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AAOS Now

Published 1/1/2014

The Orthopaedic Surgeon and Care Coordination

Why should orthopaedists care about coordination of medical care? It is about teamwork which provides efficient and quality care for patients. It can keep referral sources happy and patients coming through the door. Care coordination can optimize patient outcomes with fewer return calls, office visits, or readmissions. For some specialized practices, the cost vs. benefit of care coordination may not be apparent, but patient and health care reform demands may give a competitive advantage to those practices which recognize this component of providing “patient-centered care.”

Increasing specialization of medicine has fragmented the physician-patient relationship. The evolution of integration in medical care moved through the gatekeeper model into the medical home model (care coordinator) and now to the patient-centered medical home (PCMH) model, which is evolving into the patient-centered medical home neighborhood (PCMH-N) model.

For optimal musculoskeletal care, should there be a patient-centered musculoskeletal home? Based on the current requirements for certification of a PCMH by National Committee for Quality Assurance (NCQA), most orthopaedists would not be prepared or interested in the responsibilities of a PCMH. An alternative for specialists is to add value to the health care team by participating as a neighbor in the PCMH-N model.

Musculoskeletal care coordination (MSK-CC) provides an umbrella term for the myriad ways orthopaedic surgeons can offer value in these coordinated care models. Early involvement of orthopaedic surgeons in development of such a system presents an opportunity to improve the delivery system for the whole profession.

Team work with primary care providers and other referring colleagues can provide clear definitions of provider roles and responsibilities and ultimately improve health care delivery. As masters of the musculoskeletal knowledge base, orthopaedic surgeons can guide decisions to optimize musculoskeletal care. This might include shared educational development between various specialties, including identification of possible trigger points for referral.

Current MSK-CC Models
Current models of coordinated musculoskeletal care are common in acute care hospital settings and include orthopaedic service lines, orthopaedic centers of excellence, and comanagement agreements. With the emergence of payment models such as episode-based bundled payments, new models of care have likewise emerged.

One example of coordinated orthopaedic care is the Geisinger “guarantee” or “Proven Care.” For total joint replacement patients, care from preadmission to discharge and any complications are included in a single “guaranteed price.” The success of this model requires intense attention to efficient, predictable processes with reproducible outcomes and avoidance of complications.

Other examples include orthopaedic institute models with planned care pathways, where coordination produces referrals from primary care to sequenced specialty clinic interventions. This results in patients sent to orthopaedic surgeons when surgical intervention is most likely.

For example, interval care may be provided for arthritis by the appropriate mix of rheumatologists, sports medicine specialists, occupational medicine physicians, and midlevel professionals such as physician assistants and nurse practitioners. Appropriate interventions, diagnostic studies, and referrals are identified and coordinated to avoid inappropriate imaging or other diagnostic studies, minimize duplicative interventions, and reduce non–value-added referrals. Each care professional is utilized at the appropriate level of their training and experience. This provides a musculoskeletal care pathway with more predicable patient experience and value outcome.

Care coordination, as a concept, is simple and straightforward: provide the right care in the right place, at the right time to achieve the desired outcome. Care coordination in action is potentially as complex and challenging as any other aspect of health care delivery, but boils down to the team concept. As long as the team performs well and achieves the desired results, all stakeholders will be satisfied.

The PCMH-N recognizes the many players on the health care team and formalizes their organization. To optimize care coordination in a PCMH-N, orthopaedic surgeons should take ownership of musculoskeletal injuries and diseases. They should work with primary care and other providers to evolve coordination models that can add value to the care of musculoskeletal conditions.

This article is excerpted from the AAOS Musculoskeletal Care Coordination primer for orthopaedic surgeons, which was prepared by the AAOS Health Care Systems Committee and released in 2013. The free primer can be downloaded from the Health Care Systems Committee webpage in the government relations section of the AAOS website (www.aaos.org/dc).