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Ensuring Cost Efficient & Outcome Focused Care: Can Triage Help?

The principles of triage have been in use for centuries. When effectively implemented, triage correctly identifies needs, implements the appropriate treatment, and maximizes the use of available resources for maximum patient benefit1.

With demands on the healthcare system increasing, patient expectations and financial pressures rising, healthcare providers are challenged to find new cost effective solutions. This has resulted in an evolution of triage systems throughout the different points of entry into the medical system1. Triage has now become a vital tool in the first steps of injury management.

In the world of physiotherapy and rehabilitation, there is certainly a place for triage. In fact, we know there are other factors aside from tissue healing timelines that can impact recovery. Dr. Hamilton Hall, Medical Director at CBI, has validated this point through the triage tools he developed for low back pain (LBP). He determined that the severity of back pain is not an indication of the level of seriousness and the use of imaging or x-ray tests do not usually help point to the source of pain2. This makes obtaining a definitive diagnosis next to impossible and very frustrating for individuals. His discovery led to triaging patients based on their clinical presentations via a defined clinical interview and physical examination2. When combining information from the history with the findings of the physical examination, the clinician can rule out a number of possible serious diagnoses and an effective, individualized rehabilitation program begins based on the Pattern of Pain categorization2.

Through the success of the Patterns of Pain, and our dedication to continually advance it, we recognized another important influencer in healing times for patients with LBP --- the presence of psychosocial factors (PSF)3,6. We also recognized through research and our experience, that PSF’s are not only evident in LBP patients; they are also often present in any patient suffering an injury (including concussion and PTSD). PSFs such as personal beliefs, illness behaviours, and fear avoidance are known to add complexity to diagnosis, prognosis and treatment recommendations3,6. With this evidence and research, we have created a triage for auto claimant’s that allows us to identify and treat complex files earlier, recommend appropriate individualized treatment pathways for claimants and better help to navigate care needs. Claimants who truly need interdisciplinary care receive it, and can stay in treatment with CBI.

The auto triage tool is an exciting development in our claims management process because:

  • We are matching clinician skill sets with claim/claimant complexity post-assessment.
  • We have established a level of accuracy, consistency and precision around the care planning process.
  • Claimants receive best practice care and re-enter the workplace earlier.
  • Medical, rehab and indemnity costs are lowered.
  • We identify who requires access to the broader CBI network when timing is crucial (e.g. hospital discharge, psychology, functional restoration).

In summary, by combining effective triage with best care practices we are able to promote early intervention, ensure the right care by the right practitioner, maximize the use of our available resources, and create a solid entry point to an organized system of care to maximize outcome. We look forward to the next issue when we will share new research data into the clinical implications of the Auto Triage tool.

Contributors:

Jennifer Dunn, Physical Therapist, CBI Health Group
BSc PT (Hon), Matheson FCE Trained, PGAP Certified, Matheson Cognitive FCE Trained

Tom Carter, Physical Therapist, CBI Health Group
MSc (c), BSc PT, MCPA

Psychosocial factors (PSF)- Yellow Flags 3,6

  • Fear and avoidance beliefs of behaviours
  • Seeking passive based care in their recovery (letting others “fix” them)
  • Catastrophizing (negative expectations)
  • Belief that the pain needs to be gone before returning to activities in their lives including work
  • Sustained rest or reliance on medications, aides and devices
  • High pain ratings and behaviours
  • Depression and/or anxiety history
  • Limited financial incentive to return to work/function
  • High focus of blame on others
  • Poor work history or work relationship

Note: For many with significant ‘yellow flags’, being sent for medical testing early can actually make the situation worse. These specific populations benefit in receiving more interdisciplinary care to address all the factors, and early access to this has been shown to be more cost effective in the long-term. This is why appropriate triage early on is essential, as well as ongoing monitoring and re-evaluation of these factors as someone is recovering, especially if they are not meeting anticipating timelines.

Best care practices should include:

  • Strong focus on education, reassurance and promoting their role in their recovery6,7
  • Early return to function including daily activities and work6
  • Access to interdisciplinary treatment team6,8
  • Provision of strategies they can independently implement to manage their symptoms6
  • Progressive exposure to conditioning, including physical, emotional and cognitive, to prevent deconditioning and avoidance6
  • Goal setting6
  • Regular re-evaluation to measure progress6
  • Use of medical tests only when warranted4, 5
  • Ensuring symptom management is promoted through lifestyle and behavioural strategies, and not just medication6

Depending on the needs of the individual, these strategies may require one care provider, or a coordinated team, working together to help the individual navigate their recovery and any barriers impacting them. Coordination of care helps minimize confusion, over-medicalization, service duplication and mixed-messaging which can negatively impact recovery.

References

  1. Robertson-Steel, Iain. "Evolution of Triage Systems." Emergency Medicine Journal 23(2) (2006): 154-55. PMC2564046. Web. 20 Apr. 2016. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564046/
  2. Hall, Hamilton, MD, FRCSC. "Effective Spine Triage: Patterns of Pain." The Ochsner Journal 14.1 (n.d.): 88-95. Web. 20 Apr. 2016. https://www.cbi.ca/documents/12741/633624/Oschner+Spinal+Trage+2014-3.pdf/bc5a05b5-d67a-455f-816f-6df9b6a0c4cc
  3. Guide to Assessing Psycho-social Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss. Accident Compensation Corporation and the New Zealand Guidelines Group, Wellington, New Zealand. (Oct, 2004 Edition) http://www.topalbertadoctors.org/download/442/clinical_assessment_of_.pdf
  4. "Five Things Physicians and Patients Should Question." Choosing Wisely Canada. The Canadian Spine Society, n.d. Web. 18 Apr. 2016. http://www.choosingwiselycanada.org/recommendations/spine/
  5. Do More Screening Tests Lead to Better Health? Perf. Dr. Mike Evans.Choosing Wisely Canada. N.p., n.d. Web: http://www.choosingwiselycanada.org/resources/videos/2015/11/13/doc-mike-evans-do-more-screening-tests-lead-to-better-health/
  6. Toward Optimized Practice (TOP) Low Back Pain Working Group. 2015 December. Evidence-informed primary care management of low back pain: Clinical practice guideline. Edmonton, AB: Toward Optimized Practice. Available from: http://www.topalbertadoctors.org/cpgs/885801.
  7. Cote, Pierre. "Management of Neck Pain and Associated Disorders: A Clinical Practice Guideline from the Ontario Protocol for Traffic Injury Management Collaboration." European Spine Journal (2016): n. pag. Web: http://link.springer.com/article/10.1007%2Fs00586-016-4467-7
  8. Jull G, Kenardy J, Hendrikz J, et al. “Management of acute whiplash: a randomized controlled trial of multidisciplinary stratified treatments”. International Study for the Association of Pain. 2013. 1798-1806.