Issue: June 2020
Source:

CMS adult elective surgery and procedures recommendations: Limit all non-essential planned surgeries and procedures, including dental, until further notice. Available at: www.cms.gov/files/document/covid-elective-surgery-recommendations.pdf. Accessed May 20, 2020.

Disclosures: Beredjiklian reports he is a shareholder at Rothman Orthopaedic Institute. DiFiori, Shrock, Vigil and Waters report no relevant financial disclosures.
June 23, 2020
11 min read
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Walk-in clinics expand access to orthopedic care

Issue: June 2020
Source:

CMS adult elective surgery and procedures recommendations: Limit all non-essential planned surgeries and procedures, including dental, until further notice. Available at: www.cms.gov/files/document/covid-elective-surgery-recommendations.pdf. Accessed May 20, 2020.

Disclosures: Beredjiklian reports he is a shareholder at Rothman Orthopaedic Institute. DiFiori, Shrock, Vigil and Waters report no relevant financial disclosures.
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From 2013 to 2019, the Urgent Care Association reported an increase in the number of urgent care clinics across the United States, providing more patients with access to treatment of non-life- or limb-threatening conditions and injuries.

Urgent care clinics generally provide treatment beyond the scope, accessibility or availability of primary care practices or clinics. Use of urgent care clinics has been further expanded by orthopedic practices and hospitals that see orthopedic urgent care and walk-in clinics as a way to increase access to comprehensive musculoskeletal care.

Peter M. Waters, MD, MMSc, said urgent care and walk-in clinics provide appropriate patient care that may be more convenient than the ED and may be associated with a reduction in the cost of care.

Source: Peter M. Waters, MD, MMSc.

“As opposed to a typical urgent care where the providers are trained in a number of different areas, including to some extent musculoskeletal care, [patients] are getting a higher level of care for a musculoskeletal condition because all of the physicians and providers at that location are specifically trained in musculoskeletal care,” said John P. DiFiori, MD, FACSM, chief of primary sports medicine at Hospital for Special Surgery (HSS), which opened eight urgent orthopedic care clinics in April at existing HSS locations.

One of the main purposes of orthopedic urgent care and walk-in clinics is to keep patients out of the ED who do not need to be there, according to Peter M. Waters, MD, MMSc, orthopedic surgeon-in-chief at Boston Children’s Hospital. This model has been advantageous during the COVID-19 pandemic, with hospitals and practices implementing protocols at orthopedic urgent care and walk-in clinics to provide patients with access to care while easing the burden likely to be placed on the ED.

Protocols during COVID-19

However, even orthopedic urgent care and walk-in clinics have established protocols that follow recommended treatment guidelines during the COVID-19 pandemic. The HSS Urgent Ortho Care clinics limited patient visits to injuries that required immediate care, such as fractures or tendon ruptures, according to DiFiori, who noted they developed a phone triage system to identify patients who could be treated without an on-site visit.

“These cases were then routed to physicians providing telehealth consultations,” DiFiori said. “For on-site visits of essential cases, protocols were implemented for patient safety, as well as for safety of physicians, nurses and all essential staff.”

Daniel V. Vigil, MD, chief of the divisions of primary care sports medicine and medical director of UCLA Orthopaedic Surgery After-Hours Clinic, said they created protocols around the use of personal protective equipment for all doctors, nurses and staff when encountering patients, as well as protocols for patients coming into the office, in response to the COVID-19 pandemic. Simultaneously, they experienced a decrease in patient volume which prompted them to temporarily decrease their medical staff and their office hours, he said.

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Although the decrease in patient volume may be due to facilities following recommendations on social distancing, Vigil said the decline may be due to patients triaging their own injuries to decide if they are truly urgent.

Daniel V. Vigil

The sharp decline in people’s physical and outdoor activities may also have contributed to this volume reduction, according to Waters.

“A major thing for the children is there are no active youth sports that are going on at the moment,” he said. “The second is kids are not in schools, and so they are not on their playgrounds. At least in the Massachusetts and Boston area, parks are closed, climbing structures are taped off, so that part has been down.”

John P. DiFiori

Eased restrictions

As states are easing restrictions and some facilities and businesses are opening again, Kevin B. Shrock, MD, FAAOS, said orthopedic urgent care and walk-in clinics are once again seeing an increase in patient volume.

“We are starting to see many patients who do not want to go to the [emergency room] ER,” Shrock, medical director of Fort Lauderdale Orthopedic Walk-in Clinic, said. “They are reluctant to visit the hospital and feel safer being seen in an office. And, if needed, they are thrilled if we can do their surgeries in an outpatient center.”

