Sixty-six of the 68 GSCI team members participated and contributed to this document, which is a 97% response rate. The experts represent 13 specialties/professions. The following is a description of the GSCI model of care and suggestions for implementation. All participating experts agreed on the final report represented in this paper, which we designated to be a consensus.
Model of care principles
A model of care helps to transform a health care system to address a given health concern [39]. Davidson defines a model of care as
… an overarching design for the provision of a particular type of health care service that is shaped by a theoretical basis, EBP and defined standards. It consists of defined core elements and principles and has a framework that provides the structure for the implementation and subsequent evaluation of care. Having a clearly defined and articulated model of care will help to ensure that all health professionals are all actually ‘viewing the same picture’, working toward a common set of goals and, most importantly, are able to evaluate performance on an agreed basis. [40]
For a transformation process to succeed, underlying principles should be clearly defined to direct the transition from the current model of care into the new model of care. The following are eight principles that the GSCI expert panel agreed would facilitate the transition from an old to the new GSCI model of care (see Fig. 1).
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1.
Transform from provider-centered to person-centered
In a “provider-centered” model, the patient lacks autonomy and relies on the provider for decisions and care. The perception is that without the health care provider no healing or health could be achieved. Success metrics focus on the providers (e.g., number of procedures delivered) or may be the number of people that a provider sees with a certain condition (e.g., number of osteoporosis cases). The focus is on the provider’s thoughts (e.g., diagnosis, management decisions) and actions (e.g., surgery, drugs, manual/physical therapies, and passive therapies) and patients are seen as “cases” or “conditions” not as whole beings.
The GSCI model of care values person-centered care. Person-centered care empowers the person (or patient) to participate in the healing process [41,42,43]. The provider respects the individual’s autonomy and includes the individual’s culture, beliefs, and values in spinal health care decisions [29]. Person-centered care provides individuals with information to help them decide when to seek care, when to engage in self-care, and increases the likelihood of patient participation and compliance with the treatment plan, resulting in better outcomes, and costs. Person-centered care includes effective communication, shared decision making, holistic care, individualized care, and continuity of care [44, 45]. Person-centered success metrics focus on the spinal health of individuals and provide information about if the patients are receiving the correct care and if their health is improving. Ongoing assessment and monitoring of person-centered care delivery and systems offers objective results and encourages improvement [46, 47]. Evaluation increases awareness of processes and actions that are in alignment with best practices and could promote improved care and research [48].
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2.
Transform from system-centered to people-centered
System-centered health care focuses on business aspects or the organization that administers or houses the care. Metrics might include the number of people treated or hospital night stays, instead of serving the needs of the community. Such a focus on the delivery of care, instead of on the end-users, typically does not include community stakeholders in decisions.
The GSCI model emphasizes people-centered health care systems, which refocuses the health care system on the needs of the people in the community and society. In this model, the system engages community representatives as stakeholders and part of the health care relationship in the health care system [49]. People-centered, culturally competent health care can be integrated throughout the system such as through educational interventions, clinical encounters, health promotion programs and services, and processes at the systems level [50]. People-centered care contains a wide variety of community participants including the individual, care givers, families, and communities as participants in the health care process and includes not only the clinical encounter but also health policy and services [51]. People-centered care is participatory; therefore, there is greater accountability to local stakeholders and disadvantaged populations [46]. Success metrics include those related to community health, such as population health outcome measures and value of care indicators.
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3.
Transform from biomedical to biopsychosocial
The biomedical model has over-emphasized spinal pathology as a cause for spine pain (e.g., disk herniation, joint arthritis, and muscle strain), which has led to an overemphasis on pain management. A focus on pain leads to treatments to address pain, which tend to be passive (e.g., analgesics, massage, surgery) instead of active (e.g., therapeutic exercise, active care plans). Passive methods run the risk of addictive side effects (i.e., opioids), potential adverse reactions (i.e., non-steroidal anti-inflammatory drugs cause gastric bleeding), or dependency upon the provider for pain control (i.e., excessive or long-term use of massage and manual therapy) instead of the person being a more active participant in maintaining his/her health [52]. Back pain treated as a disease, even when there is no identifiable pathological cause of the pain, can lead to poor psychosocial outcomes and inappropriate use of treatments including analgesic medications, such as opioids and more invasive treatments such as injections or surgery and may also facilitate acute conditions to become chronic. This model also risks turning people with no severe pathology into “patients” and thereby increasing costs of spine care with little impact on the community burden of disease. The traditional biomedical model has included little consideration for local population needs, culture, or psychosocial factors that may be relevant to the healing processor prevention.
