Oup Accepted Manuscript 2019

1
2 TITLE: Development of a Comprehensive, Nonsurgical Joint Health Program for
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3 People With Osteoarthritis: A Case Report
4 RUNNING HEAD: Joint Health Program Administrative Case Report
5 TOC CATEGORY: Musculoskeletal
6 ARTICLE TYPE: Case Report
7 AUTHOR BYLINE: Morven R. Malay, Trevor A. Lentz, Jonathan O’Donnell,

8 Theresa Coles, Richard Chad Mather, William A. Jiranek
9 AUTHOR INFORMATION:
10 M.R. Malay, PT, DPT, Department of Physical Therapy and Occupational Therapy,
11 Duke University Health System, DUMC 3965, Durham, NC 27710. Dr Malay is a
12 board-certified clinical specialist in orthopaedic physical therapy and a Fellow of the
13 American Academy of Orthopedic Manual Physical Therapists. Address all
14 correspondence to Dr Malay at: morven.ross@duke.edu.
15 T.A. Lentz, PT, PhD, MPH, Department of Orthopaedic Surgery, Duke Clinical
16 Research Institute, Duke University Health System.
17 J. O’Donnell, MD, Department of Orthopaedic Surgery, Practice Transformation Unit,

18 Duke University Health System.
19 T. Coles, PhD, Department of Population Health Sciences, Duke University Health

20 System.
21 R.C. Mather, MD, MBA, Duke Clinical Research Institute and Department of
22 Orthopaedic Surgery, Practice Transformation Unit, Duke University Health System.
23 W.A. Jiranek, MD, Department of Orthopaedic Surgery, Practice Transformation

24 Unit, Duke University Health System. Dr Jiranek is a Fellow of the American College
25 of Surgeons.
26 KEYWORDS: Hip Osteoarthritis, Knee Osteoarthritis, Health Care Reform, Models,

27 Organizational, Disease Management
28 ACCEPTED: June 12, 2019

SUBMITTED: December 6, 2018
29
30
31 Background and Purpose: Existing osteoarthritis (OA) care models often fall short in
32 addressing the many biological, psychological, social and behavioral characteristics

33 that contribute to disability. As US health care shifts towards value-based payment,
34 there is an increasing need to develop and test scalable, cost-effective, and multi-
35 modal OA care models. This administrative case report will describe the development
36 and pilot of a new, value-based comprehensive care model for OA.
37
38 Case description: The Joint Health Program (JHP) is a physical therapist-led
39 conservative care model for individuals with hip and knee OA. In the JHP, physical
40 therapists with specialized training in cognitive behavioral-theory based strategy
41 function as the central care provider (i.e., the Primary Osteoarthritis Provider, or POP)
42 that delivers evidence-based, psychologically-informed interventions and coordinates
43 care within a multi-disciplinary network of dietitians, behavioral health specialists and
44 orthopedic providers. The JHP is focused on enhancing patient engagement, shared
45 decision making, self-management and multi-modal patient interaction, and long-term
46 follow-up.
47
48 Outcomes: A value-based, comprehensive care program for OA led by physical
49 therapists demonstrated feasibility and acceptability within a large, academic health
50 care system, which has led to its early growth. Barriers to development and integration
51 of the program were addressed through effective collaboration among health care
52 providers, program and health system administrators, and executive leadership.
53
54 Discussion: The JHP serves as a model for future physical therapist-led, value-based
55 care models that could be developed in other health care systems for OA and other

56 chronic conditions. Future work will identify characteristics that predict program
57 response and compare the effectiveness of this program to existing models of care.
58
59
60 Osteoarthritis (OA) is a chronic, prevalent, disabling, and costly condition that affects
61 over 30 million Americans and is a leading cause of disability.1,2 Existing OA care
62 models in the United States (US) often fail to comprehensively evaluate or address the
63 many biological, psychological, social, and behavioral factors that contribute to
64 disability.3 Moreover, evidence-based clinical practice guidelines are poorly
65 implemented despite broad agreement on best practice among clinical specialties and
66 disciplines.4 The result is fragmented, inconsistent care that emphasizes procedural or
67 surgical intervention, leaving many individuals susceptible to persistent disability and
68 high health care costs.3
69
70 Comprehensive, conservative OA care models have demonstrated good clinical and
71 economic results in other countries (e.g., osteoarthritis chronic care program in
72 Australia).3 However, the development of similar care models has been limited in the
73 US, where the predominant fee-for-service (FFS) payment system poorly compensates
74 lifestyle and behavioral health interventions and care coordination compared to
75 procedural or surgical care. As reimbursement models for orthopedics care shift toward
76 value-based payment in the US, there is an urgent need for health care systems to
77 identify scalable, cost-effective comprehensive OA care models, especially as the
78 appropriateness of some joint arthroplasty procedures has been called into question.5

