It’s a perfect kind of October day for writing – chilly, windy and gray! I can’t complain, though! This is following an unseasonably warm and sunny fall thus far here in Chicagoland. I am excited to share my experience about my site visit to Bellin Health’s Bellevue Team-Based Primary Care Clinic in Green Bay, WI. This was the first of many site visits and I’m being completely honest when I say that their team set a high standard for what right looks like! The infectious camaraderie amongst the multidisciplinary staff, even in my first 20 minutes there, was one to be reckoned with. I’ll continue sharing my experience in a moment, but I’d like to start by answering a question many may have:
Why am I doing this?
I started my career as an active duty Army PT and my first job was in a Soldier Centered Medical Home (just one of many phrases used to describe a team-based care setting). As a PT, I was co-located in a clinic with physicians, advanced practice practitioners (APPs), nurses/medics, behavioral health, and support staff. In this setting, patients could easily access a variety of care professionals to meet their needs, without having to wait for referrals or go to multiple locations. We were a team – we communicated regularly about our mutual patients, consulted on diagnosis and best management strategies, and truly learned from one another. When I left the Army, I had the unique opportunity to continue in 2 other multidisciplinary settings – a large academic cancer center and a small sports med/family med private practice. Each setting had their own definition of the team model, but the bottom line – we were able to communicate and integrate without the typical barriers of “siloed” health clinics (Fig 1).
Fig. 1 Healthcare Silos1
Team-based care offers some significant pros:
1. Patients love it! They can easily access the right professional at the right time, without having to wait for referrals or phone calls, and without having to go to multiple locations. It also exposes patients to health services that they may not have otherwise considered, if just at the suggestion of their PCP. <--THIS last bit was a consistent theme reported by the primary care physicians and APPs at Bellin Health – before they had PTs in primary care, many of their patients that they wanted to refer to PT wouldn’t entertain the idea. I’ll circle back to this later.
2. Health professionals love it! For many of the same reasons that patients love it! We get to see a patient from the different lens; we learn from each other; we grow, simply by being around other professionals that aren’t like us and seeing how they practice. This co-location, in and of itself, diversifies and enhances our capability. We also know that this setting improves the patient’s overall experience with us – what more could we ask for? After all, our patient’s experience with us and the care we’re able to offer them is why we do what we do.
Here’s the BUT. And it’s a big BUT. The vast majority of primary care clinics throughout the US (and globally) do not offer true team-based care, where a patient has access to more services than their primary care provider, in one location, at one time. Those that do offer team-based care, often exclude (or never even think to add…) services like PT. So, here’s the answer to my why:
I’m doing these site visits, in addition to many other projects, to report on
where this is happening, how it works, and what barriers we need overcome
to make this a real, mainstream possibility for every American patient.
So back to my Bellin experience:
Bellin Health began to explore the concept of team-based primary care in 2016. When they first started, in addition to the primary care physicians and APPs, they also included clinical pharmacy and behavioral health. When PT leads at the Bellevue location, Dr. Joe Kucksdorf, PT, DPT, OCS, FAAOMPT and Dr. Alyssa Torn, PT, DPT, OCS, caught wind of this, they asked to be included and received support.
They officially started offering all the aforementioned services in 2018. They even remodeled the primary care clinic to, quite literally, break down the walls between team members. At the time, PTs got their start in an 8-week pilot program with a “warm hand-off” model (Fig. 2). This model is such that, the patient is received by an MA/LPN for initial intake which is then reviewed with the PCP. The PCP then meets with the patient and determines if other services are needed. If that is the case, the PCP pulls in the other professionals to weigh in. This all takes place in a single visit!
Fig 2. The Bellin Health Primary Care Warm Hand-Off Model
The pilot program had excellent results – optimal workflow, service utilization, and provider/patient satisfaction. They were able to demonstrate that patients saved time and money by receiving needed care sooner. They also identified a significant reduction in the number of unnecessary referrals for imaging and other specialty services. While the model demonstrated in Fig 2 worked well, especially for those patients coming in for annual health checks, Bellin is still considering some alternative models of receiving patients, to optimize everyone’s time. One such model is demonstrated in Figure 3.