In the GSCI model, the biopsychosocial model for spine care considers the complex interaction among biological, psychological, and social factors that influence spinal health, disease, and disability. The biopsychosocial model considers how various determinants of health interact and that spine-related disorders are complex and multifactorial [53, 54]. Determinants of health help to identify the potential contributors of spinal conditions and functional impairment by considering other risk factors or comorbidities that could contribute to pain, disability, or spinal disease. Addressing biopsychosocial factors empowers individuals and communities to be more engaged in self-awareness, self-care, and know when to seek care and when not to seek care for a spine-related concern. A de-emphasis on pain, recognizing that some back and neck pain may be considered normal, helps individuals refocus on functional ability and their values. An emphasis on outcomes of function helps to bolster empowerment for patients and participants in their spinal health. Comprehensive care approaches the whole patient and coordinates or integrates services of many professionals working together to address biopsychosocial needs.
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Transform from reactive to proactive
Reactive health care is when the health care provider or system waits for a disease or injury to occur before any action takes place, which results in the treatment of mainly acute back and neck pain and spinal injuries. While reactive spine care addresses an immediate concern, there are few efforts toward preventing spinal conditions or injuries from occurring or worsening. Focusing only on immediate concerns is perceived to conserve resources but may run the risk of ignoring the potential for a person’s condition to become chronic or for secondary issues to arise (e.g., addiction to pain medications). Reactive health care systems are primarily focused on disease treatment and typically do not include prevention strategies, which may put an additional burden on low-income or vulnerable populations [55].
The GSCI model values proactive spine care, thus in addition to acute care, prevention, early diagnosis, and appropriate self-care and treatment are incorporated throughout health care delivery and public programs [48]. Proactive care integrates primary spine care with public health principles which include the “art and science of promoting and protecting good health, preventing disease, disability and premature death, restoring good health when it is impaired by disease or injury and maximizing the quality of life” [55]. Public health activities are implemented through the collective action of a wide variety of people including patients, health care providers, community health and social workers, administrators, educators, government officials, and many other professionals. The levels of prevention included in the model of care are primary prevention (e.g., community outreach to prevent spine injuries/conditions), secondary prevention (e.g., prevent re-injury, prevent acute spine pain from becoming chronic) tertiary prevention (e.g., prevention from worsening conditions—resulting in cost savings and reduced use of health care resources by avoiding resource demanding care) and quaternary prevention (preventing the medicalization or over-medicalization of health concerns) [32]. It is especially important to incorporate quaternary prevention since it has been shown when Western medicine is introduced, some people may turn into “patients” unnecessarily [56]. Preventive health interventions are proactive and can be delivered at an individual or community level and at various stages of spine care. The WHO global strategy on integrated people-centered health services recommends strategic goals, which includes health promotion, disease prevention, and public health [57]. Preventive care and community health programs aim to reduce the burden of health disorders to society and, as the WHO model suggests, may cost the least on average per person compared to tertiary level care [58].
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Transform from eminence-based to evidence-based practices
“Eminence-based medicine” describes the practices and procedures that are based on the opinions of the care provider that may or may not be based in best evidence [59], which may result in the use of ineffective, harmful, or unnecessary and costly procedures. Examples in spine care may include excess use of pharmaceuticals for mild back pain, overuse of passive modalities, or inappropriate indications for surgery. This may result in unnecessary procedures, increased risk for harm, decreased health benefits, increased direct and indirect costs to individuals and the community, and increased patient dependence on health care providers.
Evidence-based practices balance and combine the relationships between the person, provider, and evidence. The triad of evidence-based care (i.e., the combination of best evidence, provider expertise, and patient values) helps to ensure the best care for spine-related concerns [46, 60, 61]. It must not be assumed that traditional healing practices that prevent or treat spinal conditions are absent or ineffective; thus, thorough research should be done to find out which kinds of spine problems exist, how people are dealing with them, and what seems to be effective. By using evidence-based practices, practitioners stay updated with current practices through feedback and education. Communities and individuals are kept abreast of current evidence-based methods for self-care, information about when to seek care, and knowledge of what to expect from providers once they have entered the health care system.
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6.