79
80 The Joint Health Program (JHP) was designed to be responsive to emerging shared-
81 risk and population-based care models in orthopedics. Among its novel attributes, it
82 targets psychological and behavioral health needs and provides guideline-adherent,
83 condition-focused conservative care. In this administrative case report, we describe the
84 development, configuration and initial piloting of the JHP in accordance with the Medical
85 Research Council’s guidelines for developing and testing complex interventions.6
86
87 [H1] Program Development
88 [H2] Setting: The JHP was co-developed in October of 2017 at Duke Health by the
89 Department of Orthopaedic Surgery (Duke University School of Medicine) and the
90 Department of Physical Therapy and Occupational Therapy (Duke University Health
91 System, DUHS). The program operates within Duke Health, which is comprised of 3
92 hospitals, 14 ambulatory orthopaedic clinic sites, and 17 ambulatory physical therapy
93 clinics. Duke Health encounters approximately 9,000 patients with new hip or knee OA
94 diagnoses each year.
95
96 [H2] Conceptual Framework: The conceptual framework of the JHP was informed by
97 practical models of evidence-based OA care delivery, including (1) non-operative hip
98 and knee OA clinical practice guidelines;7 and (2) existing comprehensive OA care
99 models (Supplemental Figure).3The JHP’s focus on conservative treatment reflects well-

100 documented evidence-based hip and knee OA guidelines emphasizing early
101 conservative management.7 Allen et al.’s review of current OA care models and keys-to-

102 success provided practical insight into the design and implementation of the JHP,
103 including the composition of health care provider teams, strategies for development,
104 program logistics, and program assessment. 3
105
106 Development of the JHP was also guided by two theoretical models: (1) the
107 biopsychosocial model of health8 and (2) behavior change theories (Supplemental
108 Figure).9,10 The biopsychosocial model of health, which details the complex interaction
109 between biological, social and psychological determinants of health, informed the JHP’s
110 focus on psychological and behavioral interventions while emphasizing patient-centered
111 goal setting and shared decision-making.8,11 We incorporated various aspects of Social
112 Cognitive Theory and the Transtheoretical Model of Behavior change, including analysis
113 of behavior, identifying stages of behavior change, building therapeutic alliance and
114 enhancing self-efficacy, to promote behavior and lifestyle changes that could reduce the
115 negative impact of OA on function and disability.9,10 Taken together, these practical and
116 theoretical models guided content development, structure and deployment of the
117 program.
118
119 [H1] Program Configuration
120 Clinical implementation of the JHP is structured around delivery of conservative care,
121 including: education; nutrition guidance and weight management; physical activity and
122 prescriptive exercise; cognitive behavioral theory-based strategies for managing pain
123 associated psychological distress; functional training; and sleep hygiene (Figure 1).
124 These foci represent fundamental treatment targets that are relevant across the

125 longitudinal continuum of OA management from early stages of joint disease to post-
126 arthroplasty care. Since the program is designed as a comprehensive management
127 approach that is compatible with value-based care, it differs from existing or ―usual‖ OA
128 care models in many key areas, which are outlined in the Table.
129
130 [H2] Primary Osteoarthritis Provider
131 In the program, physical therapists operate as a condition-specific provider, called the
132 primary osteoarthritis provider (POP). The POP has the responsibility of delivering
133 conservative OA care (Figure 1) and/or coordinating more intensive services with other
134 health care partners as needed (Figure 2, e.g., behavioral health specialists, registered
135 dietitians, orthopedic surgeons). POPs work two eight-hour days each week in the JHP
136 at existing Physical Therapy and Occupational Therapy ambulatory practice sites
137 across Duke Health.
138
139 [H2] POP Training
140 In addition to expertise in treatment of physical impairments, the POP has advanced
141 education and clinical training provided by the JHP. The training program consists of
142 five didactic sessions covering program logistics, evidence-based guidelines for non-
143 surgical management of OA, pain education, sleep health, nutrition and weight
144 management as it relates to OA, and foundations of cognitive behavioral theory-based
145 strategies for OA management. Details of the didactic sessions are described in
146 Supplemental Appendix 1. Experiential training includes two half-day clinic observation
147 sessions with a practicing POP and two half-day supervision sessions by a practicing

148 POP. In addition, POPs are required to complete an intensive program designed to
149 teach them how to train patients in cognitive and behavioral pain coping skills co-
150 developed by the Duke Physical Therapy and Occupational Therapy Department and
151 Duke Pain Prevention and Treatment Research Program. The intensive training
152 program is led by health psychologists with expertise in coping skills training for pain
153 and symptom management and was specifically designed for physical and occupational
154 therapists (Supplemental Appendix 1).12
155
156 [H2] Participant Entry into Joint Health Program
157 At Duke Health, patients with OA are typically seen by either an orthopaedic surgeon or
158 advanced practice provider for their initial OA diagnosis and care. At the point of care,
159 these providers identify appropriate JHP candidates with hip and/or knee OA and refer
160 them into the program. Eligibility for the program is broadly inclusive and most
161 individuals referred into the program can be categorized by one of the following: 1) in
162 the early stages of symptomatic OA in need of secondary prevention, 2) electing non-
163 surgical OA management or are otherwise ineligible for surgical management (i.e.,
164 arthroplasty), 3) eligible for arthroplasty but require optimization (e.g., weight loss,
165 strengthening, reduction in pain related psychological distress) prior to surgery, or 4)
166 status-post arthroplasty to maintain or increase functional gains.
167
168 [H2] Participant Examination and Evaluation by the POP

