D.32 Podiatry Service Agreement.pdf

Specialty Care Referral Agreement

Service Agreement between Podiatry Section and Primary Care

Primary Care Providers (PCPs) can refer patients to Podiatry Clinic for specialty care through the mechanism of the electronic consult process in CPRS. The consult template has been created to direct the referring provider to the desired result of the patient receiving the appropriate care.

When Primary Care Providers facilitate appropriate referrals, as outlined in this Service Agreement, appropriate access to subspecialty care, advice, and management can be made available in a more efficient manner.

In an effort to most efficiently serve our veteran population with respect to podiatric needs, the management of the demand for podiatric services requires screening by the referring providers in primary care and other specialty care clinics. The screening goals are to prioritize the emergency and necessity of Podiatry Clinic appointments.

The major factor in doing so is proper workup needed prior to consulting the Podiatry Clinic, or referral for direct scheduling. This workup is outlined below and incorporated into the Podiatry consult template.

I. Services provided by the Podiatry Section

• Patient with emergent/STAT consults should be sent to the emergency room for immediate evaluation. No consult should be placed STAT unless communication with a provider has occurred and agreed to overbook for that day.

• Inpatient Care will be administered only when the podiatric concern pertains to the hospitalization/admission. Podiatric outpatient care will not be rendered to an inpatient based solely on convenience of patient’s location.

• Schedule podiatric clinic exam for veterans who need appropriate care within 30 days.

A. Management

i. The following are diagnoses for which a patient can be referred to Podiatry for Direct Scheduling:

1. Foot deformity (congenital or acquired):

STANDING WEIGHT-BEARING Foot/ankle films must be done prior to patient being scheduled in podiatry. If your patient does not want foot surgery to correct, a podiatry consult is not indicated. You may advise for deeper/wider shoe gear to accommodate for deformity. Prosthetics can assist with extra depth shoes.

2. Chronic foot or ankle pain

STANDING WEIGHT-BEARING Foot/ankle films must be done prior to patient being scheduled in podiatry. Please ensure that the patient has trialed a pair of orthotics (off the shelf arch supports) from prosthetics. Would also consider appropriate NSAID/analgesia.

3. Paronychia / infected Ingrown toenail (NOT

OVERGROWN NAILS)

a. Patient has acutely infected ingrown toenail

(erythema, edema, purulence)

b. Patient should be started on oral antibiotic course prior to scheduling.

c. Please be aware that nail hygiene is not done in podiatry clinic. Recommend that nails are cut straight across to prevent further ingrowing of nail.

If patient is a high-risk PAVE patient, please place under palliative care for medical management.

ii. The following are diagnoses for which a patient must have a

Consult placed:

1. Acute trauma of foot/ankle All fractures of the lower extremity need to be non-weight bearing to the affected side. Please order surgical shoe/CAM walker for protection as well as crutches/knee scooter as appropriate.

2. Acute diabetic foot disease manifested by (ulceration, infection, Charcot deformity)

a. All wounds must be accompanied by an x-ray

b. Please start patient off with daily cleansing of wounds with saline and a simple dry sterile dressing to prevent infection while awaiting podiatry appointment.

3. Lower extremity infections limited to the foot and ankle

4. PAVE consult: High risk patients for limb loss are patients with DM, ESRD, or documented lower extremity PVD, with neuropathy or deformity.

NOTE Exceptions:

a. Patient is blind, and is high risk for limb threatening foot wound

b. Paralyzed patient with severe motor dysfunction, must have combined 2 risk factors for limb loss.

c. Significant cognitive dysfunction and must have 2 combined risk factors for limb loss.

d. Patient with severe debilitating arthritis and must have 2 combined risk factors for limb loss.

