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Hospital Collaboration Plans
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The first page of this document presents the new nonpharmacologic standards that must be met by hospitals to maintain accreditation, and offers practical reasons for collaborating with chiropractic physicians to meet these standards. The second page gives specific examples of how hospitals could meet this standards with our help. This is not intended to be sent to hospital staff as a letter. It is intended to be used in person in a meeting discussing collaboration with the hospital.



Joint Commission Standard for Nonpharmacologic Pain Treatment
Increasing Evidence-Based Collaborative Care to Reduce Opioid Abuse
Requirement EP 2: The hospital provides nonpharmacologic pain treatment modalities.
Rationale: The hospital should promote nonpharmacologic modalities by ensuring that patient preferences are discussed and, at a minimum, providing some nonpharmacologic treatment options relevant to their patient population. When a patient’s preference for a safe
nonpharmacologic therapy cannot be provided, hospitals should educate the patient on where the treatment may be accessed post-discharge. Nonpharmacologic strategies include, but are not limited to: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy.
In summary:
1. Increase patient education on nonpharmacologic options while inpatient and at discharge.
2. Increase patient access to nonpharmacologic options in hospital and through referral.
3. Provider education on nonpharmacologic options is also essential to successful outcomes.
Successfully meeting the Joint Commission standard with Chiropractic Physicians 
Collaborating with chiropractic physicians provides a unique opportunity to meet the Joint Commission standard while also achieving the triple aim of modern medical care (improving health, improving care, reducing costs). Comparative studies including chiropractic treatment/management for spinal pain have recognized its effectiveness in improving pain and function, improving care coordination and service utilization, improving cost savings, and achieving high patient satisfaction.
As physicians, chiropractors can appropriately manage or co-manage complex painful spinal conditions. Chiropractic physicians can order further diagnostic testing or refer to a specialist when indicated. Spinal manipulation and patient education are most common evidence-based treatments used by chiropractic physicians for acute and chronic pain, consistent with current treatment guidelines. Often, chiropractic physicians also provide access to other nonpharmacologic options: acupuncture, physiotherapeutic modalities, rehabilitative exercises, massage therapy, nutrition recommendations, and lifestyle coaching.
Chiropractic is the largest, most regulated and best recognized of the complementary and alternative care professions. In fact, patient surveys reported in the Annals of Internal Medicine show that chiropractors are used more than any other alternative provider group and patient satisfaction with chiropractic care is very high. Patient use of chiropractic in the United States has tripled in the past two decades, and most insurance plans cover chiropractic care. The quick accessibility for evaluation and treatment from chiropractic physicians is an important advantage when caring for patients experiencing severe pain who may be motivated to seek risky methods of pain relief while waiting for care.



Identifying appropriate patients for nonpharmacologic pain treatment education and access
1. Hospitals should already be assessing pain according to existing Joint Commission standards.
2. Identify red flags (malignancy, progressive neurological deficits, etc.) to rule out the need for emergency/urgent medical care. (Chiropractic physicians will confirm the absence of red flags during their initial evaluation.)
3. The most common conditions to address with chiropractic and nonpharmacologic treatments are neuromusculoskeletal conditions including back pain, neck pain, and headaches. Other painful NMS conditions of the extremities should be considered as well.
4. Patients assessed and found to have a history of substance addiction or at risk of opioid abuse should especially be prioritized for education and urgent access to nonpharmacologic options.
>> Higher risk populations for opioid abuse or pharmacologic adverse effects include pregnant females, elderly, injured workers, veterans, mental health patients, patients with gastrointestinal disease, and patients with renal or hepatic dysfunction.
Increasing patient education on chiropractic and nonpharmacologic options
1. Identified patients should be provided with a brochure or literature discussing the safety and efficacy of chiropractic and nonpharmacologic options for pain while being treated in the hospital. (Literature available by request)
2. Identified patients should be provided with a brochure or literature discussing the safety and efficacy of chiropractic and nonpharmacologic options for pain when discharged from the hospital. Educational language could be automatically included in discharge instructions for identified conditions. (Literature available by request)
3. The hospital should host patient education events with chiropractic physicians or nonpharmacologic treatment providers discussing the appropriate use of these options. (Speakers available by request)
Increasing patient access to nonpharmacologic options in hospital and through referral
1. Chiropractic physicians may be provided hospital privileges to provide inpatient treatment (as of 2015, 3.6% of chiropractic physicians hold staff privileges at a hospital with VA hospitals showing significant growth). Appropriate departments in which chiropractic physicians have been utilized include the ER, orthopedics/sports medicine/physical rehabilitation, work injury, and pain management.
2. As part of their educational literature, patients should be given information on how to find a local chiropractic physician. (Available by request)
Increasing provider education on nonpharmacologic options
1. The hospital should provide educational literature and learning resources to providers that include a description of nonpharmacologic options, benefits and risks, current treatment guidelines, indications and contraindications, and common questions and answers. (Available by request)
2. The hospital should host provider education events with chiropractic physicians discussing the appropriate use of these options. (Speakers available by request)

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