Hello. I'd like to welcome you to the Academy's on-demand session, Practice Management Principles for Spasticity Management. As many of you know, spasticity has been identified by many Academy members as an area of clinical interest. And certainly, many topics during this Academy's assembly will talk about the clinical aspects and the technical aspects of spasticity management. However, spasticity management doesn't happen in a vacuum. We've all experienced a great idea that didn't execute well because the practice management principles weren't followed. Today, we've assembled some very important speakers, some nationally renowned speakers, to talk about the practice management principles of a spasticity clinic in various settings. We have Dr. Monica Gutierrez, who is chairperson at UT San Antonio. And she will talk about practice management principles in an academic setting. We have Dr. Kimberly Heckert, who is an assistant professor of rehabilitation medicine at the Sidney Kimmel College of Medicine, also known as Thomas Jefferson University. And she will talk about how to start a spasticity fellowship, which many of you may consider as a component of your practice management. And lastly, we will have Dr. Andrea Toomer, who is a private practice physiatrist in New Orleans. And she will talk about the practice management principles in the private practice settings. I hope you enjoy this setting. I hope you enjoy this presentation. And at this point, I'd like to turn it over to Dr. Gutierrez, who will talk about spasticity management in an academic medical center. Hi, thanks so much for coming to the virtual AAPM&R meeting and wanting to learn more about spasticity and setting up a spasticity clinic. And I can kind of feel that point of my talk is always, yes, a lot of it has to do with getting paid, and it's economics, and making money at the end of the day. But really, I want you to be able to do the right thing for your patient. I think that's what we all care about, is treating your patients with interventions that work and that help them have the best outcome as possible, and how to do it the right way where you can be successful in your practice. And this is specifically coming from my experience in an academic setting. So just a little bit about me. I'm currently in San Antonio, Texas. I'm obviously an academic physiatrist. Right now, we have two clinics. And this is something that you have to know when you're billing or when you're considering how clinics are going to be set up, is the site of service. So site of service is based on Medicare and how they'll pay you when you're doing services. And how they'll pay you when you're doing certain procedures. So first, we have an outpatient clinic, and the clinic is inside a hospital. It's in our large level one trauma hospital. And it is also the hospital that serves a lot of underserved patients in the population. And so because they serve those kinds of patients, we get special pricing on toxins and on drugs, including the intrathecal drugs that are called 340B pricing. And so that is a site of service 22, which is something that has to be submitted when you bill. And then I also have a separate practice. We have a UT Physicians Medical Practice. It's a freestanding clinic. There's different types of specialties in that freestanding clinic. And that's called site of service 11, which is a clinic site of service. There is also a freestanding clinic that is under a hospital. That site of service 19, which is sometimes maybe related to what academic people will practice under. And we also are developing a clinic in that arena as well. I usually will treat all types of spasticities, dystonias, movement disorders, migraine, use interventional spasticity, management for my patients, including injectable toxins, nerve blocks, sphenal neuralysis, and intrathecal baclofen pumps. And now starting to use both types of pumps. And so referrals, where do I get my... So that's one thing. If you're building a practice, where are your patients gonna come from? So before I was in San Antonio, I was at TIER. TIER was a big name. We just had a lot of patients. We got severe patients. Severe patients were more likely to have spasticity. So we had a really robust spasticity clinic. I had to come here and build the spasticity program. And so some of the referrals were internal referrals. I'm very thankful for those. And then it also helps that I already had a name in spasticity and just trying to get the word out for what we do in the community, including reaching out to different therapies, reaching out to the different inpatient rehabs to have their patients follow up with me after they discharged. So one thing just to remember about spasticity, when your patients develop spasticity, the increased costs related to that when it's been studied for stroke survivors is that with and without spasticity is that their costs can be very expensive. And it's not just because these interventions that we're doing are expensive. They just usually have more severe disease state and the secondary effects of spasticity that it costs on their life, needing more caregiving, having pain, maybe needing surgeries in the future is gonna increase costs for it. And in general, in medicine, we're looking at quality and we're looking at value-based outcomes. And so we have to make sure that what we're doing is in the best interest of the patient and that it is going to match their life and their goals and help them long-term. And we have to think about big picture, even though some of the interventions that we do maybe are more costly than a pill of Baclofen, but what difference is it gonna make on their quality of life? With that being said, just briefly talk about best practices. Again, the point of my talk is always doing the right thing, doing the right thing for your patient. So always I'm a proponent of patient-centered, multidisciplinary program where you can do physical and medical interventions and just what I do is not good enough alone and that every patient's different. And when and how we treat really matters as well. It has to be significant and disabling to the patient and to their life. And just because it may look bad, but