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Algorithm for the Chiropractic Treatment of Spine Related Pain

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Presentation on theme: "Algorithm for the Chiropractic Treatment of Spine Related Pain"— Presentation transcript:

1 Algorithm for the Chiropractic Treatment of Spine Related Pain

2 Source Documents Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain, Gregory A. Baker, DC, Ronald J. Farabaugh, DC, Thomas J. Augat, DC, MS, CCSP, FASA, Cheryl Hawk, DC, PhD; TOPICS IN INTEGRATIVE HEALTH CARE [ISSN ] – VOL 3(4) , Dec 2012. Chiropractic Management of Low Back Disorders: Report from a Consensus Process, G. Globe, MBA, DC, PhD, C. Morris, DC, W. Whalen, DC, R Farabaugh, DC, and C. Hawk, DC, PhD; JMPT, November/December 2008 Management of Chronic Spine-Related Conditions: Consensus Recommendations of a Multidisciplinary Panel, R. Farabaugh, DC, M. Dehen, DC, and C. Hawk, DC, PhD; JMPT, Volume 33, Number 7, Sept

3 Algorithm for the Chiropractic Treatment of Spine Related Pain
The scope of this algorithm is for the chiropractic management of spine related pain. It does not: Dictate or recommend the modality of treatment Guide the management of non-painful functional or structural spinal care (subluxation correction, posture correction, scoliosis management, etc) Apply to wellness care/health promotion

4 Patient presents with spine related pain
This is a new patient Patient presents with spine related pain This is an established patient with a new condition or a moderate- severe exacerbation of a pre- existing condition This is an established patient with a mild episode of a previously treated (usually chronic) condition. Perform New Patient Evaluation Perform Established Patient Evaluation Perform Evaluation1 (Often Condition Focused) Go to Acute Care Algorithm Go to Chronic Care Algorithm 1 2 3 4 5 6

5 Patient presents with spine related pain
This is a new patient Patient presents with spine related pain This is an established patient with a new condition or a moderate- severe exacerbation of a pre- existing condition This is an established patient with a mild episode of a previously treated (usually chronic) condition. Perform New Patient Evaluation Perform Established Patient Evaluation Perform Evaluation1 (Often Condition Focused) Go to Acute Care Algorithm Go to Chronic Care Algorithm 1 2 3 4 5 6

6 Patient presents with spine related pain
This is a new patient Patient presents with spine related pain This is an established patient with a new condition or a moderate- severe exacerbation of a pre- existing condition This is an established patient with a mild episode of a previously treated (usually chronic) condition. Perform New Patient Evaluation Perform Established Patient Evaluation Perform Evaluation1 (Often Condition Focused) Go to Acute Care Algorithm Go to Chronic Care Algorithm 1 2 3 4 5 6

7 Patient presents with spine related pain
This is a new patient Patient presents with spine related pain This is an established patient with a new condition or a moderate- severe exacerbation of a pre- existing condition This is an established patient with a mild episode of a previously treated (usually chronic) condition. Perform New Patient Evaluation Perform Established Patient Evaluation Perform Evaluation1 (Often Condition Focused) Go to Acute Care Algorithm Go to Chronic Care Algorithm 1 2 3 4 5 6

8 Acute Care Algorithm Patient presents with acute spine related pain.
Is Condition Outside of Scope or Practice or Skill Set Is co-management required? Refer to appropriate provider/ facility Yes No Yes Refer to appropriate provider/facility 1 4 3 2 Yes or No Assess for improvement at mid-point of trial using any of the accepted measurement tools Begin therapeutic trial of up to 12 visits within 4 weeks. 5 6 Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management No Refer to appropriate provider/facility 10 7 9 Yes Symptoms Resolved? No Continue Trial 8 11 Yes Perform Reassessment Evaluation 12

9 Acute Care Algorithm Patient presents with acute spine related pain.
Is co-management required? Is Condition Outside of Scope of Practice or Skill Set Refer to appropriate provider/ facility Yes No Yes Refer to appropriate provider/facility 1 4 3 2 Yes or No Assess for improvement at mid-point of trial using any of the accepted measurement tools Begin therapeutic trial of up to 12 visits within 4 weeks. 5 6 Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management No Refer to appropriate provider/facility 10 7 9 Yes Symptoms Resolved? No Continue Trial 8 11 Yes Perform Reassessment Evaluation 12

10 Acute Care Algorithm Patient presents with acute spine related pain.
Is co-management required? Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Yes No Yes Refer to appropriate provider/facility 1 4 3 2 Yes or No Assess for improvement at mid-point of trial using any of the accepted measurement tools Begin therapeutic trial of up to 12 visits within 4 weeks. 5 6 Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management No Refer to appropriate provider/facility 10 7 9 Yes Symptoms Resolved? No Continue Trial 8 11 Yes Perform Reassessment Evaluation 12

