Drag multidisciplinary care from ‘academic ivory tower’ to optimize GI patient outcomes
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What the poet John Donne observed about humanity — “no man is an island, entire of itself; every man is a piece of the continent, a part of the main” — holds true for health care providers. No provider operates in a vacuum; no provider stands alone.
Gastroenterologists will often manage patients with difficult-to-treat gastrointestinal conditions whose symptoms and concerns fall outside their expertise. However, with a multidisciplinary approach, they do not have to be alone in the process.
Source: Sameer K. Berry, MD, MBA
A team-based approach allows for multiple specialists with expertise in GI including nursing, nutrition, behavioral psychology, clinical pharmacy and sometimes radiology and surgery to collaborate on challenging cases and determine the best treatment plan to fit the patients’ needs.
Multidisciplinary teams are most often seen in larger health care systems but can be harder to implement in smaller community practices due to poor access to a network of necessary specialists to assist with patient care.
“In many cases, the value we can provide as gastroenterologists is nullified if our patients do not have access to other clinicians to help support the non-medical aspects of digestive care,” Sameer K. Berry, MD, MBA, co-founder and chief medical officer at Oshi Health, told Healio Gastroenterology. “Clinicians specializing in GI dietetics and the gut-brain axis have, unfortunately, been a peripheral aspect of GI care; we now realize the impact of these interventions and that they should be a default component of GI care.”
He added: “We have known for quite some time that a comprehensive, multidisciplinary approach is right for our patients. The reason this is not the standard of care relates more to a lack of reimbursement and trained clinicians, not a dearth of knowledge or awareness.”
Seeing Through a Different Lens
According to Laurie A. Keefer, PhD, director for psychobehavioral research in the division of gastroenterology at Mount Sinai and co-founder of Trellus Health, one reason gastroenterology is unique is the strong connection between the gut-brain or mind-body axis, which lends itself particularly well to integrated care.
“Patients are often overwhelmed with broad or generic recommendations, and it can be particularly therapeutic to break down the suggestions into a specific stepwise care plan,” she said.
Keefer, who specializes in the psychosocial care of patients with chronic digestive diseases, developed Mount Sinai’s integrated-care approach for patients with inflammatory bowel disease known as Gaining Resilience Through Transitions, or GRITT.
Before implementing this method, she might have seen a patient for depression while they were also seeing a nutritionist for not eating well. Both issues require treatment, but one may need to be addressed first; in other words, a clear method to prioritize behavioral change is critical to improving outcomes.
“The lens through which we, as different professionals, each see the patient differs and many times what we ask patients or what patients tell us may differ also, depending on who they are talking to,” Keefer said. “We get a much more complete picture of what is going on with the patient when we are communicating through our individual professional background.”
She added: “[Digestive disorders] need to be thought through conceptually, including how the symptoms interact with each other across life domains. Not only does a conceptually based approach provide a complete picture, it also helps providers order care for patients in a way that makes it easier for them to digest the recommendations.”
William D. Chey, MD, AGAF, FACG, chief of the division of gastroenterology and hepatology at Michigan Medicine, told Healio Gastroenterology the field has traditionally focused on the use of medications to treat patients with GI conditions.
“If medications worked perfectly, that is all we would need to know,” he said. “Unfortunately, even the most effective medications only make around half of the patients better, which leaves many patients in need of something beyond medication.”
For patients with irritable bowel syndrome, food and stress are the two most common triggers for their symptoms, so it would make sense to develop strategies that intervene on both, Chey noted.
“GIs are not dietitians, nor are they GI psychologists,” he said. “While they can identify the need for those types of interventions in their IBS patients, most gastroenterologists are not adequately trained or even able to meaningfully intervene, either in terms of diet or behavioral interventions.”
Berry added that it is impossible for one physician to be an expert in all specialties. Since many different symptoms may impact a GI patient, they need a team including the expertise of dietitians, GI psychologists and surgeons.
The need for a team of medical professionals working together is also necessary when treating patients with IBD who should be treated with a holistic approach, noted Laura E. Raffals, MD, vice chair of the division of gastroenterology and hepatology at Mayo Clinic. This includes consideration of how the foods patients eat affects disease and how IBD also affects what patients can eat.
With regard to conditions such as IBD, or even IBS, she noted that dietitians can help patients develop a personalized dietary approach to their disease, while a GI psychologist can help patients manage stress and anxiety about their diagnosis.