169 The JHP care episode begins with a comprehensive examination of the participant's
170 past medical and surgical history, pain intensity, disability, physical activity, functional

171 limitations, nutritional status, weight loss needs; sleep, psychological and behavioral
172 health; goals and expectations (Supplemental Appendix 2). Following subjective and
173 clinical examination, the POP assesses appropriate treatment options in order to
174 propose individualized suggestions for treatment pathways that may be most effective
175 for the participant. The POP then educates participants on the core principles of the
176 JHP (Supplemental Appendix 3) to set program expectations and encourage
177 participants to take active roles in their care. The participant and POP next share in the
178 decision-making process to develop the individualized, patient-centered plan of care,
179 which is weighted towards participant preference and values. Referral guidelines are
180 used to help the POP and participant determine if and when referral to additional
181 resources might be needed. Potential treatment pathways and referral guidelines that
182 inform care plan decision-making in the JHP are outlined in Figure 2.
183
184 [H2] Intervention and treatment monitoring
185 All participants begin in a clinic-based active treatment phase upon entry into the JHP.
186 Clinic-based visits may consist of developing and/or reviewing independent exercise
187 programs, self-management strategies, general nutrition and weight loss guidance, pain
188 coping skills, sleep hygiene education, gait and functional training, neuromuscular re-
189 education, manual therapy, and modalities. In this phase, the POP initially sees
190 participants once every 1 to 3 weeks to develop a personalized program. Visit frequency
191 is reduced to once every 4 to 8 weeks when the POP and participant determine
192 satisfactory progress towards the participant’s goals is being made. Between clinic
193 visits, the POP communicates with participants remotely via phone calls, email and/or

194 use of electronic health record portal (MyChart) with a goal of connecting with the
195 participant in person or remotely at least every 3 to 4 weeks (Figure 3).
196
197 Intensity of participant engagement and mode of treatment is dictated, in part, by the
198 complexity of health care presentation and needs. Participants with less complex
199 presentations and needs (e.g., low pain, low psychological distress, low BMI) may
200 receive lower touch care pathways that consist of few clinic-based visits with the POP,
201 no outside referral to partners in the JHP, and an early focus on independent self-
202 management.13 Conversely, participants with more complex presentations and needs
203 (e.g., high psychological distress, high pain, high BMI, poor nutrition, poor coping) may
204 require higher touch care pathways that include more extensive use of clinic-based
205 visits and referral to nutrition, behavioral health, and/or additional providers as indicated,
206 along with more frequent communication with the referring orthopedic provider. 13–16
207 Regardless of complexity, all participants receive general education on OA and
208 resources available in the JHP (Supplemental Appendix 3).
209
210 Participants who fail to make adequate progress determined by the provider and
211 participant after 6 weeks in the program are referred back to their referring provider
212 (Figure 2). Alternatively, their progress may be individually reviewed by a supervisory
213 panel of musculoskeletal providers to suggest other treatment approaches. In addition
214 to regular check-ins with their POP, participants are issued questionnaires at pre-
215 specified intervals (baseline, 6 weeks, 3 months, 6 months and 1 year) to monitor
216 changes in pain, disability, satisfaction, and psychological distress (Supplemental

217 Appendix 2). Questionnaire results collected while participants are in the active
218 treatment phase may be used to adjust the plan of care, while questionnaire data after
219 this phase is completed can be used to monitor continued progress remotely and
220 evaluate long-term program outcomes.
221
222 [H2] Transition to Long-term and Independent Management
223 The ultimate goal of the program is transition to independent self-management
224 facilitated by semi-structured, longitudinal engagement with the POP. As participants
225 achieve independence with their individualized program, the participant and POP will
226 make a shared decision to transition to the Long-term Management Phase of the
227 program. The Long-term Management Phase generally lasts for one year following the
228 participant’s last clinic visit. Participants in this phase no longer require in-clinic visits,
229 but remote follow up with the participant is initiated by the POP at 1 month, 3 months, 6
230 months and 1 year after their last clinic visit (Figure 3). During this phase, participants
231 are encouraged to contact their POP as needed for worsening of symptoms, new injury
232 or if in need of assistance with progressing their current home program.
233
234 While transition timeframes to the Long-term Management Phase vary, most
235 participants in lower touch care pathways progress to long-term management after 3 to
236 7 clinic visits while those in higher touch care pathways generally take longer (i.e., 7-12
237 visits). As part of the transition from active treatment to long-term management, the
238 POP helps the participant identify community resources such as group exercise
239 classes, community centers, gyms, and pool as needed and/or desired by the

