Patrick Vega is a consulting director for Vizient’s Advisory Solutions, however Cordata first met him in 2011 when he wrote a breakthrough article for Becker’s Spine on the topic of patient navigation for spine. In the article, he discussed the importance of patient navigation, specifically for spine patients, and key elements of clinical navigation that are now considered best practices in most Comprehensive Spine programs across the United States.
Here, Cam Teems, Sr Director of Healthcare at Cordata, sits down with Patrick to dive deeper into the topic of patient navigation and the concepts of the article that remain relevant over a decade later.
Cam: Hi Patrick, thank you so much for taking the time to fit us into your schedule. I’d like to begin by talking a little bit about innovation. Innovation is a bit of an overused term, but for us here at Cordata Healthcare, we define it as out-of-box thinking around providing disease navigation inside a program, whether that program is on a hospital campus, joint venture between a hospital service line and a private practice, or simply in a private practice that offers the courtesy of one-on-one support between navigation of spine cases, orthopedics, cancer, etc. Today, we are going to focus on innovation in spine navigation, so I want to start by going back to when people really began to read about spine navigation in print, mostly due to the 2011 article you wrote for Becker’s Spine. Can you give a little background on the article and role of the spine navigator?
Patrick: The article was drawn from my exposure to Cordata’s predecessor Priority Consult. I saw a flyer from the medical center at West Virginia University (WVU) about the concept of spine navigation, and how they were using it to manage access and patient navigation through a quaternary healthcare system that was really serving five states in a broad region. I was fascinated by this concept, and at the time, I was managing a spine program in Central Maryland and saw that the concepts had broad applicability to improving access and care coordination. I contacted WVU and got an understanding of their use of the Cordata platform. I was so impressed with the technology process that I contacted Cordata’s leadership and got to know the system and understand how it improved care and cost for spine patients and providers.
This was a particular interest to me because I saw that there was a real gap in coordination of care among spine patients, oftentimes resulting in long delays for an initial consult, sometimes by a primary care physician, but oftentimes by a surgeon. Considering that 90 percent of patients with back and neck pain are not surgical candidates, it really left a gap in terms of access to the most appropriate and effective type of care.
At the time, and even today, there was a need for effective nonsurgical intervention for back and neck pain. I had first-hand experience observing patients with very debilitating back and neck problems that were often left frustrated in finding effective treatments for their pain. Additionally, primary care physicians see a tremendous volume of back and neck pain complaints in their practice, and their first interventions might include rest, referrals for physical therapy, maybe a muscle relaxant or some other kind of medicinal intervention. Some of these primary care physicians don’t feel that they have the skills and time to treat these patients effectively. I was managing a spine program at the time and addressing the whole issue of access became critical.
The contents of the article you are referring to are equally true ten years later. A comment I made in that article was that patient navigators are patient advocates. They create and maintain critical linkages between the clinical, administrative, and customer service elements of care, adding value to each step of the process and enhancing the effectiveness of each treatment. So, to sum it up, the article came out of what I perceived to be a huge gap in the treatment of back pain, as well as an intervention, process, and platform that I thought really connected the dots much more effectively than what had been historically available.
Cam: At that time, it was pretty innovative for spine programs to recognize the value of a navigator as the touchpoint for a patient who was coming into a complex program. Patients normally came in seeking a consultation for their pain, and they were unsure about what kind clinical pathway they were going to be on and why. The navigator became a touchpoint that explained the rationale for everything on the care plan and reduced the anxiety that those patients normally came in with. Therefore, the presence of a spine navigator was ultimately a benefit to outcomes because of that reduced anxiety.
Patrick: Absolutely. Each of us as consumers respond favorably to somebody that can create, manage, and deliver good experiences. For example, I recently went to a department store, and even though I haven’t shopped there for many years, I felt like there was always somebody there that was very interested in what my needs and wishes were relative to buying clothing, and I really felt like they were a guide for me. I think a patient navigator can fill that role as well.
