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Primary Care Provider Frequently Asked Questions |
How was the low back pain pathway developed?
Ontario’s current low back pain pathway stems from a pilot program: the Inter-professional Spine Assessment and Education Clinics (ISAEC) model of care. In 2012, the pilot began in Toronto, Hamilton and Thunder Bay. The aim was to improve care and access to low back pain assessment, education and management.
This pilot program was quite successful and in 2018 the model of care expanded to become the provincial Rapid Access Clinics for Musculoskeletal conditions. The Rapid Access Clinics for Musculoskeletal conditions have a broadened scope to include hip and knee arthritis, in addition to low back pain, and aims to provide faster, more appropriate care to Ontarians. The division that serves patients with low back pain is called the Rapid Access Clinics for Low Back Pain.
This pilot program was quite successful and in 2018 the model of care expanded to become the provincial Rapid Access Clinics for Musculoskeletal conditions. The Rapid Access Clinics for Musculoskeletal conditions have a broadened scope to include hip and knee arthritis, in addition to low back pain, and aims to provide faster, more appropriate care to Ontarians. The division that serves patients with low back pain is called the Rapid Access Clinics for Low Back Pain.
HOW CAN A PRIMARY CARE PROVIDER OBTAIN REFERRING PRIVILEGES TO RAC LBP?
You can obtain your regional referral form by completing the RAC LBP Registration and Onboarding Module which includes an overview of the RAC LBP Model of Care as well as the crucial role primary care plays in managing low back pain patients (5-10 mins) – RAC-LBP Registration
What types of patients can I refer to the program?
With early management and mitigation of chronic lower back pain as its main goals, this proven shared-care model is designed for patients and reinforces their relationship with their Primary Care Provider.
This pathway is appropriate for patients with a wide variety of non-emergent lumbar diagnoses and presentations (< 1 year in duration or those with recurrent episodic low back pain) and addresses issues ranging from most non-urgent disc conditions, spinal stenosis, and axial / non-specific back pain.
Inclusion criteria for RAC LBP program:
• Patients with persistent lower back pain and/or related symptoms (e.g., sciatica, neurogenic claudication) that are not improving 6 weeks to
12 months from onset
OR
• Patients with unmanageable recurrent episodic lower back pain and/or related symptoms of less than 12 months duration post-recurrence.
In addition, it is recommended to consider referral in the above-mentioned scenarios prior to initiation of an opioid prescription, imaging referral, or specialist referral.
Exclusion Criteria for RAC LBP program:
➢ Possible Cauda Equina Syndrome (saddle anesthesia about anus, perineum or genitals; urinary retention with overflow incontinence; loss
of anal sphincter tone/fecal incontinence)
➢ Progressive neurologic deficit
➢ Significant trauma
This pathway is appropriate for patients with a wide variety of non-emergent lumbar diagnoses and presentations (< 1 year in duration or those with recurrent episodic low back pain) and addresses issues ranging from most non-urgent disc conditions, spinal stenosis, and axial / non-specific back pain.
Inclusion criteria for RAC LBP program:
• Patients with persistent lower back pain and/or related symptoms (e.g., sciatica, neurogenic claudication) that are not improving 6 weeks to
12 months from onset
OR
• Patients with unmanageable recurrent episodic lower back pain and/or related symptoms of less than 12 months duration post-recurrence.
In addition, it is recommended to consider referral in the above-mentioned scenarios prior to initiation of an opioid prescription, imaging referral, or specialist referral.
Exclusion Criteria for RAC LBP program:
- Patient with RED FLAGS*
- Initial low back related symptoms <6 weeks post onset
- Constant/persistent LBP-related symptoms >12 months post onset
- <18 years of age
- Unmanaged established chronic multisite pain disorder
- Unmanaged established narcotic dependency
- Active LBP-related WSIB claim
- Active LBP-related motor vehicle accident claim
- Active LBP-related legal claim
- Pregnant/post-partum patients (<1 year)
➢ Possible Cauda Equina Syndrome (saddle anesthesia about anus, perineum or genitals; urinary retention with overflow incontinence; loss
of anal sphincter tone/fecal incontinence)
➢ Progressive neurologic deficit
➢ Significant trauma
Who will assess the referred patients?