240 participant.
241
242 Once the participant has completed the Long-term Management Phase (i.e., 1 year
243 after their last clinic visit) they enter into the Independent Management Phase. During
244 this phase, participants are no longer being followed by the POP in the JHP (remotely or
245 actively); however, participants are encouraged to contact their POP as needed for
246 worsening symptoms, new injury, or if in need of assistance with their current home
247 program. This model allows participants to seamlessly re-engage with the POP to
248 address evolving chronic OA care needs (Figure 3).
249
250 [H1] Pilot Deployment and Program Growth
251 The pilot aims of the JHP included:
252 1. Determine ability to initiate provider network communication and referral streams.
253 We planned to evaluate this aim by demonstrating development of JHP-specific
254 referral systems within the electronic health record and established ancillary
255 referral destinations.
256 2. Evaluate acceptability of the program to key stakeholders, including participants,
257 providers, referring clinicians, and system leadership. We planned to evaluate
258 acceptability by obtaining feedback during quarterly JHP meetings from health
259 system stakeholders and the Net Promoter Score from JHP participants.
260 3. Evaluate initial program outcomes in participant-reported pain, mobility/physical
261 function, and psychological distress. We planned to evaluate program outcomes

262 by administering patient-reported outcome measures and calculating descriptive
263 statistics for PRO scores including describing change over time.
264 4. Evaluate impact on measures of JHP provider clinical productivity. We planned to
265 evaluate this aim by comparing each JHP provider's full-time equivalent clinical
266 productivity before and after their transition to participate in the JHP.
267
268 Orthopedic surgeons (RCM, WJ), a physical therapist (MM) and an administrative
269 physician (JO) collaborated to plan the practical implementation of the program,
270 leveraging clinical, administrative and academic resources available within the
271 academic medical center and the Duke Orthopaedics Practice Transformation Unit.
272
273 The JHP began with a single provider (MM) at a single site with a select group of
274 referring orthopedic providers (including RCM and WJ). This initial stage of program
275 deployment focused on refinement of the clinical workflow as well as the development
276 of seamless referral networks (i.e., partners) and communication pathways for
277 coordinated multidisciplinary care collaborated among clinical partners in other
278 disciplines (e.g., registered dietitians, behavioral health specialists) within the same
279 health system. The JHP implemented a JHP-specific visit type, referral order, and
280 scheduling decision-trees within the institutional electronic health record to clearly
281 identify and coordinate JHP participants distinctly from usual physical therapy referrals.
282 Multiple nutrition and psychology referral partners were cultivated and established
283 across local counties and entities.

284
285 During the first year of the program, participant, provider, and referring clinician
286 experiences were evaluated to 1) iteratively improve the program, and 2) assess
287 feasibility, acceptability and potential for expansion. Participant experiences in the
288 program were assessed with the Net Promotor Score.17 Paper and electronic
289 questionnaires were administered to participants at regular intervals following initial
290 evaluation (i.e., 6 weeks, 3 months, 6 months, and 12 months) to measure experience
291 and patient-reported outcomes (Supplemental Appendix 2). Provider and referring
292 clinician experiences were evaluated quarterly by soliciting feedback on program
293 design, ease of referral, effectiveness of communication and satisfaction with their role
294 in the treatment pathway. Outcomes and feedback were discussed at monthly JHP
295 team meetings to evaluate the need for changes in program content and/or
296 implementation. Participant experience scores suggest they would be very likely, on
297 average, to recommend this program to a friend or colleague. Feedback among
298 program stakeholders revealed increased satisfaction, as well. Referring orthopedic
299 providers were pleased to have access to an organized alternative care pathway for
300 collaborative non-surgical OA management; the number of unique referrers and the
301 average number of referrals per clinician grew rapidly. Physical therapists were satisfied
302 with an elevated role that allowed for a wider scope of care, including triage,
303 assessment, and long-term management.
304
305 Early outcomes assessments demonstrated mean improvements in participant-reported
306 pain, mobility/physical function, and psychological distress. We did not set a priori

