Medical Integration Model as it Pertains to Musculoskeletal Conditions

By Pierce Waychoff, D.C.

The purpose of this book is to provide the practice ways to maximize their opportunities, in regard to patient treatment, patient outcome, and provide a multifactorial approach to pain management. The goal of the practitioner should be to provide exceptional patent care and develop an outstanding process. This book will help the practice develop an exceptional process. The ideas that are discussed in this book will help with the treatment of patients and help with the product that can be obtained as a result. This book describes the process that my team and I followed for thirteen years (2008-2021).

• Language: English
• Publisher: Page Publishing, Inc.
• Release date: Sep 20, 2022
• ISBN: 9781662486517

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Medical Integration Model as it Pertains to Musculoskeletal Conditions

Pierce Waychoff, D.C.

Copyright © 2022 Pierce Waychoff, DC

All rights reserved

First Edition

PAGE PUBLISHING

Conneaut Lake, PA

First originally published by Page Publishing 2022

ISBN 978-1-6624-8602-9 (pbk)

ISBN 978-1-6624-8651-7 (digital)

Printed in the United States of America

Table of Contents

A Medically Integrated Pain Management Model

Organization of the Procedural-Based Pain Management Clinic

Continuity of Care Model

The Importance of Chiropractic Adjustments

The Importance of Trigger Point Therapy with Assisted Stretching

The Importance of Spinal Injections

Spinal injections are important because they help with our spinal stability program. The most common spinal injections that we recommended to our patients include medical branch blocks, radiofrequency ablations, epidurals, and sacroiliac joint injections (SIJ) injections. SIJ injections can be included in this section because these procedures were usually done on our spinal injection days.

Personal Injury (PI)

Durable Medical Equipment (DME)

Day 2: Patient Sign-up Paperwork

Financial Policy

Disclosure and Consent

Patient Assignment of Benefits Authorization and Financial Responsibility Disclosure Statement

Letters of Medical Necessity for Spinal Injections

Prescription, Pre-Authorization, and Medical Necessity

Prescription, Pre-Authorization, and Medical Necessity

Prescription, Pre-Authorization, and Medical Necessity

Prescription, Pre-Authorization and Medical Necessity

Prescription, Pre-Authorization, and Medical Necessity

Prescription, Pre-Authorization, and Medical Necessity

Prescription, Pre-Authorization, and Medical Necessity

Prescription, Pre-Authorization and Medical Necessity

Prescription, Pre-Authorization and Medical Necessity

Prescription, Pre-Authorization, and Medical Necessity

Prescription, Pre-Authorization, and Medical Necessity

Cervical Medial Branch Nerve Block Injection 1st

Cervical Medial Branch Nerve Block Injection 2nd

Cervical Radiofrequency Neuroablation (Any Level)

Cervical Interlaminar Steroid Injection 1st

Cervical Interlaminar Steroid Injection 2nd

Thoracic Medial Branch Nerve Block Injection 1st

Thoracic Medial Branch Nerve Block Injection 2nd

Thoracic Radiofrequency Neuroablation (Any Level)

Thoracic Interlaminar Epidural Steroid Injection (Under Needle-Guided Fluoroscopy)

Lumbar Medial Branch Nerve Block Injection 1st

Lumbar Medial Branch Nerve Block Injection 2nd

Lumbar Radiofrequency Neuroablation (Any Level)

L5, S1, S2, and S3 Medial and Lateral Branch Nerve Blocks (Under Needle-Guided Fluoroscopy)

L5 Medial Branch and S1, S2, and S3 Lateral Branch Radiofrequency Ablation (Under Needle-Guided Fluoroscopy)

Sacroiliac Joint Injection (Under Needle-Guided Fluoroscopy)

Intra-Articular Hip Joint Injection (Under Needle-Guided Fluoroscopy)

Trigger Point Injection (DU)

Joint Injections with Diagnostic Ultrasound

Allergy Program

Informed Consent for Allergy Evaluation and Testing

Handwritten Allergy Test

Providers Immunotherapy Order Form

Providers Immunotherapy Order Form (Cigna Only)

Durable Medical Equipment

DME Superbill

DME Consent

Prescription, Pre-Authorization and Medical Necessity

Prescription, Pre-Authorization, and Medical Necessity

Transcutaneous Electro Nerve Stimulation

TENS Unit and TENS Garment

Prescription, Pre-Authorization, and Medical Necessity

Multipost Therapy Collar L-0180

Stretching and Strengthening Exercises

Cervical Stretching Exercises

Cervical Strengthening Exercises

Lumbar Stretches

Closing

About the Author

A Medically Integrated Pain Management Model

The purpose of this book is to provide the practice ways to maximize their opportunities, in regard to patient treatment, patient outcome, and in providing a multifactorial approach to pain management. If the goal of the practitioner is to make money, then money will soon be their master. The goal of the practitioner should be providing exceptional patient care and developing an outstanding process. This book will help the practice develop an exceptional process. This process will help in the treatment of patients and help with the product that can be obtained, following having an exceptional process. This book describes the process that my team and I have done for thirteen years, from 2008 to 2021.

