Integrated-care clinics: patient management and return to work rates

Abstract

Introduction: Care fragmentation is associated with lower care quality and greater resource consumption, thereby raising healthcare costs. It is complicated by increasingly specialised providers, growing multimorbidity disease burden and case-complexity, and systemic issues of poor coordination and information sharing. Integrated-care clinics are potential solutions. We discuss our experience implementing such clinics for patients with suspected work-related complaints. Methods: The monthly Multidisciplinary Joint Occupational Medicine (MJOM) clinic was established in a large tertiary hospital for complex cases with clinically-related socio-occupational issues. A multidisciplinary review board model was used, comprising in-house specialist physicians, and employer/regulatory authority representatives as relevant. Each case was managed together with employer and patient, through a holistic approach including occupational/workplace assessments. We reviewed all cases from September 2013 to February 2017 for: symptom duration, diagnosis, work-relatedness, management and follow up. Results: Of the 81 cases, most had symptoms >5 months (Interquartile-range 3-10) prior to clinic review. Majority were dermatological (n=35, 43.2%) or musculoskeletal disorders (n=25, 30.9%), with two-thirds being work-related (n=40, 67%). Most were concluded regarding social/work-relation at the first visit (n=47, 58%). The rest (n=34, 42%) required average 2.56 visits (IQR 2 – 3, max 5). Qualitatively, our clinic model was more efficient, while remaining patient-centric. The real-time discussion format between stakeholders and care-providers reduced miscommunication and enhanced information-sharing. Direct patient involvement allowed for effective management of clinical and socio-occupational issues simultaneously within a single session. Of the 57 cases with work-related conditions, almost all (91%) were able to resume employment at discharge. Majority (n=38, 67%) were able to return to their original job scope. The rest (14, 25%) required either adjustment in job scope or transfer to a different department. Discussions: Our MJOM clinic model is a prime example to showcase the benefits of an integrated care model. The board review style of consultation allows for discussion of the patient’s needs across multiple relevant perspectives with the relevant stakeholders. This was conducted in a real-time environment allowing for simultaneous issue resolution. Uniquely, our model directly involves the patient, thereby allowing for patient-centricity and effective decision making. Conclusions: Our clinic model reduces care fragmentation and improves patient management, while potentially reducing cost. The proportion who were able to return to work at discharge was high. Given increasing case-complexity with the growing multimorbidity burden, benefits are likely significant. Lessons Learnt: Operational measures may indicate inefficiency: the clinic was manpower-intensive, with a high physician-to-patient ratio. Time spent per session was also longer than standard consultations. However, benefits could be seen with a fast resolution rate and high return-to-work proportion. Limitations: Our study was qualitative in nature to highlight non-operational benefits and implementation issues. As no comparator was included, this makes evaluation of quantitative benefits difficult. Suggestions for future research: We recommend conducting a cost-effectiveness analysis of such clinics, including quality of life measures, in order to surface the benefits more effectively. Studies looking at long-term benefits should also be considered.

Keywords

• integrated care clinics
• occupational medicine
• comprehensive care
• patient-centric