Transform from silos to collaboration
In the clinical practice environment, individual health care practitioners often work in seclusion within their disciplinary silos [62]. This culture results in little communication or collaboration between providers or with patients and others in the community. The result in these situations may be uncoordinated or redundant spine care, which in turn may result in over use of diagnostic procedures, over treatment, and wasted resources.
The culture of collaboration occurs when there is teamwork among health care providers across disciplines and with other providers and stakeholders. Practitioners who collaborate with providers from other disciplines have the potential to reduce redundancy of procedures or consultations and provide more effective, affordable, and safer care [63,64,65]. Stakeholders in these collaborative relationships may also include governmental leaders, opinion leaders, individuals/patients, families, and others [46].
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7.
Transform from isolated to integration
Many of the system processes on the meso- and macro-levels of spine care delivery are isolated. This isolation results in poor communication and inefficient distribution or linking of resources resulting in loss of quality, higher costs, and poorer outcomes.
Integration has the potential to link resources and system components together to provide best possible care for individuals and the community. The WHO defines integrated delivery as “The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system” [66]. Strategies of integration may occur in many ways, such as through systems, organizations, professions, horizontal (integrating similar levels of care) and vertical (integrating different levels of care). The principles of integration also embrace patient-centeredness in that spine care is considered through a person’s lifespan, including needs at various ages and coordinated within and across the local health system [46, 67,68,69,70]. Integrated care improves quality [71] and includes engagement of local stakeholders with the spine care program and collaboration with public health and community services. Although integrated care has the potential to be costly, components of integration may still be implemented in low-resource settings.
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8.
Transform from fragile to self-sustaining
For some low- or middle-income communities, spine care is delivered using a fragile model. Care may be inserted by a foreign entity or funded as a charity service. Spinal health care may be treated as if it were “missionary work.” This type of delivery system may be seen as fragile in that it may result in dependency on others for services and reduces the individual and community capacity to take responsibility. This model can be perceived as a foreign entity exerting its culture and devaluing the local culture of healing practices. This may result in a split or sub-culture of healing, one in which foreigners provide care resulting in the traditional methods going underground.
Self-sustaining programs require policy alignment and system-wide stakeholder engagement for successful implementation of a spine care program. Local and regional government leaders, policy makers, and community stakeholders must have a role in the development of a self-sustaining program. Each community that wishes to implement a spine care program has a unique population of people with spinal disorders, unique cultural priorities, and unique pre-existing health care infrastructure. A spine program must be developed to integrate into the currently available health care resources and culture to be sustainable. Effective delivery of health care services requires efficient financing systems and funding to support knowledgeable and skilled personnel and adequate infrastructure [46]. Sustainability requires “planning, managing, and delivering care that is equitable, efficient, effective” [46].
Model of care principles transition tool
Before implementing the model of care, we propose that the eight GSCI principles be evaluated for the target location. One way to evaluate the principles is by using a web diagram. This tool provides an assessment and an overall visual representation of the current state of spine care and targeted goals for each of the principles. Each principle is rated on a scale by the steering committee. This tool can help the steering committee team leaders communicate their vision to others when implementing the model. Figure 2 is an example of how an assessment chart might look after a local steering committee has rated the current situation (now) and the goals that they have set for themselves for each principle. Each axis represents one principle and is rated with a numeric scale. Examples of actions that could be taken to transition from the current (now) environment to the goal environment are presented in the supplemental file (see Online Resource Figure 1). These are the steps that would be selected based on the resources and community needs during implementation planning.
GSCI model of care
Based upon the eight principles, the GSCI proposes the following three components that contribute to the model of care, which are: (1) The GSCI classification and care pathway; (2) The GSCI levels of care; (3) The GSCI person’s journey. Each of these components is described below.
GSCI classification and care pathway
The GSCI classification and care pathway were developed to assist with decision making at a patient care level but also provide a structure for all providers, health care consumers, and others engaged in the health care system to use to communicate and work together. The GSCI classification and care pathway accommodates any person’s concern related to the spine and is consistent with current spine classifications and guidelines. The classification categorizes a person’s presentation so that it may be linked directly with the GSCI care pathway [33, 34]. The care pathway provides evidence-based, diagnostic procedures, and treatments that the provider may select from [3, 28, 29, 31]. The care pathway includes health promotion and prevention strategies, including primary, secondary, tertiary, and quaternary prevention [32] and psychological or social factors in patient recovery and wellness to address all levels of care needed by the population [30] (Fig. 3a, b). Goals include preventing future conditions, preventing chronicity, prevention of unnecessary medical procedures or medical dependence, and the quickest possible return to function and normal activities. A detailed description of the GSCI classification and care pathway are described in other papers [33, 34].