I also saw this in my personal experience with joint and spine programs, particularly with things like presurgical patient education. Patients were given a structured, comprehensive introduction into what their treatment was going to look like from the day of surgery to the post-surgical long-term care, and I’ve always contended that in the absence of education and a realistic expectation of what is going to happen to us in the future, that we oftentimes become anxious. So, your comment about patient anxiety really resonates with my experience leading spine and joint programs.
Cam: I want to talk about some innovation and operational moves that are currently happening out there. Let’s fast forward to today in the spine market around patient navigation. Back pain continues to be the second most common cause of a visit to a physician after the common cold, and it is possibly going to become the number one cause because of the sedentary lifestyle that has resulted from the COVID-19 pandemic. This tells us that spine programs are really going to have to innovate to become more efficient, with things like multidisciplinary pain clinics, widespread pain screening, and ongoing patient pain engagement and self-monitoring via mobile apps.
Another thing that the pandemic gave us, that will also exacerbate the incidence of spine problems, is a deeper understanding of social conditions and how they affect patients and their needs in a disease setting. We saw that many people in certain populations were more at-risk for COVID-19 and the long-term side effects, and similarly, those social conditions also have an impact on spine patients.
Can you talk a little about what you have seen out there as it relates to social conditions, social determinants, and spine?
Patrick: You mention a very important point and I think Cordata has effective processes to address social determinants of healthcare. I became familiar with the concept about eight years ago, really understanding that issues like food security, transportation, financial resources, mental health stability, support systems, and so on really do impact access to healthcare, patient engagement, as well as achieving optimal clinical outcomes and sustaining those outcomes. Those all became critical. The technical capabilities of a surgeon for back care, or even a non-surgical provider, are critical to achieving less pain, more mobility, return to work, However, they do not stand alone as the main criteria. To be effective, all those elements need to be integrated, coordinated, and delivered to optimize functional outcomes.
From my perspective, I first saw that navigation can be very effective at mitigating the negative effects of social determinants of healthcare. As we know, good outcomes are not driven exclusively by clinical interventions, but can be optimized by helping patients navigate the common barriers to care, such as affordability, patient education, and all the other factors I mentioned above. Navigation weaves together multiple elements and mitigates the social determinants of healthcare to optimize clinical administrative elements of effective treatment.
I would also like to add that being ignorant of some of these critical social determinants can cause us to develop an incomplete, and in some cases inappropriate, plan of treatment for a patient and that had we understood some of these barriers that patients face, we could have accommodated for them and been effective at helping them get the best outcome that they could. In the absence of those, a plan could have been doomed from the very start, because, for example, we didn’t understand that the patient did now have transportation or might have had other comorbidities or chronic conditions, which limited their access or engagement with treatment.
Cam: I think going through what we’ve all gone through with COVID-19 has really helped enhance what other disease centers have been able to do to evolve their programs to support their own patient populations. I agree with the concept you mentioned, that without understanding social determinants going in, the typical clinical pathway or care plan can be ill-fated from the beginning. If I put a patient on six weeks of physical therapy, and it was unknown to me that they had transportation barriers and were going to miss every other PT session, well that’s doomed from the beginning. Do you think this is part of foundational spine care, now?
Patrick: From my perspective, population health in terms of a payment and treatment model has grown steadily as a concept and in practice, and particularly, we talked about going “at-risk” for clinical and financial outcomes. I would contend that providers must have a very solid, well-defined infrastructure that sees patients getting access, care is coordinated, outcomes are documented, and financial resources are tracked. If a provider organization is going to go at risk, which from the payer side is probably an appealing arrangement, they must have a very well-defined and executed infrastructure that many providers do not have, even today.
The most effective programs have deliberate systems, structures, and processes that are defined and implemented over the full continuum of care, tracking patients are in the process and confirming if they are effectively being navigated through those processes.
