coordinator brings treatment resources and support to the patient and assists the patient in navigating through the spine program care continuum before clinic visit. The RN care coordinator initiates contact with 100% of the patients within 24 hours of spine specialist review completion. In turn, the RN care coordinator also provides a vital link to the referring physician community by collaborating with the referring physicians to obtain necessary testing or procedures preappointment.

Walker, Holloway, and Sofaer (2000), whose study followed 20 adults seeking initial treatment of low back pain at two pain clinics in the United Kingdom, identified that spine pain patients experience long periods of waiting for referrals, investigations and their results, appointments, surgery, and pain clinics. Communication was poor, and little coordination or continuity of care occurred. During the process of seeking diagnosis and treatment, adults with chronic, benign, low back pain experienced frustration and felt that they were rendered passive, powerless, and entrapped by healthcare, social, and legal systems that were initially designed to provide help and protection.

Recognizing the importance of partnering with the patient, fostering continuity of care, and maintaining effective communication, the nurse-patient relationship at WVU is further enhanced because the WVU Spine Center RNs provides both telephone triage services and direct patient care in the Spine Center Medical Director's clinic rotating clinic time and spine center office time every 2 days. These patients speak with the nurse preappointment and are then cared for by the same nurse at the clinic visit.

During the telephone interaction, the RN care coordinator verbally educates the patient on his or her condition, providing information as simple as the spelling of the word spondylolysthesis to the complex steps of an epidural steroid injection. After educating the patient, the RN then assists the patient in the decision-making process regarding his or her treatment plan options or preappointment care and facilitates scheduling further studies or procedures. The referring physician and/or primary care physician is informed of the spine specialist's initial impression and recommendation(s) and asked to authorize components of the treatment plan including additional testing and referral to pain management or physical therapy as applicable.

Through the use of this software program, the RN creates a running list (ongoing queue) of patients for follow-up at intervals he or she predetermines to be appropriate, for example, 2 weeks after initiation of therapy. Patients receive the assurance of an expedited appointment if treatment results are unsatisfactory. When unable to reach the patient by telephone after two attempts, a letter is mailed instructing the patient to call the RN telephone line directly, bypassing the main telephone line system.

The treatment recommendations are communicated by written correspondence faxed to the referring physician for authorization within 48 hours of spine specialist case review and to the RN for patient discussion completion. Those patients who are identified as urgent or a potential surgical candidate are scheduled an expedited appointment into one of the spine specialist clinics; specific clinic slots are held for these urgent patients. Guiding principles for care coordination include early, aggressive specialty treatment that promotes rapid return to work with improved function and optimized utilization of healthcare resources, allowing care within the patient's local community, use of the family practitioner in the patient's treatment plan, limited use of narcotics, reduction in duplication of services, and reduction of delays in provider appointments.

Patients who follow the preappointment recommendations may experience resolution of their pain and not require hands-on evaluation by a spine specialist. In these situations, the patient's file is closed, the referring physician is informed via written correspondence, and the patient is instructed to call should he or she desire an appointment in the future.

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Spine Center Staff and Roles

The current number of staffed full-time equivalents (FTEs) and the skill mix in the WVU Spine Center has evolved as patient and referring physician expectations and feedback have dictated and as referral volumes have increased over the past 3 years. The director of clinical program development, in addition to other program development responsibilities, functions as the administrative director of the WVU Spine Center and has administrative responsibility for program growth, including implementation of the software-enhanced triage system, operational budgets, marketing, performance improvement and quality reporting, facilitation of the WVU Spine Center Committee, and oversight of Spine Center day-to-day operations. Holding a bachelor of science and a master of science in nursing and nurse executive-advanced professional certification through the American Nurses' Credentialing Center, the director brings 25 years of nursing and, most recently, 7 years of healthcare program and business development experience to this role.

The WVU Spine Center currently staffs 2.0 FTE RN care coordinators. As discussed previously, one RN care coordinator staffs the Spine Center clinic with the medical director 4 days per week. This RN care coordinator updates the patient's medical history, accesses test results, facilitates the treatment plan (medications, physical therapy course, or steroid injections), and provides patient education regarding the plan of care.

In addition, the second RN care coordinator works in the Spine Center office triaging new referrals, providing initial impression and treatment recommendations and patient diagnoses education to patients via the telephone requesting referring MD written communications; facilitates the patient treatment plan; addresses operational issues that arise (e.g., referring MD calls and coordination of external site test scheduling); and addresses all medical director clinic patient telephone calls regarding medication refills, response to treatment, and other postclinic visit care needs. The two RN care coordinators rotate work assignments between the Spine Center clinic and office. Documentation of all patient encounters in the electronic medical record or software system supports this rotation, allowing both RNs the ability to review all patient interactions and to determine patient status quickly and efficiently (Tables 3 and 4).