307 success criteria for improvements, but rather were interested in ensuring that general
308 trends for these measures did not indicate worsening outcomes over the short term. In
309 the current fee-for-service payment model, JHP clinical productivity analysis showed
310 that POPs maintained their clinical productivity despite an increase in non-billable
311 program administrative time. This suggests that the JHP didn’t negatively affect
312 productivity in the near-term while value-based contracts continue to be negotiated and
313 implemented at the system level. These experiences and outcomes, as well as a
314 growing demand for greater participant access to the program, were presented to Duke
315 leadership within the first three months of the program. They determined the program to
316 be essential for building competencies in value-based care and teamwork around the
317 management of OA, and quickly supported the growth of the program. As a result,
318 additional referring clinicians and physical therapists were recruited to participate. As of
319 January 2019, the JHP has grown from 1 POP at 1 site with a select group of referring
320 clinicians to 10 POPs at 8 sites with >40 referring clinicians, having served over 700
321 participants (baseline characteristics included in the Supplemental Table).
322
323 [H1] Discussion
324 This pilot initiative supports the promise of addressing value-based initiatives with a
325 physical therapist-led, collaborative approach to comprehensive non-operative
326 management of patients with OA. Positive experiences by POPs, referring clinicians,
327 and participants provide impetus for further development and analysis of the JHP.
328
329 The JHP has many unique characteristics that differentiate it from current standard

330 practice. For instance, a core component of the program is facilitation of long-term
331 management that minimizes episodic, high intensity and costly resource use. It also
332 models the development of distributed interdisciplinary provider partner networks that
333 allow for seamless specialty care and collaboration when indicated. Demonstration
334 projects such as the JHP have potential to serve as a new standard for comprehensive,
335 multidisciplinary OA treatment models in the US health care system.
336
337 We have encountered various challenges while implementing the JHP at our academic
338 health center. First, the dominant fee-for-service payment model does not fully support
339 the program’s under-compensated coordination and services. The program has
340 survived through the extant billing capacity by physical therapists and thrived given our
341 local executive leadership's commitment to investing in the path toward value-based
342 care delivery, particularly given the dynamic healthcare payment environment in North
343 Carolina.18,19 Second, training physical therapists in cognitive behavioral theory-based
344 strategies, while a key program strength and point of differentiation, requires significant
345 resources and time. This type of training program requires a committed group of
346 behavioral health specialists with expertise in teaching pain and symptom coping skills
347 to deliver the training and small class sizes. The lengthy training program (27 weeks)
348 also limits the availability and frequency at which this training program can be offered
349 for training new POPs. Third, our institutional technology development process has
350 been limited and inconsistent in developing support for a comprehensive management
351 program like the JHP. For example, it took over 7 months to build and implement
352 electronic questionnaires through our electronic health record. Still, JHP administrators

353 manually sent surveys and follow-up to participants, consuming administrative time and
354 resources. Fourth, our team's capacity for program administration is constrained. For
355 example, two individuals support the development and operations for the entire
356 program, with an estimated 20 hours per week on administrative tasks. Institutions
357 interested in developing a program like the JHP may benefit from a dedicated full-time
358 operations management staff. Fifth, our distributed network of JHP sites utilizing
359 existing ambulatory clinic infrastructure permits rapid, cost-effective expansion, but also
360 creates challenges in communication and acceptance at each new site among site
361 coordinators and local leadership. It also challenges our ability to assess and maintain
362 treatment fidelity, which we are addressing by developing standard operating procedure
363 manuals. Finally, ancillary partnership expertise (e.g. nutrition, psychology) is generally
364 in short supply or lacking in many communities, even in our local urban environment,
365 whether based on quantity of such providers, geographic distribution, insurance
366 acceptance, or communication / follow-up channels. Strengthening these partnerships
367 and developing new ones is an ongoing priority.
368
369 The JHP is focused on anticipating and leading effective care model implementation at
370 the condition level for value-based payment reform in musculoskeletal care. To support
371 this goal, we plan to engage in future work to build prediction models that accurately
372 identify those who would achieve optimal benefit from the program, as well as those
373 who would receive little benefit or should not be in the JHP. Additionally, we plan to
374 compare program outcomes with historical controls or with outcomes from DUHS clinics
375 that have not yet implemented the program to assess the effectiveness of the JHP.

376
377 In conclusion, the JHP provides proof of concept for a physical therapist-led model for
378 comprehensive joint care in the US. Our initial experiences support its piloting and
379 deployment in a large, academic health care system. Work is currently underway to
380 refine its delivery and evaluate its cost-effectiveness.
381
382
383 Author Contributions and Acknowledgments:
384 Concept/idea/research design: M.R. Malay, T.A. Lentz, J. O’Donnell, R.C. Mather,
385 W.A. Jiranek
386 Writing: M.R. Malay, T.A. Lentz, J. O’Donnell, T. Coles, R.C. Mather, W.A. Jiranek
387 Data collection: M.R. Malay, J. O’Donnell, R.C. Mather, W.A. Jiranek
388 Data analysis: M.R. Malay, T.A. Lentz, T. Coles, R.C. Mather, W.A. Jiranek
389 Project management: M.R. Malay, J. O’Donnell, R.C. Mather, W.A. Jiranek
390 Fund procurement: R.C. Mather
391 Providing participants: M.R. Malay, J. O’Donnell, R.C. Mather, W.A. Jiranek
392 Providing facilities/equipment: M.R. Malay
393 Providing institutional liaisons: J. O’Donnell
394 Clerical/secretarial support: J. O’Donnell
395 Consultation (including review of manuscript before submitting): M.R. Malay, T.A.
396 Lentz, J. O’Donnell, T. Coles, R.C. Mather, W.A. Jiranek
397
398 The authors thank Benjamin Alman, MD, Daniel Dore, PT, DPT, MPA, and Gregory