However, even with the easing of restrictions, social distancing and patient screening protocols are staying firmly in place at orthopedic urgent care and walk-in clinics, sources said.

Vigil said at the UCLA Orthopaedic Surgery After-Hours Clinic, patients coming into the office will be greeted at the door for COVID-19 screening and a temperature check and either ushered into the clinic or be told to wait outside until they are ready to be seen. Patients who arrive with a fever will be sent home to await further instruction, he said.

“In our current policy, [patients with a fever] would be advised to go home, wait for a call from either a primary care doctor or someone from our clinic to give them advice about how to manage the fever as a first priority, while advising them on their urgent orthopedic problem as a secondary priority,” Vigil said. “We have those protocols in place now and my prediction is that will probably remain in place until there is treatment for COVID-19 or a vaccine to prevent it.”

Appropriate level of care

In addition to keeping patients out of the ED, Waters said urgent care and walk-in clinics not only provide an appropriate level of patient care, but can lead to a reduction in the cost of orthopedic care and inconvenience to patients compared with the ED. Furthermore, orthopedic urgent care and walk-in clinics allow for timely and efficient care for all patients, regardless of whether they have an appointment, he said.

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“When we segregated our trauma, including our trauma from the clinic, but also our trauma from the operating room, from our specialized practices, it just meant that when people were focused on spinal deformity or hand reconstructive surgery or cerebral palsy, their clinics were not being disrupted by patients who needed care,” Waters told Orthopedics Today. “We could provide care in an efficient timely way for those who needed it ... and at the same time we could provide more care to the other kids who have complex problems.”

Besides providing timely musculoskeletal-based care, urgent care and walk-in clinics are often located within an outpatient facility of an orthopedic practice. This allows for patients to receive complete care without having to seek out an orthopedic surgeon on their own after their initial visit, according to DiFiori.

“When you have one of these urgent orthopedic care centers, remember you are facilitating care for injuries that require timely care, but it is part of an overall musculoskeletal care system so the patient has appropriate comprehensive care for the time period that is needed to treat that injury,” DiFiori said. “It is not like [they are] in and out and on [their] own to seek out another physician to guide [them] through the remainder of the treatment of that injury.”

However, Pedro K. Beredjiklian, MD, chief of division of hand surgery at Rothman Orthopaedic Institute and senior vice president of clinical affairs at Rothman Orthopaedics, said orthopedic urgent care and walk-in clinics generally treat less severe traumatic injuries not indicated for the ED, such as a simple wrist or ankle fracture as opposed to a broken leg sustained from a car accident.

According to DiFiori, HSS Urgent Ortho Care clinics provide services for urgent musculoskeletal injuries that cannot wait to be scheduled for an orthopedic office visit, including onsite X-ray or musculoskeletal ultrasound, as well as splinting, casting or bracing. Although the clinics do not offer surgical treatment, DiFiori noted some sites are equipped to perform outpatient procedures, such as ultrasound-guided injections.

“If it was thought that [patients had] a surgical injury, they would be appropriately managed and then care with a surgeon who had expertise in that particular injury would be facilitated either that same day or within the timeframe that is needed to treat that injury appropriately,” DiFiori said.

Pedro K. Beredjiklian

Considerations for an urgent care clinic

Through an urgent care or walk-in clinic, practices have the opportunity to demonstrate to the community “the level of care and expertise” they can provide, according to DiFiori.

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“It is in the community setting, so it provides that awareness that we are there for patients whether [they] have a chronic condition or an acute injury and we are going to help take care of [them] for whatever [their] condition is, in a timely way,” he said.

When deciding whether an orthopedic urgent care or walk-in clinic would be a beneficial ancillary service for a practice, physicians must be able to define their objective in establishing such a clinic, including what will and will not be offered, to “avoid unnecessary redundancy of care within one’s health care system,” Vigil said.

“It goes back to our question about emergency rooms: Why would we create our Ortho Urgent Care if the emergency room is already offering the same service?” Vigil, told Orthopedics Today.

Beredjiklian recommends a market analysis be performed to identify and establish a need for an urgent care facility within the local region.

Waters said having a separate business model for the urgent care or walk-in clinic may also help identify whether there is a need within the community for the clinic and how many patients must be seen for its success.

He said, “You have to figure out how many people is it going to take to do it; you have to sort out your hours of operation; you have to be certain you have ready access to X-ray or a mini C-arm; you have to have the ability to cast people; you have to have the ability to triage folks who need to get to an operating room; you have to literally set up a business plan around it and then you have to come up with the sense of is it feasible.”