it's not affecting their life, or they may be using their tone for a good reason that maybe we don't intervene that way. But if it is disabling to them, even if it's just doesn't seem that major to you, but it's causing them pain, they won't get out of bed, they don't wanna move their limb, they have more learned non-disuse and they don't wanna do therapy, then that's gonna be something significant that we need to treat because it's gonna affect an outcome. What's the distribution of their spasticity? We have to consider those things, whether we put in a pump or just do focal management with toxin injections. What is the severity? What's the chronicity? Look at their concomitant conditions. Cost, always we have to kind of think of system-based practice and what is gonna be the best for them within their insurance that they have. And again, I always feel like it's never too late. My favorite patients ever to treat are ones who've had a stroke or a brain injury or whatever it may have been years ago and they're getting treatment for the first time because I feel we can help even if it's at a chronic state. Interdisciplinary teamwork's very important when you do this and I think this is one benefit of being in an academic setting is that I can encourage a lot of interdisciplinary and multidisciplinary work. And when you think of IHI's Institute for Healthcare that they look at quality and they work on quality and there's a triple aim where you're trying to improve the experience of care, you work towards population health and you reduce costs. Again, we have to think costs on a big term level. And then also you wanna improve the experience of providing care so that means myself, my faculty are decreased burnout and they're enjoying what they're doing. So at the end, we have to support everyone and work together to give the best outcome for the patient. And so part of the way that we do that, that we have a couple of clinics that are set up. One is more of the traditional, like I have an adult spasticity clinic and I can see a patient and I have residents and we set up patients and we're seeing them. The other thing that I've done most recently is, or I guess a lot of people had to go through telemedicine because of the pandemic. And so with telemedicine, I'm able to do a lot of virtual assessments, see patients initially, see patients in follow-up. Of course, they come in for real procedures, but this has been something that works really well for my patients who otherwise don't wanna come out and be exposed to COVID-19, who otherwise it's hard for them to get transportation sometimes during COVID-19 as well, or hard for them to get out of their homes in general. So if they have the broadband, the computer, the ability to reach out via telemedicine, we're doing an amazing amount of assessments that way. And that's another way that's saving money for the system and for the patient too. Some other parts of interdisciplinary team we can have, we've had before physical therapists come into clinic and work side-by-side with a physician. They can do a lot of hands-on assessments. They can order the DME. They can communicate with outpatient therapists. And also we also most recently set up a multidisciplinary clinic for our pediatric physiatrist. And that pediatric physiatrist is working with, you know, neuro maybe comes in PRN. Orthopedics is also in clinic with them all the time. A PT is always in clinic. An orthodist is in clinic. And then they have, of course, the nurse and then a social worker or case management to kind of help put everything together. And this is something that took work on the backend. So communications, a vision between PM&R and orthopedics where they wanted the best care for the pediatric patients. We have to also make sure on the front end when you're setting up a clinic, everything has to be set up. Well, we have Epic and Epic the right way where it's built out where a referral has to go to all these specialties, including the physical therapist for the patient to be seen together on the same day. So just kind of try to remember those things if you wanna do a multidisciplinary clinic. This is not always this huge money-making clinic. So you're not just seeing a millions of patients at a time. You're just trying to kind of give the best care side by side with a team. So where are the costs when we were setting up a clinic? Of course, you need all the materials and just depends on what you wanna order and what you plan on doing. But if you're going to be injecting botulinum neurotoxin, a lot of the cost comes from the neurotoxin itself. There's currently three type A toxins that we use for therapeutic purposes and one type B toxin. You can see them listed there. The J code underneath is what we use when you have to bill for toxins and the amount of units. And this kind of just shows you what packaging it comes in. Of course, they're not all one-to-one. They're different. And then the other thing is the cost. This is from 2019, but the cost didn't change too much between these. And you can see the cost's different, but also what you get paid back is different. And then this always changes every quarter as well. It's also important to know which are the FDA approved indications because that is what you are more likely to get paid for. So if you want to, you really like ribobotulinum toxin B, but it's only on label for cervical dystonia and scialleria, but you're using it for lower limb spasticity, you may not get paid. And so it's important to know what is on label because it's more likely that the insurers and the payers are going to pay for these things. And the other thing to know is that there's a co-pay program. So if it seems that your patient is going to have some trouble paying their co-pay, then all of the companies have this co-pay program where they can help support patients. So really how much does this do these costs? So let's say, and this is just the cost of the drug. And there's a couple of ways that it has to be done. And I'll go into that in the next slide about buy and bill or specialty pharmacy. But buy and bill means the office itself buys the toxins upfront and then they bill the patient's insurance for it. So