Hoag Memorial Hospital Presbyterian launched the Hoag Neurosurgery Spine Program in February 2014. The multidisciplinary program aims to bring specialists together for more efficient and effective care.

"The intent was to create a program not around a specialty, but around the spine care service," says Burak Ozgur, MD, chief of service of the Neurosurgery Spine Program at Pickup Family Neurosciences Institute. "We wanted to create a program that identifies different elements of spine care and triages the patient along the right pathway."

The program includes physical therapy, pain management and surgery. A nurse navigator first works with the patients' diagnoses to triage them for the best treatment. Many patients begin with conservative care; however, for the select cases where surgery is indicated, patients are placed on the fast track to see a surgeon.

"If we can treat the patient conservatively, that is the best option," says Dr. Ozgur. "But if they need surgery, we go through the spectrum of whether it can be treated minimally invasively or through traditional surgical procedures."

The care pathways are dictated by an evidence-based medicine approach to care. The specialists meet on a monthly basis to discuss cases and ensure the triage system is working appropriately. The system can be altered and amended as time goes on.
"It's a dynamic process," says Michael Brant-Zawadzki, MD, the executive medical director of the Neurosciences Institute at Hoag. "It's an evolution. Our care pathways have embedded metrics for process and outcomes measures so we get an assessment of the patient's status upon entering into the care pathways as well as the long term health and financial outcome of the process."

Analyzing outcomes and financial data will allow the Hoag physicians to learn more about trends in readmissions, infections, re-operations and emergency room visits. By tracking current data, they have already identified new trends and are beginning to make changes for better quality of care.

"We found two key elements that are important and if we can identify them early, we can be more prepared for our patients," says Dr. Ozgur. "The first is having multiple comorbidities and the second is using multiple pain medications or chronic pain medication use. As the patients come in, the navigator can identify these factors and we can actually put the surgery on hold until we optimize these elements. in the idea is to fully optimize the patient's health and status prior to going into surgery so they have better outcomes on the other end."

While the specialists aren't all under one roof yet, the program has allowed them to work together and communicate more frequently. Their discussions now focus on patient triaging and how their system will evolve.

"Unlike at Cleveland Clinic where the surgeons are all employed and clinically integrated, an organization like ours still has physicians who are at independent practices and we rely on virtual integration around the care pathway and common metrics," says Dr. Brant-Zawadzki. "We have a communication process facilitated by the modern digital age as well as the nurse navigator."

The physicians are also paying close attention to cost of care, a main theme in today's drive to reform healthcare spending. "As healthcare costs and resources are limited, we need to provide better value," says Dr. Ozgur. "If we can prove our system works, then I can see it multiplying and growing in scale to other services and hospitals."

The future of healthcare will be driven by the cost and quality initiatives different systems develop to truly provide value to patients. The Affordable Care Act provoked providers to look at new ideas and will be a big factor in how programs develop in the future.

"I think clearly that despite the Affordable Care Act's claim of being healthcare reform, its health cost reform that's paramount," says Dr. Brant-Zawadzki. "To really reform healthcare, you need physician leadership. Through physician leadership of such care pathways, through integrative methods, true healthcare transformation and reform can occur."