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Project

Using Claims Data to Determine the Efficacy of a Customized Primary Care Pilot for Patients with SCI

Funder: Craig H Neilsen Foundation

Funding period
USD 100 K
Funding amount
Abstract
Project Title: Primary Care Access and Innovations for SCI Patients (P-CAISP)
With support from the Craig H. Neilsen Foundation, Denver Health will create an inclusive, evidence-based primary care practice model for adults with spinal cord injury (SCI), drawing upon a number of principles and toolkits identified and implemented by researchers and practitioners such as Lanig, McColl, Milligan, and Mishori.

This project will lead to the following outcomes:
- In year one, we project 50 patients with SCI will have access to quality primary care that responds to their needs
- Providers will improve their skills and capacity to serve individuals with SCI
- Denver Health primary care exam rooms will be more accessible for patients with SCI
- Care coordination staff will help patients eliminate barriers to care and support patients

Patient outcomes: Denver Health’s project partner, the Center for Improving Value in Health Care (CIVHC), will analyze aggregate claims data to measure reductions in health-related complications and emergency room visits, decreased service utilization, and decreased cost.
Denver Health will form a patient-centered care team to increase accessibility and improve the quality and coordination of care. The care team will include the primary care physician, an occupational or physical therapist, a care coordinator, and a medical assistant. The team will also consult with the patient’s SCI/physical medicine and rehabilitation (PM&R) specialist. Working with this team, primary care physicians will be prepared to carry out the following tasks recommended by McColl, Aiken, McColl, Sakakibara and Smith (2012):
• Comprehensive annual health evaluations
• Multidisciplinary follow-up to address issues related to SCI
• Accessible facilities that allow for a full exam and services
• Expertise from specialists to identify and support services for common secondary complications, such as pain, bowel, and bladder complications
• Understanding and referral supports to address unmet needs, such as psychological concerns, sexual and reproductive health, and lifestyle issues

Grant funds will help Denver Health establish two accessible primary care exam rooms for use by SCI patients, including portable patient lifts, high-low accessible exam tables, and a roll-on wheelchair scale. Grant funds will also support a Denver Health care coordinator to help individuals with SCI access transportation, benefits, and community support services as needed. Additionally, Denver Health will deliver education and training to primary care physicians on topics such as barriers to health care for people with SCI, health promotion and exercise recommendations, and the secondary conditions associated with SCI. Also incorporated will be training on attitudes and implicit bias. Denver Health will also begin to use Epic electronic health record (EHR) care sets as a tool for improving point of service decision-making and care coordination. (CHN: COandI chn:wdg)
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System

Categories
  • FOR (ANZSRC)

    1117 Public Health and Health Services

  • RCDC

    Injury (total) Accidents/Adverse Effects

  • RCDC

    Injury - Trauma - (Head and Spine)

  • RCDC

    Neurosciences

  • RCDC

    Pain Research

  • RCDC

    Health Services

  • RCDC

    Rehabilitation

  • RCDC

    Spinal Cord Injury

  • RCDC

    Behavioral and Social Science

  • RCDC

    Clinical Research

  • RCDC

    Neurodegenerative

  • RCDC

    Patient Safety

  • HRCS RAC

    7.3 Management and decision making

  • HRCS RAC

    8.1 Organisation and delivery of services

  • Health Research Areas

    Health services & systems

  • Broad Research Areas

    Health Services Research