“Unfortunately, many practices do not have a dedicated dietitian or GI psychologist,” Raffals said. “These providers are in high demand, and we have to get creative about how we help our patients access these resources.”
Team Meetings Critical to Success
To increase access to IBD specialists for the treatment of complex cases, in 2017 Mayo Clinic implemented a biweekly team meeting, the IBD eBoard. These meetings provided clinicians who work with IBD from a range of specialties, even those from other medical centers in different geographic locations, the opportunity to present and discuss challenging cases through video conferencing.
Attendees have included gastroenterologists, colorectal surgeons, radiologists, pathologists, nurse practitioners and study coordinators. During each meeting, two to five patients are presented and discussed, including their IBD diagnosis, prior management and relevant medical, social and family history, followed by a review of radiology images and pathology slides by a diagnostic specialist.
ln a 2019 article published in Crohn’s and Colitis 360, Raffals and colleagues noted the IBD eBoard lead to either a new diagnosis or a change in diagnosis in nearly 12% of patients.
“We learn a great deal from one another, and overall patients benefit even more,” Raffals said. “We often bring our expertise to the table to come up with creative solutions to address some of the challenging situations that our patients are facing. This clinic has continued to build community for our IBD team, as well as providing a great service to the patients we care for. ... At a time when community is so vital to thriving in the workplace, this cannot be overlooked.”
In an interview with Healio Gastroenterology, Miguel Regueiro, MD, AGAF, FACG, professor and chair of the Digestive Disease and Surgery Institute at Cleveland Clinic, said his institution has similar multidisciplinary care meetings for IBD and colorectal cancer, incorporating a team of gastroenterologists, pathologists, oncologists, general and colorectal surgeons, radiologists, pharmacists, nurses, physician assistants and nurse practitioners, with attendees both from within Cleveland Clinic and other medical centers.
The Cleveland Clinic follows a model in which each department or institute features a multidisciplinary care team. One example is Cleveland Clinic’s Digestive Disease and Surgery Institute, which includes general surgery, colorectal surgery and specialties related to digestive health and disease, such as gastroenterology, hepatology and nutrition. All of those subspecialties fall under one umbrella, with experts cohesively working together and meeting on a regular basis to discuss cases.
“That really carries over into our clinic — how we see patients, how we meet in conferences, how we work — and that, to me, is a model that others are starting to look at,” Regueiro said. “It really is the core fabric of how we approach whole-person care.”
He added: “A whole-person care approach takes into account the whole person sitting before us in the clinic, which means understanding the disease for which the person is seeking medical treatment and the person themselves beyond the disease.”
An example of whole-person care is Cleveland Clinic’s IBD Medical Home, where “the patient is at the center of a multidisciplinary team where each member is brought in as needed,” Regueiro noted. This includes dietitians, GI psychologists, social workers, surgeons, gastroenterologists, nurse practitioners and a GI pharmacist, who come together to discuss a patient’s journey and life to understand the full picture and determine the best treatment.
“Our patients come in and they may have a disease or diagnosis, such as Crohn’s disease, but we know that behavioral health, lifestyle and diet play such important roles that if we do not cover that and only cover one thing specifically, we would miss out on whole-person or patient-centered care,” Regueiro said.
Chey added that, at Michigan Medicine, GI psychologists and dietitians interact regularly with gastroenterologists and discuss cases through a portal messenger. Additionally, once a month, these three groups hold a conference to discuss more difficult and complex cases and create an integrated plan to manage care.
At Mount Sinai, in addition to weekly multidisciplinary team meetings, Keefer explained they also apply the GRITT method, which includes developing a hypothesis on the care a patient may need and the order in which they should receive it.
“We do a lot of pre-huddling on people who are coming in, and then we spend the second half of the meeting updating people on where they are in their care plan or if there are any barriers,” she said. “We also celebrate successes. We have a care coordinator, who takes notes during the meeting and reaches out to the patient.”
Trellus Health does something similar, Keefer noted, but has adapted and scaled the GRITT method to deliver comparable care via its digital platform, Trellus Elevate.
However, the challenge with having a multidisciplinary conference is finding clinicians with expertise in gastroenterology who are willing to work on a team and then making it easy for them to work in that environment, Berry noted.
A solution to this is “purpose-building your clinical workflows to be digital-first” either through synchronous or real-time communication using telemedicine, in-person meetings, phone calls and instant messaging or asynchronous messaging which is not always immediate.
“We have to figure out a way to democratize multidisciplinary care — pull it out of the academic ivory tower and make it available to everyone,” he said.