11 Acute Care Algorithm Patient presents with acute spine related pain.
Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Yes No Yes Is co-management required? Refer to appropriate provider/facility 1 4 3 2 Yes or No Assess for improvement at mid-point of trial using any of the accepted measurement tools Begin therapeutic trial of up to 12 visits within 4 weeks. 5 6 Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management No Refer to appropriate provider/facility 10 7 9 Yes Symptoms Resolved? No Continue Trial 8 11 Yes Perform Reassessment Evaluation 12

12 Acute Care Algorithm Patient presents with acute spine related pain.
Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Yes No Yes Is co-management required? Refer to appropriate provider/facility 1 4 3 2 Yes or No Assess for improvement at mid-point of trial using any of the accepted measurement tools Begin therapeutic trial of up to 12 visits within 4 weeks. 5 6 Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management No Refer to appropriate provider/facility 10 7 9 Yes Symptoms Resolved? No Continue Trial 8 11 Yes Perform Reassessment Evaluation 12

13 Acute Care Algorithm Patient presents with acute spine related pain.
Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Yes No Yes Is co-management required? Refer to appropriate provider/facility 1 4 3 2 Yes or No Assess for improvement at mid-point of trial using any of the accepted measurement tools Begin therapeutic trial of up to 12 visits within 4 weeks. 5 6 Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management No Refer to appropriate provider/facility 10 7 9 Yes Symptoms Resolved? No Continue Trial 8 11 Yes Perform Reassessment Evaluation 12

14 Acute Care Algorithm Patient presents with acute spine related pain.
Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Yes No Yes Is co-management required? Refer to appropriate provider/facility 1 4 3 2 Yes or No Assess for improvement at mid-point of trial using any of the accepted measurement tools Begin therapeutic trial of up to 12 visits within 4 weeks. 5 6 Improvement Evident at Midpoint? Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management No Refer to appropriate provider/facility 10 7 9 Yes Symptoms Resolved? No Continue Trial 8 11 Yes Perform Reassessment Evaluation 12

15 Acute Care Algorithm Patient presents with acute spine related pain.
Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Yes No Yes Is co-management required? Refer to appropriate provider/facility 1 4 3 2 Yes or No Assess for improvement at mid-point of trial using any of the accepted measurement tools Begin therapeutic trial of up to 12 visits within 4 weeks. 5 6 Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Improvement Evident at Midpoint? No Refer to appropriate provider/facility 10 7 9 Yes No Symptoms Resolved? Continue Trial 8 11 Yes Perform Reassessment Evaluation 12

16 Acute Care Algorithm Patient presents with acute spine related pain.
Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Yes No Yes Is co-management required? Refer to appropriate provider/facility 1 4 3 2 Yes or No Assess for improvement at mid-point of trial using any of the accepted measurement tools Begin therapeutic trial of up to 12 visits within 4 weeks. 5 6 Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Improvement Evident at Midpoint? No Refer to appropriate provider/facility 10 7 9 Yes No Symptoms Resolved? Continue Trial 8 11 Yes Perform Reassessment Evaluation 12

17 Acute Care Algorithm Patient presents with acute spine related pain.
Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Yes No Yes Is co-management required? Refer to appropriate provider/facility 1 4 3 2 Yes or No Assess for improvement at mid-point of trial using any of the accepted measurement tools Begin therapeutic trial of up to 12 visits within 4 weeks. 5 6 Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Improvement Evident at Midpoint? No Refer to appropriate provider/facility 10 7 9 Yes No Symptoms Resolved? Continue Trial 8 11 Yes Perform Reassessment Evaluation 12

18 Acute Care Algorithm Patient presents with acute spine related pain.
Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Yes No Yes Is co-management required? Refer to appropriate provider/facility 1 4 3 2 Yes or No Assess for improvement at mid-point of trial using any of the accepted measurement tools Begin therapeutic trial of up to 12 visits within 4 weeks. 5 6 Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Improvement Evident at Midpoint? No Refer to appropriate provider/facility 10 7 9 Yes No Symptoms Resolved? Continue Trial 8 11 Yes Perform Reassessment Evaluation 12

19 Acute Care Algorithm Patient presents with acute spine related pain.
Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Yes No Yes Is co-management required? Refer to appropriate provider/facility 1 4 3 2 Yes or No Assess for improvement at mid-point of trial using any of the accepted measurement tools Begin therapeutic trial of up to 12 visits within 4 weeks. 5 6 Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Improvement Evident at Midpoint? No Refer to appropriate provider/facility 10 7 9 Yes No Symptoms Resolved? Continue Trial 8 11 Yes Perform Reassessment Evaluation 12