GSCI levels of care
The GSCI model of care proposes four levels for providing spine care: self-care and community spine programs; primary spine care; secondary spine care; and tertiary/quaternary spine care (Fig. 4). The GSCI levels of care demonstrate the types of spine care, population needs, and levels of resources required to cover the needs of the community. These stepped levels of care match services with individual needs and may be delivered in a variety of health care settings. Care provided by solo or group health care providers may be included in health centers, outpatient clinics, public health departments, and other ambulatory settings. More advanced care may be provided in emergency rooms, outpatient departments, hospices, ambulatory surgery centers. Care may also be provided in non-health care settings, such as at an individual’s place of residence, place of employment, or a community. The level of care should match the setting so that the safest and most effective care may be provided. To be efficient, primary spine care settings should be integrated and coordinated with other care levels including secondary and tertiary centers that provide advanced spine care.
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Self-care and community spine care programs
A majority of people do not need medical treatment but instead could benefit from education and reassurance. Therefore, we propose programs and policies that support prevention, healthy behaviors, and safe environments in the home, work, and play. Public health education and community-based programs can educate the population about factors that increase the likelihood of spine-related disability. On an individual level (e.g., patient or caregiver), the public media (e.g., internet, television, radio, social media) or encounters with health care providers can deliver educational campaigns, such as for exercise and prevention [72]. Community-based programs should address population needs, such as screening programs for osteoporosis or prevention programs to reduce traumatic spine injury.
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Primary spine care
Most people who could benefit from health care interventions have spinal disorders that can be adequately managed at a primary care level. The World Health Organization defines primary care as “first-contact, accessible, continued, comprehensive, and coordinated care to people and communities” [73]. Primary care may provide beneficial and cost-effective care for some spinal conditions [74,75,76,77,78] and is the point of entry for the majority of spine care, excluding trauma and urgent care, and plays an important gatekeeping role, including triage, diagnosis and referral of patients so people receive appropriate care as early as possible [79]. We propose that primary care for spine-related concerns should focus on common spinal conditions using non-invasive, active, and patient-driven interventions for spine-related complaints, including prevention and rehabilitation [80,81,82,83,84,85,86,87,88].
Primary spine care services may be provided in different ways depending on available resources [89]. A single clinician may suit the needs at one location, whereas in another location that might not have a primary care provider with all the necessary competencies, a team of clinicians, when combined, could have the knowledge and skills to provide primary spine care. Different provider types have the potential to offer primary spine care depending on their education (e.g., medical doctors, doctors of osteopathy, doctors of chiropractic, physical therapists, physician assistants, nurse practitioners, other clinicians) [74, 80,81,82,83,84, 90]. Those who do not yet have the necessary skills and knowledge may be trained to offer spine care. Some providers with limited general health care training, such as community health workers or traditional healers, may also be included as team members for spine care, thus expanding feasibility to offer primary spine care [91,92,93]. To function as a primary spine care provider or primary spine care team, the providers should have a professional health care degree recognized by the local or national government and the necessary training, knowledge, and skills to deliver care in the care pathway. We recommend a list of primary spine care provider competencies [3, 29,30,31,32, 38] (see Online Resource Appendix 1).
Primary spine care must be integrated into the health care system as it is responsible for coordinating the care for complex disorders that may require interventions at the secondary and tertiary spine care settings. Primary spine care is responsible for offering continuous and coordinated care throughout the patient’s condition. Patients may require treatment for comorbidities or health conditions that are related to, but not generated from the spine; thus, referral to care providers in other areas may be required. The primary spine care provider/team should develop an established protocol to give and receive referrals with other primary care physicians (family practice, internal medicine, pediatrics, obstetrics-gynecology) and secondary or tertiary spine care for specialty services (e.g., psychological care, physiatry, pain management, rheumatology, surgery, other invasive therapies, advanced pharmacologic therapy, multidisciplinary team care) and community health programs. Primary spine care services need to be connected and communicated to the community through: 1) community-based programs that educate about prevention of spine-related conditions and disability; 2) provision of educational programs for individuals on self-care and prevention; and 3) screening and education on risk factors or comorbidities associated with spine symptoms (e.g., osteoporosis/tuberculosis screening, tobacco cessation programs, avoidance of opioid or other drug dependencies)
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Secondary spine care
Only some people have spinal conditions that require more advanced care. Secondary spine care is care provided by one or more medical specialists, typically at the request of the primary care provider. Secondary services may include short-term interventions including consultation, hospitalization, or treatments such as advanced pharmaceuticals, injections, individualized rehabilitation protocols, or surgery. Secondary spine care should include specialized cognitive-behavioral interventions to address any inappropriate pain behaviors and disability, in particular work disability. Secondary spine care specialists and teams work collaboratively with other health care providers; thus, a close relationship between secondary and primary care spine providers assists with rehabilitation and conservative post-operative care or in follow-up to secondary care interventions. Secondary care providers send and receive referrals from primary and tertiary care according to the care pathway. Any person who initially presents to secondary care but who should be receiving primary care should be rerouted to a primary care provider.