‘Access is a Huge Problem’
Berry, Chey and Keefer all cited access to other specialists, such as dietitians or psychologists, as a major challenge with multidisciplinary care. Although there is an increasing number of GI dietitians available, Chey noted approximately 40% of gastroenterologists in the U.S. do not have access to one.
“Having a GI dietitian in your practice is a new phenomenon,” Chey said. However, there are not enough dietitians to staff all GI practices, which perpetuates the lack of access.
“With GI psychologists it is even worse, with only around 20% of gastroenterologists having access to a GI psychologist,” he said. “Access is a huge problem.”
Not only do gastroenterologists often not have access to other specialists, including mental health professionals, nutritional experts and clinical pharmacists, but patients themselves may have difficulty accessing these specialists because it may be costly for patients to receive specialty services, Keefer said.
Regueiro said access barriers may result from the structure of health care systems in the U.S., “where we are somewhat siloed in our institution or tertiary care centers.”
Another barrier is reimbursement, the experts noted. Many payers will not provide reimbursement for a dietitian or behavioral therapist, so patients are left paying out of pocket, Chey said.
“Unfortunately, our for-profit health care system suffers from the same focus on quarterly earnings as other industries,” Berry noted. “While we can complain about our situation, we have to learn to operate within these circumstances and figure out ways to align incentives and push for reimbursement.”
He added: “However we decide to approach solving this problem, we need to agree that multidisciplinary care must be reimbursed through traditional insurance; we cannot rely on direct-to-consumer models where patients are responsible for payment. The good news is that health plans are starting to realize that the benefits of multidisciplinary care extend beyond patient outcomes and can provide a return-on-investment through a reduction in avoidable ER utilization and high-cost imaging.”
‘Game-Changer’: Telemedicine in Multidisciplinary Care
“The advent of telehealth has been a game-changer in terms of advancing the scalability of diet and behavioral therapies,” Chey said. “There has not been much motivation for gastroenterologists to create a personal resource [of GI dietitians] and utilize the space in their offices to be able to provide multidisciplinary integrated care.”
He added, “Over time, there has been an increasing number of services that are becoming available that provide GI nutrition and behavioral health services virtually. That is a future game-changer, but it is very much still in its infancy right now.”
Chey noted that at Michigan Medicine gastroenterologists conduct both in-person and telemedicine visits, while dietitians and behavioral psychologists provide 100% virtual visits. A model like this may alleviate space concerns for busy practices “trying to maximize use of their physical plant,” he said.
Berry, Chey and colleagues recently presented research at the 2023 American Telemedicine Association’s annual conference, which demonstrated that a virtual integrated-care program in collaboration with GI practices yielded encouraging results among patients with disorders of the gut-brain interaction and those with GI symptoms but no formal diagnosis.
The prospective, single-arm clinical trial assessed the efficacy of a virtual integrated-care program for 234 patients, who were matched 1:5 with propensity-score matched controls.
Researchers reported that 83% of patients were engaged, 98% reported being satisfied with the virtual program and 92% reported improvements in symptoms and missed 1.3 fewer workdays per month.
They noted high patient engagement, satisfaction, symptom improvement, as well as reduced health care utilization and statistically significant cost-savings.
Additionally, after 6 months in the virtual integrated-care program, patients had significantly lower GI-related costs compared with controls ($3,934 vs. $9,047) as well as lower all-cause costs ($9,843 vs. $17,573). Further, researchers reported GI-related cost-savings of $6,723 and all-cause savings of $10,292, driven by significantly fewer avoidable GI-related emergency department visits (8% vs. 21%) and all-cause ED visits (20% vs. 28%) and a decrease in GI-related imaging (20% vs. 47%). These results were maintained at 9 months.
Similarly, following the implementation of multidisciplinary care program, Mount Sinai experienced an 80% reduction in hospitalizations for opioid and steroid use, Keefer said.
“When the team is looking at the patient through the same lens and everyone is talking the same language, the patient is getting much more streamlined, prioritized and less overwhelming care, which is exactly what leads to some of these savings on the other end,” she said. “If you know exactly who to call when you are having abdominal pain, chances are you are less likely to show up at the hospital.”
Additionally, remote care through Zoom and other platforms may also decrease provider burnout, Keefer noted. This is cost effective because less burnout means fewer employees leaving, so institutions will not have to manage the cost of employee turnover.
“There is a lot of downstream savings with telemedicine and increased provider satisfaction,” Keefer added.