Urgent care: Source of revenue

In addition to patient demand, local competition can also drive the need for a hospital or orthopedic practice to open an urgent care or walk-in clinic because it may be an avenue to acquire and retain new patients and provide added revenue, according to Vigil.

“Our impetus to do this had a bit of a financial component to it because we realized that it is the American mindset,” Vigil said. “If I cannot get my service here, I am going to go somewhere else. For example, if this plumber is closed, I am going to go to another one. If this mechanic is not open, I am going to go to that one. Accordingly, we did not want to lose our business.”

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Beredjiklian said orthopedic urgent care and walk-in clinics may not be “a strong revenue source for a practice.”

On the other hand, Shrock said “a walk-in clinic should be cash flow positive to the practice.” The additional patient volume from the clinic increases overall volume for the main practice, he noted.

“There is a resulting increase in ancillary volume for physical therapy, X-ray and MRI scanning” Shrock told Orthopedics Today. “Those are areas of direct volume increase; not to mention if patients do require surgery, those patients increase the surgical volume of the practice.”

It may be more economical for established practices to open an orthopedic urgent care or walk-in clinic within the facilities of the existing practice by hiring an experienced physician assistant (PA) to handle walk-in cases rather than opening a new location, according to Shrock. Creating space for an urgent care or walk-in clinic within the same office as the established practice obviates the need for redundant equipment purchases, he said.

“We have economies of scale by using the same resources and the same infrastructure, the same [electronic medical record] EMR system, the same billing system, etc., and we have the same insurance contracts as the main office,” Shrock said. “It makes it less of a burden to get it up and running than the cost of opening a freestanding center somewhere else and it ensures experienced backup is available onsite at all times.”

Select patients to treat

Orthopedic surgeons should consider treating the same patient demographics within their urgent care or walk-in clinic that they already treat in their established practice, Shrock said.

“We can see the same patients that I would see in my normal office because, at the end of the day, I will be the one handling any complicated problem that is beyond the scope of what the PA is comfortable seeing,” he said.

Beredjiklian told Orthopedics Today two common patient demographics seen at the orthopedic urgent care clinic at Rothman Orthopaedic Institute are older patients with back and joint pain, and the younger patient population that participates in sports.

Tourists may also be frequent patients at clinics in geographic areas with a high tourist population, according to Vigil.

“We get the young to the older tourists, from hikers and marathon runners to skateboarders and sightseers, as well as people who live locally. Our patients are socioeconomically diverse, who all want the same thing because everybody goes outside and has fun, and everybody falls down and gets injured,” Vigil said.

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Measurements of success

When gauging an orthopedic urgent care or walk-in clinic’s success, DiFiori noted it is important to measure patient satisfaction and ensure patients have a positive experience from the first point of contact to all follow-up appointments.

Kevin B. Shrock

“As opposed to providing a diagnosis and some recommendations, we think it is important to extend the scope of what you are providing to ensure that the patient has all of the appropriate follow-up appointments, consultations, physical therapy all wrapped up when they leave the office,” DiFiori said.

Beredjiklian said wait time satisfaction is included in their measurement of patient satisfaction to ensure clinic staff are providing timely access.

Other evaluation metrics may include patient volume, demographics, the types of conditions treated and referral patterns, DiFiori noted.

“We look at where the patients are going for their follow-up appointments,” he said. “How many of them are going to a primary sports medicine physician? How many are going to a surgical consultation?”

Regarding patient volume, Vigil noted the numbers of patients per session, week and month are quantified to identify the busiest times at the clinic and those data are used to make staffing decisions.

Orthopedic surgeons at Boston Children’s Hospital urgent care clinic also track and measure technical issues and decision-making among the physicians, according to Waters.

“We have built systems of safety around decision-making and as we bring in new employees we have ... levels of expertise as to where people are and what they can do,” Waters said. “We monitor it pretty closely, and there are always people on-site, so there is always a hierarchy by which folks can get expertise.”

Expanded community care

Overall, DiFiori said urgent care and walk-in clinics are a way orthopedic practices can expand care throughout their communities.

“Even well-established offices can create, internally, a mechanism to provide this sort of timely care,” he said. “It is not limited to freestanding sites or new sites. It is more of a way of thinking, a way of recreating access within an established practice.”

DiFiori said an orthopedic urgent care and walk-in clinic is meant to complement and not “replace the care provided by a primary care physician or an orthopedic specialist.”

“It enables patients to avoid unnecessary visits to an emergency room, potentially, and secondly, it is an alternative to other forms of urgent care settings that are broader based and do not specialize in musculoskeletal care,” he said. “It is an extension of musculoskeletal specialty care.”

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