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Tertiary/quaternary spine care
Very few people have spinal conditions that require tertiary or quaternary care. Tertiary spine care, where available, is specialized medical and surgical care for complex and unusual spine problems. Tertiary spine care provides complex invasive spinal treatments including advanced pharmaceuticals and surgery, requiring an interdisciplinary or multidisciplinary health care team. Tertiary spine care teams work collaboratively with others in the health care system. They send and receive referrals from primary and secondary care according to the care pathway. Providers in tertiary and quaternary spine care work collaboratively with other health care providers including secondary and primary care. Quaternary care is extremely rare, highly specialized and may be experimental, thus unlikely to be found in low-income countries or underserved areas. We recognize that some regions do not readily have access to either tertiary or quaternary care.
GSCI person’s journey
The GSCI person’s journey provides a visual diagram of how someone with a spine-related concern might navigate the GSCI model of care. This map helps communicate with stakeholders (patients, community members, health care providers, decision makers, payers, etc.) so they may visualize how a person will journey through the model of care (See Fig. 5). The GSCI model of care approaches care delivery by focusing on how an individual may perceive or search for care and answers to spine-related questions. Care should be delivered based upon the local culture and within the available resources. The spine care provider considers initial information that is presented and triages the patient according to current evidence-based guidelines and recommendations of the GSCI classification and pathway. Interventions range from self-care and community-based education through more advanced care when indicated.
GSCI model of care implementation
We propose six steps that should be considered when deploying the GSCI model of care. Each community and setting is unique; therefore, the implementation plan will need to be customized. Some steps may need to be expanded, modified, or even skipped depending upon the spine care needs of a community, available resources, and how similar or dissimilar the current system is to the model of care. The timeline for implementation will vary as it is dependent on the given situation and will need to be customized for each location.
Step 1 Project initiation and initial preparations
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1.
Identify a community whose members want and need a spine care program [40]. A community may self-identify or an external entity may identify a community as a potential candidate.
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Define and prioritize the spine-related issues for that community. Perform a preliminary review of the spine-related concerns, burdens, facilitators, and barriers [44, 46, 94,95,96,97]. These baseline measurable outcomes will shape implementation and measure progress. Examples may include: number of work days lost due to spine pain or injury, cost of care for a given spinal condition, or number of people who have or develop a spinal condition.
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Assess if key stakeholders and decision leaders are interested and able to establish a spine program. Obtain preliminary information, such as location/region, population, health care delivery system, level of human resources, infrastructure, funding mechanisms, and specific needs help determine feasibility.
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Once a clear need has been identified and the capacity for change appears feasible, develop a “case for change” statement. This statement should clearly describe the need, goals, and scope of the project [98]. Use this vision statement when communicating with others about the project. The “case for change” will help to ground the pathway of change, such as through using a logic model. (See Online Resources Figure 2 for an example of a logic model). Share the vision of the program and obtain agreement and participation from leadership. Support from decision makers (executives, clinical champions) is essential since change is unlikely if recognized leaders are not involved in the decision-making process.
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Meetings should take place between key stakeholders to evaluate the assessments and to weigh benefits and barriers to implementation [99]. A final decision should be made regarding if the project appears feasible and if it should begin.
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After it is agreed that the project should begin, obtain support from additional stakeholders, such as those receiving care (patients and community), those providing care (community health workers and providers, health care clinics, hospitals), and those funding the care. Additionally, consider including those who are thought leaders within the community, such as traditional healers and religious leaders.
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Establish the steering committee and the implementation team [99].
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a.