Fig 3. The “Optimized” Warm Hand-Off Model
In this “optimized warm hand-off” model, the patient is received by an MA/LPN (or triaged over the phone/online booking system), and is then directed to the most appropriate provider(s) based on their complaint. This can be a single provider or several. The types of providers on any given care team may differ based on caseload or local needs. After they meet with the patient, the providers then have a “huddle” where they discuss their findings/recommendations with one another and outline a shared plan/treatment strategy. The PCP then has a checkout discussion with the patient, and the patient makes the final call on how they wish to proceed with their care. This is just one of many alternative pathways for team-based workflow.
After the pilot, all involved providers at Bellin felt it was essential to continue, but Bellin’s PT department was then faced with a pretty big problem –
How do PTs bill for their services when the care provided is sort of
a “package deal” with other primary care services?
The literal million-dollar question. In a traditional insurance model, PTs bill under the 97- series codes. Many insurance companies require pre-authorization for these codes to be billed, only adding to the time delays when accessing a service like PT. Patients would have to be notified and consent to this as copays and/or deductibles often apply. Additionally, the existing PT codes don’t really make sense when a PT is working in a primary care setting – sometimes doing brief consults, providing education, prescribing durable medical equipment (DME), consulting with other providers on management strategies – none of this really fits in to the description of billing codes that PTs are limited to. So how did Bellin Health justify a full PT FTE in primary care, when they would ultimately be a non-revenue-generating service?
All parties agreed that they wanted PTs to be in primary care, as they felt it was the right thing to do for patients, and they didn’t want cost to be a barrier. They decided to go for it and “eat” the upfront cost. They were able to demonstrate, however, that PTs in primary care created improved downstream revenue for the system. One factor they noticed, which I mentioned earlier, was the improved utilization of outpatient PT services. Believe it or not, most individuals who have a complaint that seems like a “PT issue”, never end up seeing a PT. In fact, some studies indicate that only 6-13% of patients with low back pain ever see a PT.2-4 At Bellin, the improved utilization of outpatient PT and improved outcomes amongst those patients was a win! They got off to a great start and started expanding the model into other locations.
Then, like we’ve heard so many times before…. COVID happened.
With the sudden decrease in visits across the board, the PT department had to remove their FTE from primary care for budget preservation. Understandable – we all felt that! But this left primary care providers feeling a significant void. I had the opportunity to interview many of the physicians and APPs. One reported “…during COVID, it was terrible when PT wasn’t here” and another stated “…we really had to scramble to figure out what to do”. They reported calling and running downstairs to the PT clinic for assistance on a frequent basis. It took a whole year to be able to justify getting a PT back in primary care. And now, 18 months after COVID poisoned all of us with its nasty, relentless presence, the Bellin Health Primary Care Team is reunited and operating at its potential once again.
While Bellin continues to offer this service that patients and providers love, the question of financial sustainability amidst a Fee-For-Service (FFS) payment system, is a something that comes up on a regular basis. I was able to brainstorm on this with Drs. Kucksdorf & Torn. We discussed several possibilities for this service to be reimbursable by third party payers, some of which they have already entertained and unfortunately, eliminated. To take a deeper dive into this monstrosity of a payment question, join me in my next article, coming sometime before the end of 2021 (I have a LOT of background work to do for that!).
By Dr. Katie O’Bright, PT, DPT, OCS
References:
1. Photo Cred: Margaret McCartney: Breaking down the silo walls | The BMJ. https://www.bmj.com/content/354/bmj.i5199
2. Fritz JM, Brennan GP, Hunter SJ, Magel JS. Initial management decisions after a new consultation for low back pain: implications of the usage of physical therapy for subsequent health care costs and utilization. Arch Phys Med Rehabil. 2013 May;94(5):808-16.
3. Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with a new consultation for low back pain to physical therapy: the impact of the timing and content of care on future healthcare utilization and costs. Spine 2012;37:2114-21.
4. Gellhorn AC, Chan L, Martin B, Friedly J. Management patterns in acute low back pain: the role of physical therapy. Spine 2012;37:775-82.
Comments