20 Acute Care Algorithm Patient presents with acute spine related pain.
Is Condition Outside of Scope or Practice or Skill Set Refer to appropriate provider/ facility Yes No Yes Is co-management required? Refer to appropriate provider/facility 1 4 3 2 Yes or No Assess for improvement at mid-point of trial using any of the accepted measurement tools Begin therapeutic trial of up to 12 visits within 4 weeks. 5 6 Consider Modifying treatment methods Additional diagnostic procedures Referral or co-management Improvement Evident at Midpoint? No Refer to appropriate provider/facility 10 7 9 Yes No Symptoms Resolved? Continue Trial 8 11 Yes Perform Reassessment Evaluation 12

21 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

22 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

23 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

24 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

25 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

26 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

27 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

28 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

29 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

30 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

31 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

32 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

33 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

34 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

35 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

36 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

37 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

38 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

39 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

40 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

41 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

42 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

43 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

44 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

45 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

46 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

47 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

48 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

49 Acute Care Algorithm Do Significant Symptoms and/or
Functional deficits Remain? Release with home care instructions or transition to wellness care Yes No Is condition Stable or resolved? Yes MTB Achieved? 15 13 16 14 No/Not Sure No/Not Sure Yes Yes No Functional/symptom improvements? Yes Trial withdrawal desired? Consider co-management 24 22 17 Provide home care instructions and initiate trial withdrawal. Other Treatment Options available In this facility? No No Refer Refer 25 19 23 18 Reassess condition status Yes 26 Continue up to 12 visits within 4 weeks Yes Additional improvement likely? Has condition deteriorated No 27 20 21 Yes Go to Chronic Care Algorithm No

50 Chronic Care Algorithm
Chronic Care Goals Minimize lost time on the job Support patient’s current level of function/ADL Pain control/relief to tolerance Minimize further disability Minimize exacerbation frequency and severity Maximize patient satisfaction

51 Chronic Care Algorithm
Patient presents with chronic/recurrent spine related pain. Chronic Care Algorithm Refer to appropriate provider/facility or provide home management instructions. Do the benefits of chronic pain management outweigh the risks? No Yes Yes Red flags present? Refer to appropriate provider/facility 2 4 3 1 No or yes but appropriately managed. This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. This is a symptom flare for a known chronic condition or recurrence of acute condition This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms 5 7 8 Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Yes Traumatic cause of exacerbation? 9 6 Consider imaging 10 No Moderate to severe exacerbations follow Acute Care Algorithm. No Mild Exacerbation? 11 12 Yes Continue

52 Chronic Care Algorithm
Patient presents with chronic/recurrent spine related pain. Chronic Care Algorithm Refer to appropriate provider/facility or provide home management instructions. Do the benefits of chronic pain management outweigh the risks? No Yes Yes Red flags present? Refer to appropriate provider/facility 2 4 3 1 No or yes but appropriately managed. This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. This is a symptom flare for a known chronic condition or recurrence of acute condition This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms 5 7 8 Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Yes Traumatic cause of exacerbation? 9 6 Consider imaging 10 No Moderate to severe exacerbations follow Acute Care Algorithm. No Mild Exacerbation? 11 12 Yes Continue

53 Chronic Care Algorithm
Patient presents with chronic/recurrent spine related pain. Chronic Care Algorithm Refer to appropriate provider/facility or provide home management instructions. Do the benefits of chronic pain management outweigh the risks? No Yes Yes Red flags present? Refer to appropriate provider/facility 2 4 3 1 No or yes but appropriately managed. This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. This is a symptom flare for a known chronic condition or recurrence of acute condition This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms 5 7 8 Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Yes Traumatic cause of exacerbation? 9 6 Consider imaging 10 No Moderate to severe exacerbations follow Acute Care Algorithm. No Mild Exacerbation? 11 12 Yes Continue

54 Chronic Care Algorithm
Patient presents with chronic/recurrent spine related pain. Chronic Care Algorithm Refer to appropriate provider/facility or provide home management instructions. Do the benefits of chronic pain management outweigh the risks? No Yes Yes Red flags present? Refer to appropriate provider/facility 2 4 3 1 No or yes but appropriately managed. This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. This is a symptom flare for a known chronic condition or recurrence of acute condition This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms 5 7 8 Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Yes Traumatic cause of exacerbation? 9 6 Consider imaging 10 No Moderate to severe exacerbations follow Acute Care Algorithm. No Mild Exacerbation? 11 12 Yes Continue