Regueiro noted that Cleveland Clinic’s IBD Medical Home also saw fewer ER visits and hospitalizations, as well as improved activity scores and quality of life. He noted that if experts collaborate as a team to develop treatment plans for patients, it is likely more cost-effective than a siloed approach to patient care.
“If patients have to go individually to each of those [specialists] or their physicians do not communicate regularly, that adds costs and time,” Regueiro said.
Multidisciplinary care conferences have also improved provider education, Raffals added. For instance, Regueiro established IBD Live in 2009 to offer weekly 1-hour interactive webcast discussions of notable IBD cases from around the world. The broadcasts average 250 health care provider attendees each week, representing nearly 50 countries.
Other medical centers could implement similar multidisciplinary care conferences with comparable results, Raffals noted. “It requires engagement from key stakeholders across various departments, and a champion to lead the conference,” she said. “Although it does take some upfront work, the payoff is tremendous.”
Optimizing Patient Care Teams
Multidisciplinary care programs can be implemented in both large health care systems and small practices. Chey suggested larger health systems hire full-time equivalent GI dietitians and GI psychologists as Michigan Medicine did.
As for GIs in smaller practices, Chey recommends they outsource to a commercial vendor or company that provides services for hire, which improves access to dietitians, nutritionists or behavioral health care specialists.
“Utilize companies that provide those services, as opposed to you having to hire and pay benefits for those providers in your own practice,” Chey said. “By our conservative calculation, it takes eight to 10 gastroenterologists to generate enough referrals to be able to maintain one GI dietitian or behavioral psychologist.”
Keefer added that GI-focused Trellus Health was developed to help smaller community practices gain access to multidisciplinary care to better optimize patient care.
According to Berry, there is a difference between having access to clinicians who cover a wide range of services and having clinicians who actually work together for the care of the patients.
“If clinicians on a multidisciplinary care team work for the same institution but do not meaningfully interact beyond reading each other’s notes, they are unlikely to achieve the improvements in outcomes and savings seen in our study,” Berry said. “In order to maximize outcomes, clinicians need to have the right structures in place that incentivize and support protected time outside of patient visits required to truly collaborate on patient care.”
Berry noted that this type of collaboration requires daily communication between clinicians, which can be hard to justify in a system that only pays for the volume of patient appointments.
Keefer added that implementing multidisciplinary care requires scientific methodology, such as the GRITT method, which uses an algorithm to weigh and prioritize various aspects of IBD self-management. The methodology would establish “the pathway patients should follow with respect to their individual self-management strategies” while reflecting the clinician’s approach to their care.
“A [multidisciplinary team] approach requires less effort and training on the front end if you have a scientific framework,” she said. “Otherwise, it becomes everyone just sitting there talking about problem patients. There needs to be a north star for interdisciplinary team meetings or endpoints that you are looking to target as a team.”
Multidisciplinary care does not involve one approach, but it is helpful to have either a framework, method or shared language the team agrees on, Keefer noted.
“It is a commitment to making sure everyone is viewing a patient holistically, regardless of their role on the team,” Keefer said. “I would underscore that you can work with what you have and build [multidisciplinary care team meetings] from what you know and use what you currently have to make sure that you are optimizing your care team in a way that benefits the patients.”
- References:
- Berry SK, et al. A virtual integrated care program improves patient outcomes, engagement, and satisfaction at reduced costs: A prospective trial. Presented at: American Telemedicine Association Annual Conference; March 4-6, 2023; San Antonio.
- Quinn KP, et al. Crohns Colitis 360. 2019;doi:10.1093/crocol/otz013.
- For more information:
- Sameer K. Berry, MD, MBA, is co-founder and chief medical officer at Oshi Health and can be reached at sameer@oshihealth.com.
- William D. Chey, MD, AGAF, FACG, is chief of the division of gastroenterology and hepatology at Michigan Medicine and can be reached at wchey@med.umich.edu.
- Laurie A. Keefer, PhD, is director for psychobehavioral research in the division of gastroenterology at Mount Sinai and can be reached at laurie.keefer@mssm.edu.
- Laura E. Raffals, MD, is vice chair of the division of gastroenterology and hepatology at Mayo Clinic and can be reached at raffals.laura@mayo.edu.
- Miguel Regueiro, MD, AGAF, FACG, is professor and chair of the Digestive Disease and Surgery Institute at Cleveland Clinic and can be reached at regueim@ccf.org.
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