if you're buying on a botch line of toxin A upfront on label for upper limb spasticity is 400 units, the cost of the toxin is 2,400. And let's say the insurance pays you 2,200 for it, then you're going to be taking a loss. Or let's say that the insurance pays you 2,600 for it. And that's good, that's $200. But then you also have to remember if you're in a practice, what's your overhead going to be? Is there a dean's tax, that sort of thing, if you're in the academic setting. Disport on label for upper limbs spasticity is up to a thousand units. So the cost of the toxin would be 1,700 in that case. So even though, okay, that sounds like a good deal compared to what Botox is, but it's also what the insurance is going to pay you back for it and how much Medicare is paying you back for it. And then if you're getting the right authorization. So I talked a little bit about if you're doing your own clinic. So if you're in a clinic based in a hospital, then usually the hospital is going to do the buy and bill where they're going to have to buy it beforehand, know what you want, know which ones you're going to want to order, and then they'll bill the patient for it. This is something that if we have our freestanding clinic and we're also do buy and bill, but another option is specialty pharmacy. And that's where you just order what you want. And then the patient takes that and they figure out what's offered within their insurance. And they will take a specialty pharmacy, we'll fill it and usually send it to you, which puts a little bit less risk off of the provider in case the insurance doesn't reimburse, you don't get reimbursed later and you don't just lose thousands of dollars worth of toxin. But the important thing is, is that you have to get authorizations for these things and you have to beforehand make sure you get authorization for what you're going to order. Otherwise you won't get paid and there's no way you can fight about it. The other thing is we talked about, I said before 340B pricing, this is offered in certain hospital based clinics where they serve a certain percentage of Medicaid patients. And so that makes the toxin be about 60% less of cost. And so one of our clinics, the one in the hospital, the level one trauma center in a poor town has that pricing for drugs. So it is better pricing that the hospital gets and then we get to pass it on to the patients as well. So it may be really good option for patients who are Medicaid or who have dual eligible Medicare Medicaid and because a lot of patients won't get that service from private practice where they're not going to make money from that. But again, it's doing the right thing for people and a lot of disabled patients who have spasticity are going to have these types of payers. So if you can partner with a hospital that has that pricing, it's a good thing to do. So about getting paid and how you get paid, this is the Medicare audit contractor. So these are the different jurisdictions. So each of these for Medicare, they have their own rules of what they cover for toxins. So most of what I'm going to tell you is the Novitas, the JH1 that has to deal with Texas because I don't know how they pay it in the Northeast part of the United States or California. But so this is mostly what I know based on the rules in Texas. So just to let you know that, but this is all available on CMS website if you want to know exactly how much you would be paid in your area for what you're doing with the codes. So for example, these are some of the codes that are used for, so if you want to set up a practice, you have to know how you're going to bill to, other than just, you have to buy all the equipment that you're going to need when you set it up, you're going to have to build your patient population true, but you have to know at the end, what are you going to be billing? What are you going to be coding? And what are you going to get paid for it? And so these are the four main CPT codes and we're just talking about spasticity, injections with neurotoxin. And something that's interesting is non-facility fee versus facility fee. So non-facility fee you see is higher than facility fee. And this is what the patient, this is what the physician's getting paid for the procedure. So in this case, you say the non-facilities, that means the freestanding clinic. That's the clinic, the site of service number 11. So you get paid more than when you're doing it in a hospital the physician, what the physician gets back is less. And that's because the hospital is billing the patient as well. So the patient's gonna have a hospital bill and then a physician bill that's different. And so you have to consider that when you're setting up a practice in the academic setting, you'll get paid more when it's done in a freestanding clinic, but you're not gonna get like the 340B pricing for the drug. And so there may be some more risk associated with that. What about phenol? Phenol is something, and alcohol, the neurolysis is that, they say it's a dying art and it's not being done very much. It actually gets paid very well because this is what you get paid per nerve. So not that this is all about money, but I really like to think that I'm a full service, spasticity management place for patients. And so sometimes when we, you know, I talk about, oh, what's on label and insurance is only gonna pay for what's on label. The toxin may not be, very much for what you want, then start using other things. And this one can be profitable. The other thing is people always ask about what guidance technique. You know, you can buy a little machine, a myoguide or a clavis that can do EMG and E-stem. And those are what you get paid for that. Modifier 26 is it's owned by the facility, the hospital, and then you get paid a little bit less. The ultrasound, those are the, you know, you get actually paid less for that than you would for the EMG or E-stem. And you think about having to buy the ultrasound and it take a longer time to feel, to pay it back. But again, I'm all about doing the right thing for the patient. Just a quick little points about profitability and losses. This was, in Texas, they stopped paying for the Medicaid part of the MediMedi patients. So