Table 3
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Table 4
Table 4
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Referral specialists (2.6 FTEs) obtain patient medical histories, facilitate all patient scheduling, facilitate scheduling of patients to other providers outside the spine center but within the WVU Health Sciences Center, obtain authorizations for testing, manage the medical director's clinic and business calendar, and courier films between multiple sites within the Health Sciences Center complex (Tables 3 and 4). A staff assistant (1.0 FTE) triages calls from the main telephone line, performs data entry on all new referrals, processes all referring physician written correspondence (Tables 3 and 4), and provides limited secretarial support for the medical director.

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Outcomes Evaluation

Meeting bimonthly, a WVU Spine Center Committee, composed of those from the neurology-neurorehabilitation, orthopedic surgery, neurosurgery, physical therapy-rehabilitation, occupational medicine, osteopathic medicine, pain management, nursing, and administration departments, is responsible for the development and implementation of standards of care, algorithms and policies and procedures, utilization review, and quality outcomes evaluation. The perceived patient experience and pain relief are the true litmus tests of service quality. Patient satisfaction is routinely assessed in many ambulatory medical facilities for practice management, marketing, and outcomes research, and the effectiveness of evaluating interventions is based on the quality of the data collected (Zoller et al., 1998). The instruments used for assessing satisfaction range from "home-grown" informal surveys to elaborate, scientifically developed ones. There are limited data on the association between patient satisfaction and future use of services except to demonstrate that dissatisfaction leads to nonreturn (Zoller et al., 1998).

At WVU, the patient is the central focus of the spine care program. A variety of approaches are used to collect information relative to patient satisfaction including patient interviews, referring physician feedback, and direct-mail home-grown patient surveys. Patient satisfaction was assessed in fall 2007 through the use of a Likert-type scale survey instrument with questions about eight aspects of service-ease of access, history completion, scheduling, explanation provided by the RN, patient inclusion in decisions regarding treatment by the RN, follow-up instructions provided by the RN, overall experience, and likeliness to recommend to the WVU Spine Center. The survey instrument was mailed, along with a stamped self-addressed return envelope, to a random sampling of 100 patients who had completed all phases of the triage process within the previous 2 months, with an accumulation of 38 responses.

Survey results reflected high satisfaction with all aspects of the services provided, but more specifically, relevant to the RN care coordination role, patient satisfaction scores ranged from a score of 4.33 to 4.44 on a scale of 1 (very dissatisfied) to 5 (very satisfied; Table 2). Overall patient satisfaction with their experience at the WVU Spine Center was rated at 4.42, whereas the likeliness to recommend the WVU Spine Center to others was rated at 4.55.

Table 2
Table 2
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Likewise, referring physician satisfaction was assessed in fall 2007 through three aspects of service-comfort with triage, communication, and likeliness to recommend the WVU Spine Center to his or her patients. The home-grown survey instrument was mailed, along with a stamped self-addressed return envelope, to the top 100 referring physicians, with an accumulation of 36 responses. Survey results were analyzed into three categories: surgeon as the referring MD, family medicine practitioner as the referring MD, and both surgeon and family medicine practitioner combined (Tables 3 and 4). Satisfaction was reported as fair to good for the combined family medicine practitioner and surgeon group for comfort with triage (3.47), communication (3.77), and likeliness to recommend the WVU Spine Center to his or her patients (3.68). Family medicine practitioners reported higher satisfaction scores than did their surgeon counterparts in two areas: comfort with triage (3.91 as compared with 3.62) and communication (4 as compared with 3.87), whereas likeliness to recommend the WVU Spine Center to his or her patients was equal at a rating of 3.87.

The RN care coordinators play a vital role in referring physician satisfaction. The RN care coordinators accompany the medical director on, at minimum, three site visits per year to a referring physician's office or group practice. Suggestions received from the referring physicians are then brought back to the spine center director and staff for discussion. One example of a practice change implemented because of referring physician feedback and dialogue with the RN care coordinator would include simplification of the referring MD letters to include only the patient demographics and an abbreviated patient summary highlighting the spine specialist initial impression and recommendations versus a complete printing of the patient's medical history along with the aforementioned information. In addition to site visits, the RN care coordinators will call the referring MD office and speak to either the nurse or the referring physician directly to expedite care of a patient who presents with red flags or in which the spine specialist has identified a non-spine-related medical condition warranting medical intervention (i.e., abdominal masses and renal stones). This one-to-one contact further demonstrates the vital role of the RN care coordinator in treatment of the patients entrusted with their care.

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Ancillary Utilization

As discussed previously, through the use of RN care coordinators and preappointment spine specialist determination of diagnostic needs, patient testing is offered to the patient at WVU Hospitals (WVUH) or the patient's local community if travel distance warrants. Because of facilitating ancillary testing at WVUH, volumes have increased 36% to 54% from 2002 to 2007 for diagnostics including spine MRI, x-ray, and computed tomography scan and electromyography-nerve conduction studies.