399 Ruskan, PT, for their support and assistance with the development of the Joint Health
400 Program; and Francis J. Keefe, PhD, Rebecca Shelby, PhD, and Dr Dore for
401 comments that greatly improved the manuscript.
402 Ethics Approval:
403 This study was approved by the Duke University Institutional Review Board.
404 Funding:
405 There are no funders to report.
406 Disclosures and Presentations:
407 The authors completed the ICJME Form for Disclosure of Potential Conflicts of
408 Interest and reported no conflicts of interest.
409 This manuscript is based in part on a presentation on the background, piloting, and
410 early outcomes of the Joint Health Program at the North Carolina Physical Therapy
411 Association Fall Conference, DATE 2018 October 19, 2018, Greensboro, North
412 Carolina; at the American Physical Therapy Association’s Combined Sections
413 Meeting (platform), Washington, DC, January 24-26, 2019; and at AAOS 2019
414 (American Academy of Orthopaedic Surgeons Annual Meeting), Las Vegas, Nevada
415 March 12-16, 2019.
416
417
418
419
420
421
422
423 References
424 1. Cross M, Smith E, Hoy D, et al. The global burden of hip and knee osteoarthritis:
425 estimates from the global burden of disease 2010 study. Ann Rheum Dis.
426 2014;73:1323-1330. doi:10.1136/annrheumdis-2013-204763

427 2. Neogi T. The epidemiology and impact of pain in osteoarthritis. Osteoarthr Cartil.
428 2013;21:1145-1153. doi:10.1016/j.joca.2013.03.018
429 3. Allen KD, Choong PF, Davis AM, et al. Osteoarthritis: Models for appropriate care
430 across the disease continuum. Best Pract Res Clin Rheumatol. 2016;30:503-535.
431 doi:10.1016/j.berh.2016.09.003
432 4. Dziedzic KS, Allen KD. Challenges and controversies of complex interventions in
433 osteoarthritis management: recognizing inappropriate and discordant care.
434 Rheumatology (Oxford). 2018;57(suppl_4):iv88-iv98.
435 doi:10.1093/rheumatology/key062
436 5. Riddle DL, Perera RA, Jiranek WA, Dumenci L. Using surgical appropriateness
437 criteria to examine outcomes of total knee arthroplasty in a United States sample.
438 Arthritis Care Res (Hoboken). 2015;67:349-357. doi:10.1002/acr.22428
439 6. Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex

440 interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655.
441 7. Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of
442 recommendations and guidelines for the management of osteoarthritis: The chronic
443 osteoarthritis management initiative of the U.S. bone and joint initiative. Semin
444 Arthritis Rheum. 2014;43:701-712. doi:10.1016/j.semarthrit.2013.11.012
445 8. Engel GL. The need for a new medical model: a challenge for biomedicine.
446 Science. 1977;196:129-136.
447 9. Bandura: 1986. Social foundations of thought and... - Google Scholar.

448 https://scholar.google.com/scholar_lookup?hl=en&publication_year=1986&author=
449 A+Bandura&title=Social+Foundations+of+Thought+and+Action%3A+A+Social+Co
450 gnitive+Theory. Accessed February 14, 2019.
451 10. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change.
452 Am J Health Promot. 1997;12:38-48. doi:10.4278/0890-1171-12.1.38
453 11. Borrell-Carrió F, Suchman AL, Epstein RM. The Biopsychosocial Model 25 Years
454 Later: Principles, Practice, and Scientific Inquiry. Ann Fam Med. 2004;2:576-582.
455 doi:10.1370/afm.245
456 12. Bryant C, Lewis P, Bennell KL, et al. Can physical therapists deliver a pain coping
457 skills program? An examination of training processes and outcomes. Phys Ther.
458 2014;94:1443-1454. doi:10.2522/ptj.20130444
459 13. Meneses SR, Goode AP, Nelson AE, et al. Clinical algorithms to aid osteoarthritis
460 guideline dissemination. Osteoarthritis Cartilage. 2016;24(9):1487-1499.
461 doi:10.1016/j.joca.2016.04.004