that was a big loss when our patients had Medicare and Medicaid. So it's just something to watch out for and how they pay that in your state. And then also look at denials. And so I'm just gonna give you some examples so that way you don't make the mistakes at the beginning. And so first was using unapproved FDA indications, just denied. And also you have to look at what insurance will allow for billable units, otherwise it'll deny. And then prior authorization didn't always mean guarantee of payment. And then also you have to make sure that you're getting, the patient has a 20% copay that you're asking for it. You have to remember most of the patients, a lot of patients that you end up treating with spasticity are disabled. So they have Medicare and Medicaid. And so you have to follow those rules too. And you have to see how much you're actually getting reimbursed. At one point, and this was at my old practice, it was $8 for a cost for five units of disport and Medicare was only reimbursing $7. So that was a loss for everyone that was getting that. And then managed care, you did really well. And yes, it's a good idea. Like, oh yeah, I'm only gonna do managed care patients. But like I said, fewer and fewer patients with disabilities have just managed care, but they also are more likely to follow the FDA guidelines for what's on label. So again, just look at payer mix, look at what's been denied, do what's on label. The other thing is this study talks about injecting people early. And if you inject them early, their median time to reach reinjection was a lot further out. And so maybe if I recommend therefore trying to inject as early as possible, because it may be able to save money if you don't have to inject them as frequently. The other thing is this was Dr. Salino's patient paper about pumps and how medical cost can, looking at medical costs of severe spasticity patients who got pumps. And then yes, there's a big cost related to it when you get the pump, but longer term, actually it was, there is more cost savings and there's a bigger impact of savings once you get intrathecal therapies. So don't just think it's an expensive thing. It is actually cost savings longterm. And I want you to be organized. If you have an ITB program, you'll be hearing this a little bit more. Make a plan, find a team, educate, reach out to the pump companies and the medication companies, because they will help you. The other, the rule, I have another talk I gave that was about dealing with insurance companies and peer to peers and that sort of thing. So you can find that one and hear all about this, but you have to, again, know the rules, know the insurer, know the guidelines, know what the FDA says, know what the literature says, because that's what's going to be covered. Who's going to be your friends? Actually, I feel that it's okay to be friends with industry and the reps because, not because they bring cookies, but really because they have resources there. They can tell you about the co-pay program. They have patient, people who can look at the finances if you want them to get into that, work with your social worker, with your pharmacist, the prior authorization people, and then make friends with your therapist because they'll send patients to you. So thank you very much and hope you enjoyed it. Well, thanks so much to Monica for that great presentation. I'm Kimberly Heckert, and as Mike said, I am the director of a spasticity management fellowship at Sydney Chemo Medical Center at Thomas Jefferson University in Philadelphia. Thanks for joining this presentation today, and thanks for inviting my participation. I'm going to be talking about spasticity fellowship training and why would we need this in the first place? Well, to begin with, there is a tremendous need for physicians with expertise in spasticity management. And that is because we have roughly 13 million patients in this country with the upper motor neuron syndrome. And about a quarter of those people have spasticity with a high number of that portion falling into this category where their spasticity is really undertreated. And honestly, these figures are probably even higher. These are probably very conservative numbers because as you know, the conditions that cause the upper motor neuron syndrome, such as stroke, continue to grow in this country. So why should this be addressed with fellowship training? Well, the breadth of our field, as you know, continues to explode, especially in the last decade. And so requirements for a PMNR residency program are really not comprehensive of advanced spasticity management. Presently, to complete a PMNR residency program, only 15 neurotoxin injections are required. And there actually is no requirement for neurolysis procedures or a baclofen pump refill or other procedures related to intrathecal drug delivery. And this of course comes from the ACGME. So it simply just may not be possible to complete these objectives within a PMNR residency program. And there's also gonna be very wide variability program to program. So getting started, let's say for the sake of this discussion that you would like to start a spasticity fellowship. If that is your goal, the first thing that you ought to do is sit down with some other smart people and form a working group. Get them in a room or on Zoom together and get your ideas flowing and decide first what you would like a fellow to be able to do upon completion of your program and determine those objectives for your program. And also decide the key curriculum that is going to allow your fellow to obtain that knowledge. And I mean the knowledge aspect and the procedural aspect and get together and talk about these things, what's important for your program with a group of people. And then you're gonna wanna think about who are the players in your program. Explore what faculty will participate in this fellowship. And that begins in your own department, of course, where probably the majority of your faculty will be. But that also looks at other departments that will play a role in training your fellow in creating relationships with this department. For instance, at your institution, if physiatrists are not implanting the pump, if