Remodelling care for low back pain: tripartite partnership among general practitioners, physiotherapists and hospital specialists

Abstract

Introduction : Government-run primary healthcare polyclinics in Singapore are often overcrowded and overloaded due to the high fee-for-service (cost gradient) when patients visit private general practitioners (GP: USD22 vs. USD6) and physiotherapists (PT: USD91 vs. USD36). Moreover, patients often experience long wait time before receiving care due in part to limited physiotherapy services in the polyclinics. As a result, patients suffering from low back pain (LBP) and require physiotherapy are often referred to specialist doctors sited at government-run tertiary hospitals, complemented with acute physiotherapy services. However, patients are reluctant to receive follow-up care at the overcrowded polyclinics when their condition was assessed to be stable. There is a need to decongest acute care services for more deserving complex patients. Practice Change Implemented : A tripartite relationship among private GP, PT and public hospital-based orthopaedic surgeons was forged [Delivering-on-Target GP – Allied Health Partnership Programme (DOT GP – AHPP)] to narrow the cost gradient. Stable patients can now be right-sited to less crowded privately-run primary care facilities for follow-up. Aim : We aim to demonstrate that patients receiving care from this new model are satisfied with the cost, quality, and effectiveness of services provided by the DOT-AHPP liaison officers (DALO) and private partners. Methods : Seventy-seven patients suffering from LBP, suitable for conservative treatment, and assessed to be stable by orthopaedic surgeons from Singapore General Hospital (SGH) participated in this new model of care from August 2015 to April 2016. Patient satisfaction with our DALO and AHPP PT were described. Visual analogue pain scores (VAS) were evaluated before and after physiotherapy at AHPP using Wilcoxon signed-rank test. Results : Forty-two (54.6%) and Forty-five (58.5%) patients are very/extremely satisfied with the clarity of information and helpfulness presented by the DALO respectively. Twenty-two (28.6%) patients were referred for physiotherapy at AHPP but only 16 (20.8%) actualised the visit; Twelve (75.0%) patients were either satisfied or very satisfied with the overall affordability, friendliness, knowledge and ambience of the AHPP clinics. Significant improvement in VAS was observed after AHPP physiotherapy [n=9; before: 6.3(1.7); after: 4.0(1.6); P=.007]. Discussion : Patients receiving care from this new model are generally satisfied with the right-siting process. Overall, patients receiving care from AHPP PT reported improvement in their condition and were satisfied with the cost gradient reduction. Further strategies can be implemented to increase the enrolment. These include deepening the AHPP and specialists relationship by governing the care provision, regular case discussion and building trust. Further cost reduction, for example, with government subvention may increase patient enrolment. Limitations : The number of AHPP physiotherapy clinics is limited and most of them are geographically located in central Singapore. This may prohibit patients from enrolling into the new care model. More partners can be co-opted, especially in the northern and western parts of Singapore. These partners should be located close to Mass Rapid Transit (MRT) stations in order to reduce travel inconveniences to patients. Conclusions : The tripartite public-private partnership model has proven useful to decongest acute care services. However, more strategies to increase uptake by patients are needed.