American Society of Regional Anesthesia and Pain Medicine November 2017 - 36

A Novel, Clinic-Based Approach to Address Patients with Complex
Back Pain in a Veterans Administration Hospital: The Back Pain Home

O

ver the past several decades, we have witnessed the care
of patients with spine-related pain growing in complexity.
There is a tremendous expansion in the modalities available
to the interventional pain, neurosurgical, physical medicine, and
rehabilitation (PM&R), as well as psychological specialties for
the treatment of chronic painful conditions of the spine. Although
the additional resources are welcome developments, they have a
significant downside. When commonly employed treatment plans
are spread out concurrently over several specialties, we can see
a wasteful overlap of resources. The multiple processing of initial
intakes, imaging, electromyography (EMG), physical therapy (PT),
and surgical or interventional pain procedures consume significant
clinic capital. This problem becomes more pronounced in patients
with complicated clinical pictures as they become disproportionate
utilizers of care.
To address this problem and streamline care, involved providers
at the Veterans Administration (VA) Hospital in Palo Alto, California,
created a new clinical environment: the Spine Clinic. We staff our
clinic with attending-level physicians from the pain medicine,
neurosurgery, and PM&R specialties. We also have providers from
PT and psychological specialties. During an evaluation at the Spine
Clinic, the patient presents with all providers simultaneously. Prior
to seeing the patient, clinicians review the patient's history, prior
imaging, EMGs, physical exams, and psychological demeanor from
prior documentation, when available.
In selecting patients for
the Spine Clinic, we have
centered on treating patients
whose high degree of spinal
pathology requires frequent
provider input. We chose
those patients for several
reasons, one of which was
to preserve the standard tiered system of managing spine-related
pain. This system relies on primary care providers to spearhead
the delivery of care through the consult process. We recognize the
effectiveness of this system in managing most patient complaints
and therefore chose not to alter it. Rather, Spine Clinic patients are
selected by providers themselves from a cadre of pre-existing clinic
patients. Participation in the Spine Clinic requires no litmus test,
although typical Spine Clinic patients have had significant previous
interactions with one of our involved services and failed to make
meaningful progress with their condition. While there are no direct
consultations available to outside providers, the Spine Clinic staff
identify appropriate patients based on their knowledge of them and
of other specialties. By avoiding compartmentalization of specialties,
we enjoy a broader understanding of other involved professionals
and gain an appreciation for the effectiveness and appropriateness
of various plans of care. We feel that this cross-training has become
invaluable in directing all our clinic patients into appropriate care.

The Spine Clinic uses the
well-developed concept of a
multidisciplinary care model.
Significant data has shown that
addressing the physical as well as
the biopsychosocial pathologies
of patients leads to better
outcomes. Additionally, some
patients who have completed all
reasonable, validated conservative
and interventional care have
been deemed to be nonsurgical
Peter Barelka, MD
candidates and yet still suffer
Assistant Clinical Professor
from chronic daily nonmalignant
Department of Anesthesia, Pain and
pain of spinal origin. The
Perioperative Medicine
ubiquitous emotional pathology
Stanford University Hospital
of such patients often remains
Stanford, California
unaddressed in solitary clinics.
We have found the collaborative, Section Editor: Magdalena Anitescu, MD
multidisciplinary setting to be
helpful because it allows us to
address the patient's outstanding questions and emotional state in
a comprehensive manner. It also sets up a unique support system
for physicians, allowing us to collaboratively address a patient's
consideration of more high-risk, expensive, and often-unproven
treatment modalities. As such, the Spine Clinic practitioners are
occasionally in the situation of having nothing else reasonable
to offer. We believe that
having this discussion
with patients is important.
In a traditional clinical
construct, patients may
leave a clinic or become
lost to follow-up, only to
matriculate to another
clinical provider and repeat already disproven modalities. The Spine
Clinic's cooperative construct allows providers the unique capability
of telling a patient that there is likely nothing else to be done. This
allows us to address outstanding questions and emotional issues
that can assist the patient in adhering to a reasonably conservative
plan of care.

"During an evaluation at the Spine
Clinic, the patient presents with all
providers simultaneously."

36

Our Spine Clinic approach allows for a streamlined clinic
experience for the patient. No longer are patients asked to
complete up to five or more separate consultations and imaging
appointments to determine a plan of care. Rather, we offer timely
input from all the providers: a one-stop shop for patients that
brings to bear all available resources of various specialties. The
time a patient saves-although perhaps difficult to objectively
assess-is subjectively clear to see. The typically larger catchment
area of patients in the VA system may amplify this characteristic
and result in more significant time savings. However, even patients

American Society of Regional Anesthesia and Pain Medicine
2017



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