it's neurosurgery, you're gonna want to create a relationship where your fellow can spend some time with your neurosurgical colleagues and gain that piece of the education. And if within your faculty at your institution, you don't have a robust pediatric program, you might want to consider partnering with a local pediatric hospital and pediatric physiatrist to give your fellowship that area of programming. And then you will need to develop institutional agreements if you're going to need to send your fellow for some outside rotations. You'll also want to explore just some logistical patient care systems-based practice issues. And what I mean by that is, think about if your program, when you have a spasticity fellowship, take my word that your spasticity program will grow. And as that program grows, you may find that more people are presenting to your system with issues. And you want to know, for instance, if a patient with an ITB pump comes to the emergency department, who will be called first to help troubleshoot this patient's problem? Will it be your fellow? If the patient requires an admission to the hospital, will it be the PMNR doctor admitting? Will it be the neurosurgical service admitting? Will it be one of the medical services? And that is some dialogue that you want to have and explore before your fellowship is up and running. And then there's that funding piece, right? You can do almost anything if you can pay for it. So we've got to think about how you are going to pay for this fellowship, which we will explore in a little more detail in a moment. As you are gathering this information, you want to look closely at what your requirements are for fellowship program. Center, that is going to mean some dialogue with your graduate medical education office. Look at what is required for a fellowship program look at what is required for non-ACGME fellowships, because right now that's what spasticity fellowships are. And then make sure that you're drafting your fellowship proposal to meet those guidelines. And then ultimately, depending on what your process is at your institution, you will likely need to present this to a GME committee. That's what we had to do in our institution and presented and had to be voted upon for it to come into fruition. So let's talk about funding this fellowship. Some important considerations are, as spasticity fellowship programs are presently non-ACGME accredited, what that means is that non-ACGME accredited fellows may be allowed to bill in order to cover some of their costs. So they will be learning, but they will also be able to potentially bill for some of the services that they provide. Now, it may or may not be possible. I can tell you that at my institution, there are a lot of barriers to doing this. So we don't do this, but that could cover a portion of your costs. The other thing I should say is, be absolutely certain that you know exactly what all of your costs are, of course, as you're developing your budget. And then, as I mentioned before, having a spasticity fellowship is going to grow your spasticity program. And when I mentioned that spasticity is undertreated, it is undertreated and you will get more patients. So for that reason, when you develop a program that's going to bring business to an institution, you may find that, in fact, you can get some institutional support because you have shared goals. And speaking of shared goals, that's where you may be able to apply for grant support, educational grant support, because in fact, there are both charitable organizations and many industries that share similar goals. So for instance, industries related to spasticity management who share the goal of improving treatment for patients may be able to help. You know, founded for people with say spinal cord injuries or MS also may have goals of educating physicians in the problems that these people endure. And so you may find that you can apply for educational grant support through those avenues. And then finally, charitable donations can be actually a significant source of your funding. And my institution, we have an office of institutional advancement that helps me greatly with this so that I don't have to go around and ask anybody for money in that regard. But, you know, you would be surprised how many grateful patients are out there who may want to support your initiatives. So if you have an office that can connect grateful patients who want to support with your program, that certainly takes a burden off the physician and can be a huge help. I would say the downside of that is that you don't always know how much funding you can get that way year to year. So it can be tricky for your budget, but hopefully you have some support and the folks that are supporting you can get people to make a commitment so that you have some sort of idea at how much you have to be able to raise from other places in order to support your costs for the fellowship. And then a good idea is to have an evaluation process in place. And what I mean is we always have to come back to our goals. If you set up a fellowship program, you want to make sure that you have not only a process, a formal process in place to evaluate your fellows and evaluate the faculty who are teaching your fellows, but also even the objectives themselves and the outcomes. And I think one of the things that has been so exciting about our fellowship program, which is now just in its third year is that each year our fellows have met their objectives and goals earlier and earlier within the specified time of the fellowship, which means that each year we have been able to expand our objectives for the fellowship. We've been able to add competencies and additional procedures that we weren't sure we would be able to attain competency in. So that's been very exciting. And then if you're looking at evaluating all of these areas, and again, we're talking about a fellowship, growing a program, you're going to have not only growth of your spasticity program, but you may be able to grow your fellowship program as well. So perhaps you might be able to open additional offices or train more than one fellow at a time because of program growth over time. So that can be very