55 Chronic Care Algorithm
Patient presents with chronic/recurrent spine related pain. Chronic Care Algorithm Refer to appropriate provider/facility or provide home management instructions. Do the benefits of chronic pain management outweigh the risks? No Yes Yes Red flags present? Refer to appropriate provider/facility 2 4 3 1 No or yes but appropriately managed. This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. This is a symptom flare for a known chronic condition or recurrence of acute condition This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms 5 7 8 Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Yes Traumatic cause of exacerbation? 9 6 Consider imaging 10 No Moderate to severe exacerbations follow Acute Care Algorithm. No Mild Exacerbation? 11 12 Yes Continue

56 Chronic Care Algorithm
Patient presents with chronic/recurrent spine related pain. Chronic Care Algorithm Refer to appropriate provider/facility or provide home management instructions. Do the benefits of chronic pain management outweigh the risks? No Yes Yes Red flags present? Refer to appropriate provider/facility 2 4 3 1 No or yes but appropriately managed. This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. This is a symptom flare for a known chronic condition or recurrence of acute condition This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms 5 7 8 Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Yes Traumatic cause of exacerbation? 9 6 Consider imaging 10 No Moderate to severe exacerbations follow Acute Care Algorithm. No Mild Exacerbation? 11 12 Yes Continue

57 Chronic Care Algorithm
Patient presents with chronic/recurrent spine related pain. Chronic Care Algorithm Refer to appropriate provider/facility or provide home management instructions. Do the benefits of chronic pain management outweigh the risks? No Yes Yes Red flags present? Refer to appropriate provider/facility 2 4 3 1 No or yes but appropriately managed. This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. This is a symptom flare for a known chronic condition or recurrence of acute condition This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms 5 7 8 Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Yes Traumatic cause of exacerbation? 9 6 Consider imaging 10 No Moderate to severe exacerbations follow Acute Care Algorithm. No Mild Exacerbation? 11 12 Yes Continue

58 Chronic Care Algorithm
Patient presents with chronic/recurrent spine related pain. Chronic Care Algorithm Refer to appropriate provider/facility or provide home management instructions. Do the benefits of chronic pain management outweigh the risks? No Yes Yes Red flags present? Refer to appropriate provider/facility 2 4 3 1 No or yes but appropriately managed. This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. This is a symptom flare for a known chronic condition or recurrence of acute condition This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms 5 7 8 Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Yes Traumatic cause of exacerbation? 9 6 Consider imaging 10 No Moderate to severe exacerbations follow Acute Care Algorithm. No Mild Exacerbation? 11 12 Yes Continue

59 Chronic Care Algorithm
Patient presents with chronic/recurrent spine related pain. Chronic Care Algorithm Refer to appropriate provider/facility or provide home management instructions. Do the benefits of chronic pain management outweigh the risks? No Yes Yes Red flags present? Refer to appropriate provider/facility 2 4 3 1 No or yes but appropriately managed. This is a scheduled visit for ongoing/recurrent care for a patient expected to progressively deteriorate based on previous treatment withdrawals. This is a symptom flare for a known chronic condition or recurrence of acute condition This visit follows a trial withdrawal and there is a recurrence or worsening of symptoms 5 7 8 Treat according to ongoing/recurrent care plan (1-4 visits per month). Re-evaluate every 12 visits at minimum. Yes Traumatic cause of exacerbation? 9 6 Consider imaging 10 No Moderate to severe exacerbations follow Acute Care Algorithm. No Mild Exacerbation? 11 12 Yes Continue

60 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

61 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

62 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

63 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

64 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

65 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

66 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

67 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

68 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

69 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

70 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

71 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

72 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

73 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

74 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

75 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

76 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

77 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

78 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

79 Chronic Care Algorithm
Treat for up to 6 visits. Chronic Care Algorithm 13 Does Condition Worsen upon repeated attempts to withdraw care? Release patient Provide home management recommendations if appropriate Has patient returned to pre- episode status? No Yes No Consider further diagnostic testing 15 14 23 25 Red Flags present or other conditions outside of scope or skill set? Yes Refer to appropriate provider/facility Yes Consider ongoing/ Recurrent care plan of 1 – 4 visits per month. Re-evaluate at least every 12 visits. 16 17 No 24 Symptoms Improved?/Are Chronic Care goals being Met? Yes Yes MTB/Pre-Episode Status 18 22 No No Other Treatment options Available at this facility? Discontinue care and refer to appropriate provider/facility for opinion/management No 19 20 Yes Treat for up to 6 visits. Consider multimodal, multidisciplinary care. 21

80 In Summary Spine related pain
All decisions should take into account provider experience and patient preference. Care is appropriate provided improvement is demonstrated and/or expected.

81 Two Items of interest Thera-band System Appeal Letters
Thera-band System Appeal Letters * Thank you North Carolina Chiropractic Association (NCCA)

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