462 14. Linton SJ, Shaw WS. Impact of psychological factors in the experience of pain.
463 Phys Ther. 2011;91(5):700-711. doi:10.2522/ptj.20100330
464 15. de Rooij M, van der Leeden M, Heymans MW, et al. Prognosis of Pain and
465 Physical Functioning in Patients With Knee Osteoarthritis: A Systematic Review
466 and Meta-Analysis. Arthritis Care Res (Hoboken). 2016;68:481-492.
467 doi:10.1002/acr.22693
468 16. Bastick AN, Wesseling J, Damen J, et al. Defining knee pain trajectories in early
469 symptomatic knee osteoarthritis in primary care: 5-year results from a nationwide
470 prospective cohort study (CHECK). Br J Gen Pract. 2016;66:e32-39.
471 doi:10.3399/bjgp15X688129
472 17. Reichheld FF. The One Number You Need to Grow. Harvard Business Review.
473 https://hbr.org/2003/12/the-one-number-you-need-to-grow. Published December 1,
474 2003. Accessed October 7, 2018.
475 18. North Carolina: The New Frontier For Health Care Transformation | Health Affairs.
476 https://www.healthaffairs.org/do/10.1377/hblog20190206.576299/full/. Accessed
477 July 29, 2019.
478 19. Blue Premier — a Rapid Shift to Value-Based Payment in North Carolina. NEJM
479 Catalyst. https://catalyst.nejm.org/blue-premier-nc-value-based-payment/.
480 Published January 23, 2019. Accessed July 29, 2019.
481 20. Lyman S, Lee Y-Y, Franklin PD, Li W, Mayman DJ, Padgett DE. Validation of the
482 HOOS, JR: A Short-form Hip Replacement Survey. Clin Orthop Relat Res.
483 2016;474:1472-1482. doi:10.1007/s11999-016-4718-2
484 21. Lyman S, Lee Y-Y, Franklin PD, Li W, Cross MB, Padgett DE. Validation of the
485 KOOS, JR: A Short-form Knee Arthroplasty Outcomes Survey. Clin Orthop Relat
486 Res. 2016;474:1461-1471. doi:10.1007/s11999-016-4719-1
487 22. Horn KK, Jennings S, Richardson G, Vliet DV, Hefford C, Abbott JH. The patient-
488 specific functional scale: psychometrics, clinimetrics, and application as a clinical
489 outcome measure. J Orthop Sports Phys Ther. 2012;42:30-42.
490 doi:10.2519/jospt.2012.3727
491 23. Connelly DM, Thomas BK, Cliffe SJ, Perry WM, Smith RE. Clinical Utility of the 2-
492 Minute Walk Test for Older Adults Living in Long-Term Care. Physiother Can.
493 2009;61:78-87. doi:10.3138/physio.61.2.78
494 24. Kennedy D, Stratford PW, Pagura SMC, Walsh M, Woodhouse LJ. Comparison of
495 gender and group differences in self-report and physical performance measures in
496 total hip and knee arthroplasty candidates. J Arthroplasty. 2002;17:70-77.
497 doi:10.1054/arth.2002.29324

498 25. Wright AA, Cook CE, Baxter GD, Dockerty JD, Abbott JH. A Comparison of 3
499 Methodological Approaches to Defining Major Clinically Important Improvement of
500 4 Performance Measures in Patients With Hip Osteoarthritis. Jo Orthop Sports
501 Phys Ther. 2011;41:319-327. doi:10.2519/jospt.2011.3515
502 26. Lentz TA, Beneciuk JM, Bialosky JE, et al. Development of a Yellow Flag
503 Assessment Tool for Orthopaedic Physical Therapists: Results From the Optimal
504 Screening for Prediction of Referral and Outcome (OSPRO) Cohort. J Orthop
505 Sports Phys Ther. 2016;46:327-343. doi:10.2519/jospt.2016.6487
506 27. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression
507 severity measure. J Gen Intern Med. 2001;16:606-613.
508 28. Posner BM, Jette AM, Smith KW, Miller DR. Nutrition and health risks in the
509 elderly: the nutrition screening initiative. Am J Public Health. 1993;83:972-978.
510
511
512
513
514
515
516
517 Table. Comparisons Between Characteristics of the Joint Health Program and
518 Predominant Existing Models of Clinical Practice for the Management of OA
Characteristic Predominant Existing Joint Health Program

Clinical Practice Models for
OA
Approach Discipline-focused care Condition-focused care
Content Primarily focused on Balanced between biomedical,
biomedical and anatomical anatomical, behavioral,
needs psychological and social needs
Provider expertise Primary expertise in Expertise and condition-specific
biomechanical, anatomical training in biomechanical,
and movement-related anatomical, movement-related,
characteristics of OA; limited behavioral and psychosocial
training in behavioral and characteristics of OA
psychosocial determinants of
health
Treatment Uniform, standard approach; Personalized, adaptive; stratified
protocol-focused, heavily by risk for persistent pain and
weighted to pharmaceuticals disability
and procedures
Decision-making Primarily driven by health Shared decision-making
care provider between provider and patient;
Coordinated team approach,
oversight via dashboard
approach
Treatment horizon Discrete episodes of care Longitudinal, focused on self-
management
Payment model Well-suited for fee-for-service Responsive to value and
design reimbursement, but with risk outcomes-based reimbursement
for overutilization of high
reimbursement procedures
Patient Primarily clinic-based and Multiple channels, including in-
engagement episodic clinic and telehealth; longitudinal
Provider network Fragmented, isolated from Network of interdisciplinary
other disciplines partners (neighborhood); open
communication and referral
channels
519
520
521 Figure 1. Foundations of the joint health program and primary osteoarthritis
522 provider