Steering committee The steering committee directs the course of action at a high level. This committee invites the stakeholders who have the authority to make changes and are relevant to the success of the project to be members of the steering committee, such as stakeholders who are decision makers, who provide input, and who may be affected by the program. The steering committee decides on the overarching goals, objectives, and scope of the project based upon available local health information and estimated needs. These initial goals should be locally relevant and all stakeholders on the steering committee should agree. (See Online Resource Appendix 2 for sample checklists)
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b.
Implementation team The steering team selects implementation team members who are the local stakeholders involved with planning and implementing the model and have the knowledge and skills to implement the plan on a day to day level. The steering committee and the implementation team have different members, but they could overlap. The strategic planning members continue to work with the implementation team through the entire process.
Step 2 Assessment of the current situation
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Before making any changes, the implementation team must first assess the current health care system (infrastructure, resources, funding, processes, personnel, and clients (individuals and community)) to identify needs related to spine care. This information helps establish baseline resources and further informs the implementation process before the program can be implemented [100]. Consider using or modifying a checklist throughout this process. The following are actions to consider in the assessment step.
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a.
For the location that you will implement the model of care, use the Model of Care Principles Transition Tool to measure the eight principles: person-centered, people-centered, biopsychosocial, proactive, evidence-based, integrative, collaborative, and self-sustaining.
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b.
Assess the community and individuals’ values and needs as they relate to spinal disorders, health, and care, including knowledge about spinal disorders, risk factors and comorbidities, population demographics, access to care, and social factors (e.g., religion, culture, and language) [101].
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Determine roles of participants, including patients, family, health care providers/staff, community, health care system [102,] and other participants such as funders and collaborators. During assessment, consider establishing collaborative connections between health and other sectors that influence success of the program.
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Assess the local health care system resource capacity required to implement the desired spine care program. This helps to determine what resources will need to be developed (e.g., human resources) or obtained (e.g., materials) [3]. Also assess if current resources are being used effectively.
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e.
Identify processes and how spine care is currently being delivered. Assess the gap in behaviors, processes [103], and resources between the current model and the new model of care, such as using the GSCI classification system and care pathway to see what type of gap must be closed before implementation.
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Establish a list of resources and processes that are needed to implement the model of care.
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Identify barriers and facilitators in the local community. If possible, use a theoretical framework to address barriers and facilitators. Select evidence from the literature that will support the steps in the plan for change [103]. Barriers and facilitators vary in types and complexity and are unique to each local community thus should be addressed in implementation plans.
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Assess policies, systems, and other available resources in the target community. Identify if professional, educational, and health care policies are able currently to support implementation or if policy updates are needed [102].
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Identify determinants of change in the current health care system to implement or transition to a new model, which includes barriers and facilitators. Assess health care system readiness and what may be needed locally to optimize sustainability [40].
Step 3 Planning and designing solutions
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After reviewing the initial assessment, the steering committee provides direction and the implementation team then develops the plan based upon information from the assessments. Implementing evidence-based models of care can be challenging, especially in low- and middle-income countries [95]. Multifaceted strategies are effective, whereas single faceted strategies are unlikely to be adopted or make a change [95]. Thus, a clear plan with multifaceted strategies may be helpful. Include health care providers in planning and provide training program so they may learn or be refreshed on the evidence-based care pathway. Those who are not directly engaged but were identified in the process assessment are included so that they may properly refer or collaborate with the process. Capacity building begins during planning but continues through the implementation, evaluation, and scaling up. Once the plan has been drafted, invite additional stakeholders to review the plan to provide input and feedback. The following are items to include in the plan.
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Include the guiding principles in the implementation plan (e.g., person-centered, people-centered, biopsychosocial, proactive, evidence-based, integrative, collaborative, and self-sustaining) as they relate to local needs [98].
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Clearly describe the steps needed to transform the current system in preparation for implementation of the spine program for each of the principles, so that stakeholders and those doing the implementation can understand the process and will know what to do. Each plan will be unique based upon the current resources and needs of the community.
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c.
Include the plan for capacity building (e.g., training health care workers to use the GSCI model of care, securing resources), budget, evaluation process, identifying key performance indicators, short, intermediate, long range goals, and other essential items, which may include a memorandum of understanding with decision makers and infrastructure issues [104]. If not already in existence, consider adapting tools to local language and culture [105]. Using well-known planning tools, such as logic models are recommended [100]. (See Online Resources Figure 2 for an example of a logic model).