Rapid Access Clinics for Low Back Pain follow an inter-professional shared-care model where patients may be seen by one or more providers, who are part of the care team, based on the patient’s presentation and clinical needs.
Patients will be initially assessed by an Advanced Practice Provider (specially trained community-based physiotherapists, chiropractors, or nurse practitioners) in the community close to their home. The Advanced Practice Provider (APP) will provide your patient with a thorough standardized assessment as well as create a personalized self-management plan to help them better manage their low back pain.
Those patients deemed potential surgical candidates will be referred by the APP to a Practice Leader for further assessment and management. Practice Leaders are hospital-based health professionals (chiropractors, physiotherapist or nurse practitioners) who receive advanced training from spine surgeons to manage potential surgical candidates.
The Practice Leader will order diagnostic imaging (e.g. MRI), recommend appropriate advanced interventions (e.g. spinal injections), and refer patients for a consultation with a spine surgeon when indicated.
The Practice Leader is typically more centrally co-located at the surgeon(s)’ institution and acts as regional clinical program manager who: (1) oversees the community-based aspects of the program performance and quality; and (2) works closely with the spine surgeon(s) who are part of the RAC LBP pathway.
A Surgeon Sponsor (a physician spine specialist) supports the management of surgically appropriate patients identified by the Practice Leader and provides ongoing clinical leadership for the Practice Leader and APPs supporting ongoing knowledge transfer and evidence-informed practice.
Patients will be initially assessed by an Advanced Practice Provider (specially trained community-based physiotherapists, chiropractors, or nurse practitioners) in the community close to their home. The Advanced Practice Provider (APP) will provide your patient with a thorough standardized assessment as well as create a personalized self-management plan to help them better manage their low back pain.
Those patients deemed potential surgical candidates will be referred by the APP to a Practice Leader for further assessment and management. Practice Leaders are hospital-based health professionals (chiropractors, physiotherapist or nurse practitioners) who receive advanced training from spine surgeons to manage potential surgical candidates.
The Practice Leader will order diagnostic imaging (e.g. MRI), recommend appropriate advanced interventions (e.g. spinal injections), and refer patients for a consultation with a spine surgeon when indicated.
The Practice Leader is typically more centrally co-located at the surgeon(s)’ institution and acts as regional clinical program manager who: (1) oversees the community-based aspects of the program performance and quality; and (2) works closely with the spine surgeon(s) who are part of the RAC LBP pathway.
A Surgeon Sponsor (a physician spine specialist) supports the management of surgically appropriate patients identified by the Practice Leader and provides ongoing clinical leadership for the Practice Leader and APPs supporting ongoing knowledge transfer and evidence-informed practice.
Who will be responsible for the ongoing care of patients referred to Rapid Access Clinic for Low Back Pain?
The program utilizes a shared-care management approach for referred patients as no one provider can do it all. The patient’s Primary Care Provider plays an integral part in the management of his/her patient’s progress in relation to the treatment goals. If no clinical improvements are realized, the RAC LBP care team will be there to further evaluate and manage patients.
Will the Advanced Practice Providers follow-up with my patients?
Advanced Practice Providers will provide one or more follow-up appointments for patients identified as being at risk of chronic low back pain (e.g., those with complex presentation including yellow flags or opioid dependency).
Will my patients be referred to specialists other than spine surgeons?
If there is an indication for referral to a non-spine specialist (e.g. for possible inflammatory or pain disorder issue), the Primary Care Provider will receive this recommendation from the APP or Practice Leader to arrange the necessary referral.