exciting too. So in summary, spasticity is widely undertreated across the board in this country. We as physiatrists are leaders in the field of spasticity management, but at this time there are very few requirements in completion of a PM&R residency program related to advanced spasticity management. So the experience that a resident gets coming out of a PM&R residency program is going to be variable. So fellowship training really is going to be, I believe, the way to go for the future. Just like any other facet of our great field, when you want to be really good at something, you're going to spend some additional time training in that area. And the same will be true for spasticity management. Fellowship is going to be necessary if you really want to do all the cutting-edge treatments that are available. So you're going to need, in order to do this, you're going to need great players, you're going to need great teachers, you're going to need funding, and you're going to need a method to continually always evaluate what it is that you're doing and see how you can improve upon it. And that is how you get it done. Should you have additional questions for how to do it, please feel free to contact me. And thanks again for your presence here. Hi, I'm Andrea Toomer, a physiatrist in New Orleans, and today I'll be speaking about spasticity in the private practice sector. So I do have a number of disclosures. I am a speaker and on the advisory panel for a number of different pharmaceutical companies. So today we will be talking about methods for building and growing a spasticity practice in the private practice world. Discussing how to create effective documentation systems that help you be more efficient in practice and also help with patient education. We will review methods for regulating clinic appointments to make sure that patients don't miss appointments or appointments aren't inadvertently scheduled later than they should be so that we're not risking intrathecal back off and withdrawal. We will talk about the different options available for obtaining pharmaceuticals, and then also talk about obtaining reimbursement for those expensive pharmaceuticals. And then we will review developing and utilizing an emergency and an on-call protocol when necessary. So first talking about building and growing a spasticity practice. Sometimes that's very difficult to get the word out into the community about you being there and being able to treat spasticity and also about the effectiveness of treating spasticity and how by treating spasticity we can really improve function. So you really want to get out and speak to your referral sources or your potential referral sources. We're talking about primary care physicians and neurologists and anyone who may see someone who has rehabilitation needs. I have found that the most successful method is getting out and educating the physical and occupational therapists in the community. These therapists are the ones most likely to identify spasticity. They're the ones most likely to realize how spasticity can negatively impact function. So they seem to be the most effective in referring those patients in for more evaluation and treatment. Also take the opportunity to educate the people in your community. Hold some patient education events where you can actually get some of your patients to get up and speak about their experiences. Utilize things like your practice website. Put up some patient stories showing the difference between before and after spasticity treatment. Use things like social media and YouTube. Use everything that you can to get the word out about treating spasticity so that more and more patients will seek out evaluation from you for this. When talking about documentation, obviously this is sometimes a real time consuming and difficult task. So if you have things prepared ahead of time to make you more efficient and to make things easier, it will certainly help when you're building your practice. So when you're creating things like consent forms, your post procedure education forms, make sure that you're using clear patient-friendly language, outlining the potential side effects, giving the patients the package insert when applicable. These forms should really clearly outline for the patients how do they contact you or someone on your team and when should they be contacting you depending on what symptoms they're showing. We all know that maintaining appointments is really, really important, particularly with intrathecal baclofen and we certainly don't want to risk anyone missing an appointment and having baclofen withdrawal. We know that patients sometimes are not the most compliant and you have to have a really good system in place to make sure that your patients are not missing appointments and also to make sure that you're not missing scheduling someone's appointment when it should be scheduled. And we know that patients sometimes have a little bit of difficulty with compliance so we do need to have methods in place to help them with this. So maintaining these necessary appointments and the timing of the appointments, it's really necessary not just to prevent bad outcomes like potential withdrawal, but also just to make sure that we are being the most efficacious that we can be in giving our patients consistent spasticity control. Of course intrathecal baclofen withdrawal is serious and potentially life-threatening and that's not a situation we ever want our patients to get into. So really being organized is very necessary when you have a spasticity practice because of these timing elements. So giving patients and their caregivers appointment cards is really, really important. Put something in their hand so that they know when their next appointment is. Use patient reminder calls, whatever you have available to you, whether that's an automated call, whether those are texts, whether those are emails that are going out to the patient. Utilize all of those methods so that the patients get reminders and they don't miss their appointments. You have to do a lot of education with your patients so that they understand the importance of making these appointments. Don't let a patient leave your clinic without making the