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Patient Access

Through a review of the patient's presenting symptoms and diagnostics combined with the use of frozen expedited appointment slots per spine specialist, the RN care coordinator can request the referral specialist to expedite patients with more urgent needs (e.g., fractures, tumors, acute injury, and bowel and bladder symptoms) to a surgeon's clinic, typically within 24 to 48 hours of identified need. The spine surgeon now has more flexibility to focus on problems that require surgical intervention because appropriate referrals of nonsurgical candidates to nonsurgical spine specialists have opened spine surgeon clinic slots for potential surgical candidates, resulting in a 17% increase in surgical volume from 2003 to 2007. Wait times for access to the medical director's clinic in 2005 meant a wait time of 9 to 12 weeks, today, wait time for the first available appointment is 1 to 2 weeks. Other outcome metrics include the following:

1. Average time from initial referral receipt to completion of the medical history intake process is 24 to 48 hours.

2. Ninety percent of spine specialists case reviews are completed within 1 week of film receipt.

3. Ninety-nine percent of patients referred are scheduled an appointment with a WVU provider.

4. Fifty percent of the referrals to a spine surgeon are triaged, after spine surgeon preappointment case review, to other nonsurgeon spine specialist providers.

5. Patient referral volume increased 21% from 2003 to 2007 and has resulted in the recruitment of two additional spine surgeons.

6. Twenty percent of patients will not complete the process and exit out of the system for reasons such as not returning calls to complete the medical history intake, not sending requested films, or declining the treatment plan.

7. Ancillary utilization for WVUH has increased because patients are encouraged to have studies or testing performed at WVUH (Table 5).

Table 5
Table 5
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Key Lessons Learned

WVU Spine Center was the first academic medical center to implement this software-assisted medical triage approach to spine care. Key lessons learned as pioneers in the use of software-assisted spine care coordination and patient triage include the following:

1. RN care coordinator knowledge of relevant disease processes and treatment modalities is essential to the provision of a seamless, quality service.

2. No two spine patients are alike. Protocols, policies, and procedures can serve as a guide for care, but the sound clinical judgment of the RN care coordinator is essential to optimize each patient's outcome.

3. Preappointment patient triage is not a concept embraced by all referring physicians and patients. Offering the option to bypass patient triage and the scheduling of the first available appointment are viewed as necessary compromises for a select few to maintain relationships.

4. Preappointment patient triage is only as efficient as the spine specialist's ability to complete patient reviews on a regular, timely fashion and the patient's willingness to adhere to the recommended treatment plan.

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Summary

It is the goal of the WVU Spine Center to start the patient's treatment plan so that the patient can get on the road to recovery as soon as possible, even prior to a spine specialist clinic appointment. A software-assisted patient triage process and the use of an electronic medical record to document all patient encounters by telephone, fax, and mail are essential to facilitating seamless patient care. The use of RN care coordinators to assist in appropriate patient triage and patient navigation through a complex multidisciplinary, multimodality treatment plan is imperative to provide the patient the optimum treatment options and seamless efficient access to the appropriate level of spine care to maintain his or her quality of life.

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Acknowledgments

The authors express their gratitude to the WVU Spine Center referral specialists; staff assistant; medical staff; and Michael Graham, director, Priority Consult™ who have contributed to the success of the WVU Spine Center.

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References

Chen, J. J., & Yang, R. K. (2008). A look inside an interdisciplinary spine center at an academic medical center. Iowa Orthopaedic Journal, 28, 98-101.

Gilligan, M. (2006). Taking a new posture: Case study: How electronic triage supports efficient spine care in one surgical group-and how you can adapt the approach for your spine practice. MGMA Connexion, 6(6), 44-47.

Manek, N. J., & MacGregor, A. J. (2005). Epidemiology of back disorders: Prevalence, risk factors, and prognosis. Current Opinions in Rheumatology, 17(2), 134-150.

Martin, B. I., Deyo, R. A., Mirza, S. K., Turner, J. A., Comstock, B. A., Hollingworth, W., et al. (2008). Expenditures and health status among adults with back and neck problems. JAMA, 299(6), 656-664.

Poitras, S., Rossignol, M., Dionne, C., Tousignant, M., Truchon, M., Arsenault, B., et al. (2008). An interdisciplinary clinical practice model for the management of low-back pain in primary care: The CLIP project. BMC Musculoskeletal Disorders, 9(54), 1-14.

Sg2 Health Care Intelligence. (2007). Clinical intelligence. Developing a comprehensive spine program. Skokie, IL: Author.

Van den Bosch, M. A., Hollingworth, W., Kinmonth, W. L., & Dixon, A. K. (2004). Evidence against the use of lumbar spine radiography for low back pain. Clinical Radiology, 59, 69-76.

Walker, J., Holloway, I., & Sofaer, B. (1999). In the system: The lived experience of chronic back pain from the perspectives of those seeking help from pain clinics. Pain, 4(80), 621-628.

Zoller, J., Lackland, D. T., Dunbar, J., Evert, H., Gross, A., Johnson, J., et al. (1998). Identification of satisfaction components that predict patient return behavior. Abstract Book: Association for Health Services Research Meeting, 15, 215-216. Charleston, SC: Center for Health Care Research, Medical University of South Carolina.

© 2009 American Association of Neuroscience Nurses

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