Overview

• The pilot team implemented an integrated practice unit (IPU), which improved access to care and surgical outcome for musculoskeletal (MSK) procedures in an underinsured and uninsured patient population.

Organization Name

Dell Medical School, The University of Texas at Austin

Organization Type

• Academic Medical Center
• Integrated healthcare system/network

National/Policy Context

• A large portion of the US population experiences underinsurance (up to 31 million people) or uninsurance (over 28 million people).
• Uninsured and underinsured patients suffer from disparities in access to musculoskeletal care, including having more difficulty making appointments, having longer wait times to appointments, and having to travel longer distances to get to appointments.
• These issues are thought to be worsened by a traditional fee-for-service model, which incentivizes expensive procedures and often limits the number of new patients seen by physicians.

Local/Organizational Context

• In Travis County, Texas, the county hospital district serving these populations was riddled with long wait times of more than 365 days to see an orthopedic surgeon and receive proper follow-up.
• At this time, a new medical school was being established in Austin, providing the opportunity to implement the IPU model.

Patient Population Served and Payor Information

• The project was conducted through a safety net clinic that saw patients who were insured primarily by County-based Medical Access Program (MAP) and Medicare or were uninsured.

Research + Planning

• The health system negotiated contracts with the county health district contracts that transitioned their payment structure from fee-for-service, paying providers for each clinic session regardless of the number of patients seen.

Workflow Steps

• Starting in June 2016, patients were referred to the newly established IPU if they had hip and elbow issues and/or were 50 years old with shoulder and knee problems.
• IPU clinic
  • The clinic included a multidisciplinary team of providers including physicians, chiropractor, nutritionist, and psychiatrist.
    • • Physicians provided medical care.
      • The chiropractor taught patient home exercises for better recovery.
      • The nutritionist provided weight loss counseling.
      • The psychiatrist provided behavioral health services.  
  • MSK providers received referrals via phone or email, and all incoming and wait-listed referrals were triaged by a staff member (either MSK-trained a chiropractor or family nurse practitioner).
    • The referrals were primarily for MSK-related concerns, including joint pain, and reduced mobility.
    • Appropriate patients were offered “virtual visits” via video call or telephone..
    • IPU staff also educated clinics seeking referrals about their new referral-triage system, logistics, and preemptive treatment before patients present at the IPU clinic.
  • Before each patient encounter, various providers collected clinical data and patient-reported outcomes measures (PROMs) related to a specific condition.
  • After collecting relevant data, all providers participated in a multidisciplinary team huddle to engage in collaborative decision making.
  • The collected data and shared decision were presented to the patient and allowed for counseling and care that aligned with the patient’s goals.

Where We Are

• This project is still ongoing.

Outcomes

• Primary outcomes
  • Access to care
    • Number of referrals addressed
    • Wait time from referral to appointment: The wait time improved by 84%, from an average of  >365 days to 59 days, for patients referred after the start of the pilot.
  • Surgical outcomes
    • Number of procedures performed: During the pilot program, 37/1368 patients seen in the IPU underwent surgery compared to 54/1167 in the PFFS clinic.
    • Hospital length of stay (LOS): The average LOS for IPU patients was 1.4 days, compared to the HFFS (2.9 days) and PFFS (2.6 days) (p<0.001).  
    • Discharge destination
    • 30-day readmission rate

• Secondary outcomes
  • Percentage of referrals addressed within 30 days: Of the referrals received after the pilot, 19% (239/ 1238) were addressed within 30 days compared to 2% (29/1401) before the pilot (p<0.001).
  • Proportion of new vs. follow-up appointments
  • Number of virtual visits: There were nine virtual appointments.
  • Patient-reported outcomes

Refer to Table 1 for detailed information.  

Future Outcomes

• The pilot team suggests that future outcomes to measure are the long-term benefits and sustainability of this approach.
• An extensive financial analysis is required to determine the cost-effective of the IPU model.

Benefits

The project demonstrated that an active referral system, combined with a team-based approach to care, improved access to care for underinsured patients.

Unique Challenges

• The IPU model implemented was multifaceted, so it is difficult to ascertain which factors contributed the most to improved access and outcomes.
• Study limitations:
  • The presented data is limited by the sample size and patient population that might not be generalizable.

Glossary

• Integrated practice unit: Multidisciplinary care teams that are bundled and paid for around specific medical conditions.   
• Fee-for-service: Payment for services are unbundled and paid for individually; this approach incentives quantity over quality.

Sources

• Williams, D. V., Liu, T. C., Zywiel, M. G., Hoff, M. K., Ward, L., Bozic, K. J., & Koenig, K. M. (2018, October). Impact of an integrated practice unit on the value of musculoskeletal care for uninsured and underinsured patients. In Healthcare. Elsevier.
• Roser MA. Some needy patients in Travis County wait a year to see a doctor. Austin Am-Statesman. 2015.