523
524
525
526
527
528
529
530
531
532
533
534
535
536
537
538
539
540
541
542
543
544
545
546 Figure 2. Treatment pathways and referral guidelines that inform care plan
547 decision-making in the joint health program. ADL = Activities of Daily Living; BH=
548 behavioral health; BMI = Body Mass Index; DM = diabetes mellitus; GI =

549 gastrointestinal; OA =Osteoarthritis ; OSPRO-YF = OSPRO- Yellow Flag; POP =
550 Primary Osteoarthritis Provider; RDN = Registered Dietitian.
551
552
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556
557
558
559
560
561
562
563
564
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566
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568
569
570
571
572
573
574
575
Figure 3: Usual joint health program plan of care
576
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2 TITLE: Development of a Comprehensive, Nonsurgical Joint Health Program for

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4 RUNNING HEAD: Joint Health Program Administrative Case Report

5 TOC CATEGORY: Musculoskeletal

6 ARTICLE TYPE: Case Report

7 AUTHOR BYLINE: Morven R. Malay, Trevor A. Lentz, Jonathan O’Donnell,

17 J. O’Donnell, MD, Department of Orthopaedic Surgery, Practice Transformation Unit,

19 T. Coles, PhD, Department of Population Health Sciences, Duke University Health

23 W.A. Jiranek, MD, Department of Orthopaedic Surgery, Practice Transformation

26 KEYWORDS: Hip Osteoarthritis, Knee Osteoarthritis, Health Care Reform, Models,

28 ACCEPTED: June 12, 2019

32 addressing the many biological, psychological, social and behavioral characteristics

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36 and pilot of a new, value-based comprehensive care model for OA.

38 Case description: The Joint Health Program (JHP) is a physical therapist-led

40 therapists with specialized training in cognitive behavioral-theory based strategy

42 that delivers evidence-based, psychologically-informed interventions and coordinates

43 care within a multi-disciplinary network of dietitians, behavioral health specialists and

44 orthopedic providers. The JHP is focused on enhancing patient engagement, shared

45 decision making, self-management and multi-modal patient interaction, and long-term

48 Outcomes: A value-based, comprehensive care program for OA led by physical

49 therapists demonstrated feasibility and acceptability within a large, academic health

52 providers, program and health system administrators, and executive leadership.

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61 over 30 million Americans and is a leading cause of disability.1,2 Existing OA care

63 many biological, psychological, social, and behavioral factors that contribute to

64 disability.3 Moreover, evidence-based clinical practice guidelines are poorly

66 disciplines.4 The result is fragmented, inconsistent care that emphasizes procedural or

67 surgical intervention, leaving many individuals susceptible to persistent disability and

68 high health care costs.3

70 Comprehensive, conservative OA care models have demonstrated good clinical and

71 economic results in other countries (e.g., osteoarthritis chronic care program in

74 lifestyle and behavioral health interventions and care coordination compared to

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82 targets psychological and behavioral health needs and provides guideline-adherent,

83 condition-focused conservative care. In this administrative case report, we describe the

85 Research Council’s guidelines for developing and testing complex interventions.6

87 [H1] Program Development

89 Department of Orthopaedic Surgery (Duke University School of Medicine) and the

90 Department of Physical Therapy and Occupational Therapy (Duke University Health

92 hospitals, 14 ambulatory orthopaedic clinic sites, and 17 ambulatory physical therapy

94 diagnoses each year.

97 practical models of evidence-based OA care delivery, including (1) non-operative hip

99 models (Supplemental Figure).3The JHP’s focus on conservative treatment reflects well-

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104 program logistics, and program assessment. 3

110 focus on psychological and behavioral interventions while emphasizing patient-centered

119 [H1] Program Configuration

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126 arthroplasty care. Since the program is designed as a comprehensive management

130 [H2] Primary Osteoarthritis Provider

137 across Duke Health.

139 [H2] POP Training

144 management as it relates to OA, and foundations of cognitive behavioral theory-based

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154 therapists (Supplemental Appendix 1).12

156 [H2] Participant Entry into Joint Health Program

165 strengthening, reduction in pain related psychological distress) prior to surgery, or 4)

166 status-post arthroplasty to maintain or increase functional gains.

168 [H2] Participant Examination and Evaluation by the POP

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176 JHP (Supplemental Appendix 3) to set program expectations and encourage