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Merging the Podiatry Practice with the Cardiovascular Practice: A Win-Win Formula Desmond Bell, DPM, CWS First Coast Cardiovascular Institute Jacksonville, FL, USA President and Founder The Save A Leg, Save A Life Foundation Disclosures Speaker’s Bureau: • Organogenesis • Derma Sciences • Diatherix PAD: The Unnoticed Health Crisis Peripheral Arterial Disease constitutes “a health crisis that is largely unnoticed” by the public and all too often physicians as well, but that’s all about to changeDr. Mark Creager 2015 Presidential Address, American Heart Association The PAD and CLI Epidemic • PAD is the natural extension of CAD, even though they are technically different diseases, both are clinical manifestations of atherosclerosis • PAD affects an estimated 200 million people worldwide • US healthcare costs associated with PAD account for $20 Billion per year • The risk of Acute MI, Stroke, or Cardiovascular death among patients with PAD exceeds that of patients with established cerebrovascular disease AHA: New Spotlight on peripheral arterial disease. Jancin B. Cardiology News Digital Network. Dec. 2, 2015 Value Based Care Procedure-driven fee for service reimbursement is being phased out in favor of performance based reimbursement Value Based Care • “…overarching goal for providers, as well as for every other stakeholder, must be improving value for patients, where value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes” • 6 Components identified Porter ME, Lee TH Harvard Business Review. Oct. 2013; 1-19. Integrated Practice Units (IPUs) • The first principle in structuring any • IPUs treat not only a disease but also the related conditions, organization or business is to complications, and circumstances organize around the customer and that commonly occur along with it— the need. such as kidney and eye disorders for patients with diabetes • In health care, that requires a shift from today’s siloed organization by • IPUs not only provide treatment but specialty department and discrete also assume responsibility for engaging patients and their families service to organizing around the in care—for instance, by providing patient’s medical condition. education and counseling, • In an IPU, a dedicated team made encouraging adherence to treatment and prevention protocols, and up of both clinical and nonclinical supporting needed behavioral personnel provides the full care changes such as smoking cessation cycle for the patient’s condition. or weight loss Porter ME, Lee TH Harvard Business Review. Oct. 2013; 1-19. Integrated Practice Units (IPUs) • In an IPU, personnel work together regularly as a team toward a common goal: maximizing the patient’s overall outcomes as efficiently as possible • They are expert in the condition, know and trust one another, and coordinate easily to minimize wasted time and resources • They meet frequently, formally and informally, and review data on their own performance Porter ME, Lee TH Harvard Business Review. Oct. 2013; 1-19. • Armed with those data, they work to improve care—by establishing new protocols and devising better or more efficient ways to engage patients, including group visits and virtual interactions • Ideally, IPU members are colocated, to facilitate communication, collaboration, and efficiency for patients, but they work as a team even if they’re based at different locations The Virginia Mason Model • Virginia Mason Medical Center in Seattle created an IPU for back pain • “Spine Team” pairs Physician board certified in physical medicine and rehabilitation with Physical Therapist • Patients with low back pain call a central phone number, most seen the same day • Team members usually assess patient during the initial visit • Follow up care often done in satellite locations Porter ME, Lee TH Harvard Business Review. Oct. 2013; 1-19. • Virginia Mason patients miss fewer work days (4.3 vs. 9) per episode than regional averages • Need less PT visits (4.4 vs. 8.8) • MRI use to evaluate low back pain has decreased 23% since launch • Have seen more new patients per year (2,300 vs. 1404) under old system with same number of staff • Results have been faster treatment, better outcomes, lower costs and usually improving market share for the condition treated The Team Approach to Lower Extremity Preservation has already been Validated • Whether “Toe and Flow” or “Plumbing and Drywall”, the teaming of Podiatry with the Cardiovascular specialties is essential to lower extremity preservation • We must recognize and understand each other’s skill sets and they can optimally benefit patients The Lower Extremity Preservation Team • Zayed et al reported results of a retrospective analysis of 312 patients with diabetes and critical leg ischemia and demonstrated a reduction in amputation rate in a multidisciplinary setting • The team was composed of a vascular and podiatric surgeon, diabetologist, tissue viability nurse, interventional radiologist, and a radiology coordinator Sacramento SALSAL Chapter Driver, Fabbi, Gibbons, et al: The costs of diabetic foot: The economic case for the limb salvage team. Journal of Vascular Surgery, Volume 52, Issue 6, December 2010, Page 1751 Zayed, Hawala, et al. Improving limb salvage rate in diabetic patients with critical leg ischemia using a multidisciplinary approach Int J Clin Pract, 63 (2009), pp. 855–858 The FCCI Model • First Coast Cardiovascular Institute, Jacksonville, FL • Practice began as Cardiology specialty practice • Several interventionists within the group prefer performing lower extremity endovascular interventions • Cath lab on site as well as hospital performed procedures The FCCI Model • Full vascular lab testing, including nuclear stress, arterial and venous • Over the past several years, locations have increased to 12 throughout NE Florida • 2 plus years ago, brought on Podiatrists who specialize in wound care and limb preservation • Other services have grown to include Sleep Study/Pulmonology, Primary Care, Nutritionist, Nurse Practitioners The FCCI Model Final Thoughts • Organizing into IPUs makes proper measurement of outcomes and costs easier • Organizations that progress rapidly in adopting the value agenda will reap huge benefits, even if regulatory change is slow • Measuring outcomes is likely to be the first step in focusing everyone’s attention on what matters most Porter ME, Lee TH Harvard Business Review. Oct. 2013; 1-19. • Better measurement of outcomes and costs makes bundled payments easier to set and agree upon • With bundled prices in place, IPUs have stronger incentives to work as teams and to improve the value of care. Final Thoughts • Merging of specialized practices, such as cardiovascular medicine with podiatry makes sense on several levels • It is the most efficient model where lower extremity limb preservation is concerned • It is also the model that will be rewarded as the reimbursement shifts to Pay for Performance/Value Agenda • Slow adapters will not be remain financially viable Thank You! Merging the Podiatry Practice with the Cardiovascular Practice: A Win-Win Formula Desmond Bell, DPM, CWS First Coast Cardiovascular Institute Jacksonville, FL, USA President and Founder The Save A Leg, Save A Life Foundation