Will the Rapid Access Clinics for Low Back Pain provide patients with pharmacological or non-pharmacological therapy to support their low back pain self-management plans?
The program will not provide patients with adjunct pharmacological or non-pharmacological therapy. It is an interprofessional shared care model that provides evidence informed assessment, education and personalized self-management plan. The self-management plan is to help your patient better manage their low back pain, improve their mobility and improve their overall physical function. Self-management plans include advice on the importance of staying active as well as instruction on exercises and modified activities as needed.
While the Advanced Practice Providers will not provide your patients with treatment, they will educate them on their condition and may recommend evidence informed adjunctive hands-on or other available non-pharmacological treatments as indicated to enable self-management.
While the Advanced Practice Providers will not provide your patients with treatment, they will educate them on their condition and may recommend evidence informed adjunctive hands-on or other available non-pharmacological treatments as indicated to enable self-management.
How will referrals be handled?
Primary Care Providers will complete and submit a standardized Rapid Access Clinic for Low Back Pain referral form to the Central Intake office in their Local Health Integrated Network.
Referred patients will be offered an assessment within 4 weeks of referral and will be matched with an Advanced Practice Provider based on location proximity and availability. The Advanced Practice Provider’s office will contact the patient directly to schedule an appointment.
The referral process is automated using an electronic Case Management System and patients are automatically matched with the closest APP via their home postal code. Auto-matching patients with APPs helps minimize both travel time and wait time for the first appointment. In some circumstances, patients may be manually matched to a different provider due to a specific preference (e.g., closer to work or provider gender). These specific preferences should be noted on the referral form.
Referred patients will be offered an assessment within 4 weeks of referral and will be matched with an Advanced Practice Provider based on location proximity and availability. The Advanced Practice Provider’s office will contact the patient directly to schedule an appointment.
The referral process is automated using an electronic Case Management System and patients are automatically matched with the closest APP via their home postal code. Auto-matching patients with APPs helps minimize both travel time and wait time for the first appointment. In some circumstances, patients may be manually matched to a different provider due to a specific preference (e.g., closer to work or provider gender). These specific preferences should be noted on the referral form.
What type of communications will the referring Primary Care Provider receive from the program about their patient?
The patient’s referring Primary Care Provider will receive a consultation note post-assessment outlining the patient’s clinical presentation, risk/prognostic factors, individual self-management plan (including activity/work modifications) and next steps, including any recommended follow-ups or additional referral recommendations.
In this shared-care model it is important to maintain good communication between all providers involved in the patient’s care. For complex patients, the Advanced Practice Provider, Practice Leader, and the Primary Care Provider are encouraged to initiate further discussions regarding the consultation, any items needing clarification, and to address identified concerns.
In this shared-care model it is important to maintain good communication between all providers involved in the patient’s care. For complex patients, the Advanced Practice Provider, Practice Leader, and the Primary Care Provider are encouraged to initiate further discussions regarding the consultation, any items needing clarification, and to address identified concerns.
Where to find additional program information and resources?
Please refer to the RAC LBP website for program information as well as patient and provider resources at www.lowbackrac.ca
I am a community Physiotherapist, Chiropractor or Physician Specialist with a patient who would benefit from further LBP assessment and management. How can I refer my patient to rac-lbp?
Only primary care providers can currently refer into this program (Family Medicine Physician, Sports Medicine Physician or Nurse Practitioner in a family practice in Ontario).
If you are a community Physiotherapist, Chiropractor or Physician Specialist with a patient who would benefit from further LBP assessment and management, there is a form you can use to communicate with the patients’ primary care provider regarding registration and referral to the RAC-LBP program. The form can be found on the "Refer to RAC-LBP" page of the website.
If you are a community Physiotherapist, Chiropractor or Physician Specialist with a patient who would benefit from further LBP assessment and management, there is a form you can use to communicate with the patients’ primary care provider regarding registration and referral to the RAC-LBP program. The form can be found on the "Refer to RAC-LBP" page of the website.