next appointment. So always schedule that appointment at the time of the procedure. You had a pump refill today. Your next pump refill is this particular date. Give them a card in their hand. Don't let them leave without the next appointment scheduled. And then if you're bringing patients in and you're doing any sort of titration on that intrathecal baclofen dose, make sure that you're updating their information, giving them a new card, updating that refill date as their alarm date is going to change because you're increasing their dose. Make sure that you have a good clinic protocol. Keep an accessible calendar of everyone's refill dates on hand. We like to keep a separate calendar, separate from our electronic health record so that we have easy access and we know when patients are coming in for refills. This easy access is especially important with impending natural disasters. And I'm on the Gulf Coast. We've had a particularly busy hurricane season, but we always plan for a busy hurricane season every year. We'll talk about that in a little bit. But having that calendar written down is really, really helpful in doing that. So setting your pump refill appointments a few days to a week in advance of the alarm date is always good practice. This is always going to depend on your patient too. Different patients are going to have different levels of compliance. They're going to be on different doses. So you know that you need to give yourself a little more or a little less time on particular patients. You want to contact the patient and the caregiver. If they miss an appointment, contact them that day and get them rescheduled as soon as you can. And then considering what we've done is having one point person in our office. She is the only member of our team who can reschedule spasticity appointments. That way, we know that we're not bringing in someone too early for their next toxin appointment. We know that we're not bringing in someone too late for their pump refill based on when their last procedure was and based on when their alarm date is. So that one point person is the only person who can change an appointment date. So what we don't want, and I have a fairly big office, we have 13 physicians in our office. I have a number of front desk people. I don't want one of them receiving a phone call and rescheduling an appointment without knowing when that appointment date can be. So we always make sure that our one point person does that. And this has given us a lot of leeway and kept us away from having a lot of issues with timing. So impending weather, as I mentioned, I'm on the Gulf Coast and hurricane season is our problematic time of the year. But depending on your location in the country, your problematic weather season is going to be different. But you always want to have that in mind and have a plan in place so that if we do have problem weather, this is how we address it. So you should have a very clear protocol between you and your office staff on how we're going to address things when impending weather is coming. The patients and the caregivers should also be very aware of what your protocol is so that they know if something's happening, they're not going to be. So what we actually do is we have a hurricane protocol sheet that we hand out at the beginning of every hurricane season. It's basically just an updated form from the year prior. So my patients have many, many of these forms, but we hand one out every year. We always include on their contact information, the name of the pump manufacturer, where they're going to be, what they're going to be doing, what they're going to be doing. And then we also include on their contact information the name of the pump manufacturer. We always include signs of withdrawal, all this information that we're updating and handing out every year to our patients. So as I said, hurricanes are impactful to us. So what we do when we know that we're going to be in hurricane season when the patient needs their next refill, we are setting their appointments 10 to 14 days prior to their alarm date. So we're giving ourselves more time than usual so that we have some time to play with if a storm's coming. We can easily then say, this is not going to be a big storm. We know it's only going to be a tropical system or a category one. We don't expect to be out for a long time. We can just push your appointment back to next week. We have a lot of time before your alarm date. Whereas if we know that things are going to potentially have a bit more of impact, we bring in all those patients early and get them refilled before the weather system. Sometimes we don't know in as much advance as other times. And we're also sometimes guessing on the timing, but if we give ourselves those extra days before we need to refill them, we always have some time to play with. We always call all of our patients when there's an approaching storm. Anyone who's set to be refilled anywhere close to that time frame, we're calling them before they're calling us. It alleviates a lot of issues with the front desk fielding a lot of calls. If we're just reaching out to the patients first, our patients feel very confident that we're going to reach out to them. They don't have to call us and question and worry, what are we going to do? How are you going to handle my refill? We call them first. That just makes it easier. So my patients always know, and I hand it to them on the forms, we're going to reach out to you. You don't have to worry about calling us because we're going to get to you first. So having a system like this for your impending weather time of the year, whatever it is, the more education and the more reassurance that you give to your patients up front, the easier the actual issue is for you. It's easier for you and your office members to handle it. So obtaining the medication is going to be a big issue when you're in private practice. So if you're in an academic institution, you typically have a pharmacy, whatever toxin you need, whatever concentration of drug you need, it's right there and you just get it and you use it and you don't have to think about it. In the private practice world, we have a lot more to consider. We have to actually