Please read About the Author Section. My goal is to help you achieve similar results in regard to patient satisfaction. It is estimated that 90 percent of American adults will experience some level of back pain in their lives. There is an opioid epidemic that needs to be addressed with this great nation. It is estimated that fifty thousand to seventy thousand people die per year from overdosing on opioid medication. This is a problem that needs to be discussed.

With being solution oriented, a very productive approach in helping to reduce the number of people dependent upon opioid medication is by having multiple centers that advocate the use of procedural-based pain management. The pain syndrome is a complex health challenge that requires a multifactorial approach in addressing this health concern. This book will describe various treatment options for patients. This book will also describe to the office different organizational and proficient strategies in order to maximize the opportunities of the practice.

Organization of the Procedural-Based Pain Management Clinic

The clinic director (CD)

The clinic director plays a pivotal role in the success of the clinic. This role is termed The Face of the Clinic. The goal, with being a clinic director in a multifactorial pain management practice, is to be a familiar face for patients. If patients see a familiar face, this enhances stability throughout the clinic.

In an ever-changing health care office, this person provides stability for current and prospective patients to see on a regular basis. In a pain management office, it is very important to promote stability. The goal of patient care is to promote spinal and joint stability.

Additionally, the goal of the office is to promote mental stability with patient interaction. In practice, providers change locations, change their working days, or change their hours. It is very frustrating for patients to have to explain their current health challenges to multiple providers. The patient's story does not change. The providers' change. Time is of the essence for everyone. Therefore, when a patient spends ten to fifteen minutes nearly every appointment explaining their current medical condition, that is very time-consuming.

The role of the clinic director is to be that face of the clinic where, even though, there will be a lot of provider and staff turnover, the clinic director stays. The clinic director usually owns the facility, is an equitable partner, or simply cares the most about the success of the patients and the success of the clinic. The clinic director has invested in this facility. The clinic director has a set schedule and has vacations, but if this is done right, this position is vitally important in promoting stability throughout the clinic. This is a focused, purposeful position.

Important to note

The clinic director, in a medically-integrated facility, can be a chiropractor, a medical doctor, or someone that truly cares about the success of the patients and the facility. This person is not just a chiropractor or medical professional. This is a clinic director position. You are a focal point and a guiding light to your patients. This means you are the point of contact of the facility that you are in. You now represent a medical-integrated facility. Our medical-integrated facilities focus on a multifactorial approach to meet the pain management needs of our patients.

When a new patient arrives

Front desk requirements with incoming prospective patients:

When a patient arrives at the office, the front desk staff greats them with a smile. The staff member asks, Do you have an appointment here?

The patient says, Yes.

The staff member says, May I please see your health insurance card and picture ID?

We make a copy of their health insurance card (front and back) and a copy of the driver's license.

This portion will be role-played, and the staff member walks the patient into the clinic director's office for the D1.

D1 stands for Day 1. This means that this is the first time that the CD meets with the patient.

(This is a guideline. We can role-play this scenario multiple times in order to increase proficiency.) For example, we should know the incoming D1 schedule. Asking, Do you have an appointment here, serves as an icebreaker question. The question could be, How may I help?

D1 script

CD, enters D1 room. The CD is cordial, of course. Have you been to a chiropractic office before?

Listen to answer. This is the moment when you first start to build trust with your patient. Very few practitioners listen to their patients. In our facilities, we listen to our prospective patients. The CD has time to do this. The CD, in a multifactorial pain management facility, has some patients doing therapy, some patients with the medical provider, some patients waiting for x-rays, etc. There are a lot of moving parts, but this gives time to the CD to fully think about the task at hand. That task is listening to your prospective new patient and getting ready to help this patient.

Have you ever talked with someone and you knew they were not listening to you? Perhaps, the person you were talking to was only thinking about what they were going to say next? If this has been done to you, I guarantee the patient has had this done to them and knows if you are doing this to them.

