This past year, the Ontario Chiropractic Association (OCA) receivedfunding and support from the Ministry of Health and Long-Term Care todevelop, implement and evaluate a consulting chiropractorrole in primary care for low back pain. This was part of the ministry'sinitiative to address barriers to the provision of high-quality andappropriate care for LBP in Ontario. This model of care is based on theintroduction of an assessment clinic for LBP in a primary carephysician's office. The consultant, a chiropractor, performs anassessment of approximately 30 minutes in length with a patientpreviously identified as having acute, recurrent or chronic LBP andreferred to the clinic by the primary care provider.
It is important to note that the assessment clinic was not designedas a treatment model – but rather assessment and education. The outcomeof the assessment is advice and decision support provided to thephysician, and the inherent knowledge transfer that takes place betweenproviders. The objective of the pilot project was to test thefeasibility, acceptability and value of this model of care in theOntario context. This project met the pre-pilot expectation indemonstrating the consulting chiropractors' ability to contributepositively to the care for patients with low back pain in physicianprimary care settings.
Four DCs were partnered with four group primary care practices for asix-month pilot phase. A total of nine hours was allocated per month persite for the assessment clinics, which took place in the primary carepractice. Thirty-three physicians signed the consent form to participatein the pilot project.
A mixed-methods approach was used to capture the data required tomeet the evaluation objectives of the project. Data was collectedpre-pilot, during the pilot and post-pilot. Methods includedsemi-structured interviews, clinical practice guideline and reflectivesurveys with both the chiropractors and physicians. Some patient-leveldata was collected via graded chronic pain scale questionnaires,clinical notes and patient satisfaction surveys following each visit.
The consulting DCs appeared to influence the primary care physiciansin their decision-making regarding the management of patient cases;specifically, the appropriateness of advanced imaging / referral tospecialists and in their understanding of patient self-management /education strategies. There was strong evidence that physiciansbenefited from the knowledge transfer, as they reported higher levels ofconfidence in dealing with similar cases in the future. Most of thephysicians valued the participation of and access to the chiropractors.An external agency was commissioned to develop the evaluation frameworkand conduct an independent evaluation of the project.
This model of care was built on the framework of evidence-basedrecommendations to the physicians. In addition, because of theco-location of the assessment clinics, there was an expanded opportunityto encourage collaborative care that focused on joint diagnosis andinterprofessional patient care plans. Based on established clinicalpractice guidelines and evidence-informed criteria, the consulting DCprovided advice to the physician on whether the patient was a potentialsurgical candidate with a recommendation for referral to a spine surgeonor other specialist; whether the patient had received appropriate andsufficient guideline-driven conservative care, and what treatment /referral options, if any, should be considered; and what, if any,advanced diagnostics should be ordered / considered.
Key Findings
Satisfaction
Knowledge Transfer
Value
From the perspective of the physicians, quick turnaround betweenphysician referrals to the assessment clinic resulted in several keybenefits, including the following:
The majority of participating physicians identified that the clinicalnote(s) provided by the consulting DC was a key benefit to this modelof care. Effective communication between professional groups is animportant facilitator to successful collaboration. Traditionally withinprimary care, this communication has relied on written formats: referralforms, feedback forms, case notes, care plans, letters, faxes andmessage books. Unfortunately, most physicians continue to cite that theyrarely receive any communication following shared patient care fromchiropractors. In consultation with family physicians, the OCA hasdeveloped a consultation note for this purpose.
Some of the potential challenges of sharing patient informationoriginate with how the information is captured in patient charts andclinical / consultation notes. The form creates common terminology oncharting relevant to the data elements that are most relevant to thephysician. The OCA encourages members to use this form to send clinical /consultation notes back to the physician, at a minimum, following theinitial patient visit. This form has also been incorporated into theOCA's Patient Management Program (PMP), allowing users to access andcomplete this form electronically through the system, making the sharingof patient information much faster and more efficient.
Submitted by the Ontario Chiropractic Association. For further information related to this project, contact AndreaEndicott, OCA senior health policy analyst, ataendicott@chiropractic.on.ca, 416-860-7188 or toll-free 1-877-327-2273,ext. 7188.
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