obtain all that medication. We have to store it somewhere. And then of course, we have to make sure that we are getting reimbursed for it. So looking at pharmaceuticals, looking at asbestos city practice in private practice, it does add an extra layer of work that has to be done. So it's really important that you have the necessary drug on hand. So we keep an order sheet of all of our toxins that we're ordering and all of our pump drugs that we're ordering. We keep it separate from the electronic health record. We're keeping a list of what we have to order. We're keeping a list of what drug the patient needs and what their appointment date is so that we can make sure we order in enough time. We do not order in bulk. I don't want to have a whole lot of a particular toxin sitting around that I may or may not use that the expiration date may or may not be an issue depending on how much I use. Before we're going to be doing the procedures is when we're making the order. So every month we're ordering and we're ordering a month ahead or a month and a half ahead. And of course, we need to make sure that we're storing all of our drug properly. So if you do have a hospital pharmacy and you are able to obtain from the hospital pharmacy, that is certainly a very easy and efficient way to get what you need. Sometimes we have to order our medications from specialty pharmacies. There are certain insurance providers and payers in my region who require that we use a specialty pharmacy. That takes a bit more work on our end on the front end in order to obtain the medication and make sure that that medication is shipped to me and not to the patient. Sometimes even though we go through all the steps that medication does get shipped to the patient, we try to not let that happen. And we try to have it shipped to us so we can ensure that it's stored properly in the proper temperature. And then the other option, as I said, is buy and bill where we order our medication. We use the medication and then we are turning around and billing the patient's insurance company. And we have to make sure that we're billing that properly so that we do get the proper reimbursement for the drug, which is very, very important. These pharmaceuticals tend to be particularly expensive. So we want to make sure that we are getting the right reimbursement for these medications. And of course, it's a risk. If you're not getting reimbursed properly, you could lose a lot of money. So it's very important that your staff and your billing staff in particular are sending out all these claims promptly and correctly so that you're getting your reimbursement in a prompt fashion. So we have office staff members who are trained in ordering the drug, trained in getting the authorization, and trained in getting billing. And it's a separate office staff members who are doing all of these things. But we want to make sure that we're ordering correctly. We're not over ordering. We're not ordering more than what we need. We're ordering exactly what we need. We are obtaining the authorization first. And then we are sending out that bill correctly. So we are scrubbing the bill, making sure that we have the right code, the right number of units, the right number of muscles, the right guidance, all of those things before we actually send it out. All toxin bills are reviewed by one particular staff member who has special training in this. We, of course, are always getting the prior authorization for both the drug and for the procedure. And we're making sure that we're using proper ICD-10 codes because some codes are not covered by particular payers. So we want to make sure that we're using the right payer so that we can get the reimbursement. So having an emergency response system is important. And I did already talk about impending weather. And of course, you need an emergency response system for that situation. But also just in general, when a patient might be having issues, when a patient may, for instance, think that they're having signs of withdrawal, they need to know who do they call and how do they go about doing everything. So emergencies in spasticity are really not common. But there has to be some sort of an all-on-call system so that when the patient has a concern or when the patient shows up in the ER, you know how to get in touch with the physician. They know how to reach you or the appropriate person on your staff who is taking those calls. So the patient and their caregivers have to know who to contact after office hours. They should always be given post-procedure instructions for any procedure that they're having in the office. And that should include what criteria should trigger them to call you and then how do they call you. Put your phone number on there so that they always have your contact information. So in summary, managing an efficient spasticity private practice can be very rewarding, both clinically and financially. Having an efficient workflow for documentation and for patient education really makes workflow much easier. Your clinic organization is necessary to prevent withdrawal, to prevent missed appointments, to prevent poorly scheduled appointments. And you really have to take a lot of effort to ensure that those expensive pharmaceuticals are ordered properly and then billed properly so that they are reimbursed properly. And then educating patients and your staff members and having a very clear emergency and on-call protocol for a spasticity practice is really essential. Thank you. I'd like to thank all the faculty for their expertise that they've shared today. They all shared very dense presentations that hopefully you will be able to take back to your own practice and integrate into your own individual situations. All the speakers I know have been very forthcoming with their information and please feel free to reach out to them with individual questions. I'd like to thank you for your participation in this on-demand session and hopefully you enjoy the rest of the assembly.

spasticity clinic

practice management

patient-centered care

interdisciplinary teamwork

spasticity fellowship

private practice setting

building and growing

efficient documentation systems

clear communication