Again, this is the time for the CD to listen and devote your time and energy to this conversation. This first conversation will pay itself back to you and your practice ten times over. This is all about building trust with the patient.

CD. Have you been to a pain management office before?

If patient says yes, then

CD. Are you currently taking any pain medication?

CD notes in mind that if they are taking too high quantities of medications, they might need to be referred to another facility. If a patient says no, that is good.

Everything a CD does on a D1 is to raise the awareness, in the patient's mind, of their present condition. Patients, more times than not, have seen multiple providers for their pain. The vast majority of the time, the provider they saw, have discounted their complaints and offered medication. We, as the clinic director, listen to the patient's complaints and then offer procedural-based pain management services to limit their symptoms or eliminate their present condition.

The goal on D1 is to take x-rays of their present condition. X-rays are a medically necessary diagnostic tool to evaluate the patient's spinal column. This is a useful tool to raise awareness of the present condition of the patient.

On the D1, it is important that the clinic director closes the gap between what the patient thinks and what is needed to promote spinal stability with the patient. Further, the patient thinks that maybe one or two treatments are needed to fix the problem. In their mind, the problem is back pain, so fix it, doctor. They might think that one or two visits are needed in order for them to get rid of their pain.

It is our job as physicians to educate the patient on our model, and this treatment plan might require more than two visits. This conversation is called, Bridging the Gap. With this model, we focus on spinal stability. This model is not for everyone. There are plenty of chiropractors that charge $50 for an adjustment, which is fine. However, this model focuses on the treatment of the entire patient. The whole patient is treated, not just the treatment of the spinal column of the patient. We, as the professionals in our clinic, can explain this to the patient and help them along their health journey.

In this manner, we can reason some with the patients too. We can explain to the patient that they don't expect to see their dentist one or two visits for the management of their dental health. They don't expect to see their general practitioner one or two visits for the management of their diabetes. They should not expect to see their chiropractor one or two visits for the management of their spinal health. This can be done in a very nonconfrontational way, but it helps to bridge the gap between the mindset of the patient and the mindset of the physician.

Closing Questions

Closing questions are needed at this point, to accomplish the primary objective. The CD's primary objective is to take x-rays and schedule the patient for their D2 (Day 2). The D1 should only take five to seven minutes. The patients will sometimes have a tendency to talk about a wide range of topics. Some of these topics include the weather, their hometown, their family, etc. The job of the CD is to be courteous but know what needs to be done.

We, as a CD, need to focus the conversation into the closing questions. This is important because as a CD, we will have patients waiting for adjustments, patients waiting for therapy, patients waiting for the medical provider, patients waiting to talk with you regarding the necessity of spinal injections, other patients waiting for additional x-rays, and finally other patients who are here for their D1 appointments. These closing questions are important for the D1 process to be as efficient as possible.

Closing question number 1:

How long?

CD asks patient, How long have you had this present condition?

Patient answers. CD listens to answer. This may take one or two minutes of listening.

Closing question number 2:

How often?

CD asks patient, How often do you suffer from this present condition?

Patient answers. This may take one or two minutes of listening.

Closing question number 3:

CD asks patient, Does the pain travel down your arms or legs?

Patient answers. CD listens.

This might be the first time in a patient's life where a medical/chiropractic professional has listened to the patient's health concerns. The patient is beginning to trust the CD. These questions also build awareness in the patient's mind that the symptoms they are currently experiencing is not normal. They need medical help to lessen or eliminate their current health challenge.

CD says, Wow! That is a lot. What we need to do now is take x-rays. We need to take x-rays of the area of concern. We are as thorough as possible with these x-rays. We take them, evaluate them today, and they will be ready for viewing by later today or by tomorrow.

The CD asks, Will later on today or tomorrow be okay to come back and view the x-rays?

CD, based on patient's response, you will know if the patient trusts you or not. If the patient trusts you, they will be agreeable to come back and view the x-rays as soon as possible. The patient wants to view their x-rays in a timely fashion because they are concerned with their present health challenge. If they don't trust you, they will schedule further out. CD sets the appointment right then.

CD says, Great! Later on today around 3:00 p.m. will be perfect or great tomorrow at 10:00 a.m. will be perfect.

This appointment is a preliminary appointment time only to be confirmed when the CD walks the patient to the front after x-rays.

Then the CD walks the patient to x-ray room and takes x-rays.

Important dialogue

CD, after completion of x-rays. Okay, that is great. Could not have done it without you.