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Establish evaluation measures for key performance indicators, whether this includes modification of an existing evaluation system or the adoption or creation of a new system and use of new measures. Evaluation plans should be focused to efficiently assess the most important concerns of the stakeholders [100].
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Identify outcome measures to assess major components and principles of the model and the processes by which they will be measured. Include outcomes such as metrics focused on the patient (values, function, activities), population health outcomes, costs/cost savings, and value of care indicators, biopsychosocial metrics, program success, and sustainability metrics. Patient outcomes, satisfaction by clinical, staff and an assessment of community acceptance will demonstrate improvement, identify the strengths and weaknesses, and allow for modification during implementation.
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Describe and outline the reporting structure and how the participants and the system will be held accountable. Incorporate into the plan collaborative relationships, communication systems, educational programs to prepare the health care workforce, and funding sources.
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g.
Describe how you will recruit and train local community health workers and qualified primary spine care providers to use the GSCI model of spine care. Describe the preparation of workforce, infrastructure, and sustainability factors (funding) to support the implementation of the model of care. Describe steps to educate and do outreach to health care providers and the community to prepare for the implementation of the model of care.
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h.
Include key components, such an explicit list of steps with who is responsible for each step, a timeline (e.g., Gantt chart), budget, and communications strategy.
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i.
Develop a communication plan and prepare the existing health system and community for the upcoming program implementation [99, 100].
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The final action in this step should be to have key stakeholders review the implementation plan before moving to the next step.
Step 4 Implementation
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Perform an initial small scale implementation.
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a.
Once the steering committee and key stakeholders have approved the plan, the implementation team should complete a small level rollout. This will help demonstrate effective implementation. This initial implementation step builds confidence with the stakeholders and informs the steering committee and implementation team if the system is ready for more substantial scale implementation.
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Include all components and assessments but on a small scale. Because the initial implementation will test the system, the pilot should incorporate all other components to test the full system in addition to the implementation of care.
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Include collecting outcome measures in the pilot.
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Evaluate the pilot both formative and summative manners, which will help inform the steering committee what additional resources or assistance is needed to implement the complete model of care. Because each location is unique, successful implementation requires flexibility and demonstration of proof of concept before initiating the larger scale rollout.
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e.
Revise and update the implementation plan based on the information from the pilot.
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Full implementation. Once the steering committee and implementation team agree that full implementation is feasible, commence the implementation plan for a full scale rollout.
Step 5 Assessment and evaluation of program
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Assessment and evaluation
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Collect outcome measures for levels that were established during the planning stage, including the eight principles.
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The steering committee and implementation team should evaluate the data to identify strengths and weaknesses, identify areas of potential improvement, to see if program goals are being met, what course corrections are needed, and if any new goals need to be introduced.
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c.
Consider continuing to use the Model of Care Principles Transition Tool to identify if the program is meeting its original goals.
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d.
On a regular basis, the team should review the data and then develop a plan to make improvements based on the data. These steps are part of the continuous quality improvement process (“plan do study act” cycle), which will evaluate the key performance indicators at regular intervals and inform further direction of change from the old to the new model of care. Key performance indicators inform program sustainability [100]. A continuous quality improvement cycle is essential to improving the program to reach the community health care goals [95]. During evaluation, updates are made to the course or plan to improve and maintain initiatives. Further plans are made to implement the improvements and to better maintain the program.
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e.
Once the steering committee feels the program is sustainable, future evaluations may include action research if resources are available.
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f.
The steering committee should communicate evaluation findings to stakeholders.
Step 6 Sustain program and scale up
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1.
Sustain program
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a.
Monitor the program to ensure that support, resources, communications, and ongoing training will continue.
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b.
Use ongoing continuous quality improvement measures to make sure that the program stays on course and addresses evolving community spine care needs.
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c.
Engage with stakeholders. Share information about long-term benefits and impact of implementation of the model of care [102].
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d.
Ensure that leaders are committed to sustaining the program. Provide access to training in sustaining programs, if possible [100].
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2.
Scaling up
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a.
Once the program has demonstrated success at a local level, scaling up should be considered [106, 107]. Scaling up means “doing something in a big way to improve some aspect of a population’s health and requires sustainability, equity and the effects of scaling up an intervention (or a package of interventions) on the rest of the health system (external consequences)” [108]. Scaling up is taking a smaller-scale successful initiative and implementing it on a larger scale. This could mean expanding the program on a local level, expanding nationally, or bringing the program to other regions.