In preparation for this conversation, you asked me about value-based care, so I’d like to touch on that for a bit. In a value-based environment where outcomes are divided by cost to yield measures of value, anything that supports patients getting access to the most effective treatment in an expedited fashion and supports their long-term care with the most helpful resources, also validates the value of patient navigation. It’s concerning that, even though the concept of patient navigation in spine has been available to providers for probably 25 years, surprisingly few programs use it. Oftentimes, the patient access coordinator and care are highly disjointed, and we know from experience that when you have disjointed care and communication, not only is it less clinically effective, but it is typically more costly as well. So, you have the opposite effect where a patient’s treatment and prognosis are poorer as well as more costly than under a scenario with navigation.
Certainly, a well-designed and delivered spine program is not going to be able to address every element, eventuality, and variant to a system in process, but let’s think about an emergency department. Emergency departments don’t know what is going to come into their treatment space, but once the patient hits the floor, they do have very well-defined protocols, that define the best practice for whatever situation they encounter. The crossover to spine is that in spine care, we do know what the best practices are. There are defined protocols and having those systems and processes in place can optimize clinical care, decreasing costs and improving functional outcomes.
Cam: There is one more topic that I want to fit in to this conversation, and that is the concept of hotspotting. It surfaced in the early 1990s and is re-emerging. We know all these social determinants about patients and so why not let programs, such as an innovative spine program, create their own hotspots to find, for example, where patients are automatically in a food desert, or are agriculture workers who will go back to physically rigorous work after being discharged, or other factors that the program needs to understand to manage readmission rates in a dynamic way. So, hotspots, in other words, are where those concentrations of social determinants are across a program population. What do you think about hotspotting as an innovative move for a spine program?
Patrick: The concept of hotspotting makes sense in terms of identifying the at-risk patients and populations. I think if you break down this concept, it is very aligned with the Cordata products and services, and the whole concept of patient navigation. It is really about understanding who our perspective patients and patient populations are, identifying what determinants are impacting that patient or population, and crafting very specific potential solutions for those particular challenges. If it’s transportation, what other transportation alternatives can be used? Could those patients be effectively evaluated virtually? It is about validating those perspectives and solutions, and where those solutions are validated, applying and tracking them.
My bottom line on the whole concept of patient navigation really strikes me as something that is very deliberate, very intentional, and not only considers multiple barriers, but also addresses those so they be met and overcome on an as-needed basis to ensure effective engagement, treatment, and sustained outcomes over time. With that said, the concept of hotspotting is complementary with patient navigation.
I think that any seasoned back and neck pain specialist, whether they are clinical or administrative, will understand 99.9% of what we are talking about today. However, oftentimes they are in systems where these kinds of processes and platforms are not in place. So even though they are highly knowledgeable, from a system standpoint, they are somewhat impaired in terms of being able to deliver this kind of care. From my service line work in strategic assessment, planning, development, and implementation, one of the fundamental questions that providers need to ask if they aspire to improve access to care and improve patient outcomes, is how will they go about implementing? I think it comes down to two issues. Can they design this kind of system, and can they deploy it themselves? Or, should they seek services like Cordata that can help them with the infrastructure and move rapidly. With providers at the ground level, one of the challenges is that most staff in the hospital have 120% of a job and it is very, very difficult to breakaway to create these kinds of systems and processes and platforms.
I really appreciate the opportunity to join your readership today. I’m a huge advocate of patient navigation for spine and I’d be happy to talk with you again.
Patrick brings over 25 years of achievement in service line and business development for hospitals, health systems and physician practices. His broad expertise in assessment, planning and implementation coupled with highly developed physician relations abilities has resulted in a history of successes in the most challenging environments.
Patrick consults, writes and speaks in Spine, Orthopedics, and Neurosciences in the areas of: Strategic Assessment & Planning, Program Development and Center of Excellence Development. Additionally, he writes a biannual column for OrthoKnow, a vendor-facing publication, on key vendor-provider issues.
As a Consulting Director for Vizient’s Advisory Solutions, Patrick supports member hospitals, health systems and physicians in musculoskeletal services with a focus on high-value care, aligning cost and quality. He can be reached at firstname.lastname@example.org.