B. Inappropriate Podiatry Section consults categories

i. Onychomycosis in patients where oral antifungals have not been trialed (unless liver disease is present) and when patients do not want the nail removed as definitive treatment plan.

ii. Inpatient routine foot care

iii. DM neuropathic pain (DM nerve pain is to be treated in PCP clinic)

iv. Tinea pedis (antifungal creams and oral medication are not restricted to podiatry)

C. Information to be provided by the referring clinicians

i. Consultation must be entered into the CPRS Consult template

ii. Specify the type of podiatric problem/ reason for request with proper provisional diagnoses (foot pain or ankle pain will not suffice) and associated symptoms and findings.

iii. Provide a history about previous podiatric surgeries. Provide a pertinent history of prior foot problems i.e. (amputations, vascular status, ulceration, lower extremity infections).

iv. Standing plain film radiologic exams prior to consult when clinically indicated. Required in all acute conditions.

v. Required labs (ESR, CRP, CBC, HA1C) and MRI/ or SPECT scan for all

vi. infections as stated in consult template.

vii. Vascular noninvasive studies (ABI’S and PVR’s) are required for all patients being consulted to podiatry with PVD as a stated risk factor.

D. Communication and timeliness

Consults needing STAT vs Routine attention:

i. The referring clinician must contact a podiatric physician directly for a STAT consult (from 8:00am to 4:30pm). The podiatry contact pager number is 214- 786-2794 and is also found on the consult template. Beyond the “tour of duty” (8:00am-4:30pm), the podiatry department is not available, and the referring providers may send patients to the ER for STAT evaluation in the outpatient setting.

Inpatient STAT evaluations should be directed to the general surgery consult team.

ii. Podiatry will respond within the same day to primary care or other specialties for emergent consultation, however, STAT consults must be warranted.

iii. Routine Consults

1. Podiatry will respond to electronic requests within 2 days and patient will be scheduled within 30 days for appointment.

2. Consults will be automatically discontinued when a patient is a “no- show” for two consecutive visits, or one “no show” combined with a patient cancellation, and patient will require a re-consult from the referring provider.

3. If patient arrives more than 30 minutes past scheduled appointment time their appointment will be rescheduled.

E. Criteria for discharge from Podiatry Clinic

i. Purpose/Process: To improve access for Podiatry outpatient consultations, electronic charting of patients followed in the Podiatry Clinic will be reviewed to ensure patients are being discharged appropriately. Patients enrolled in Podiatry Clinic, who have stable, chronic medical conditions where the podiatric work-up and treatment interventions are completed, will be discharged from Podiatry Clinic with a documented follow-up management plan for continued care by Primary Care clinic.

ii. Exceptions: The following categories of patient will be retained in Podiatry Clinic.

1. Patients with current infection or ulcers.

2. Patients with non-traumatic amputation due to risk factors, such as PVD, DM, or Infection.

3. Trauma cases until healed.

4. High-risk patient for whom podiatric care is necessary to prevent loss of limb or infection.

5. Patient with deformity or biomechanical dysfunction until condition improves or is stable.

6. Patients who are in the post-operative follow-up period.

7. Any fracture will be followed until healed.

8. Surgical candidates for podiatric conditions awaiting surgical intervention (i.e., bunions, hammer toes).

9. Patients will not be retained in the Podiatry Clinic for pain management purposes unless treatment encompasses a surgical procedure that is being planned or completed.

F. Evaluation of Service Agreement

i. Podiatry Clinic performance, wait times, and responses to electronic consultation requests will be monitored by Surgical Service using DHCP databases. Podiatry Clinic staff and Surgical Service will monitor Primary Care and other specialty compliance with consultation request guidelines.

ii. The relevant parties to the agreement will remain in open communication and provide bidirectional feedback as a basis for evaluating the Service Agreement on an annual basis.

iii. Renewal of this service agreement will be completed within three years of date of final signature or sooner as deemed necessary by all stakeholders.

Rose Lumare, DPM John Modrall, MD Section Chief, Podiatry Chief, Surgical Service

Richard T. Miller, MD Rajani Potu, MD Chief, Medicine Service ACOS/Ambulatory Care

Jeffrey L, Hastings, MD, MS Chief of Staff

Rose M Lumare 700805

Digitally signed by Rose M Lumare 700805 Date: 2019.04.09 13:14:00 -05'00'

John G. Modrall 1020714

Digitally signed by John G.

Modrall 1020714 Date: 2019.04.16 14:18:51 -05'00'

Richard T.

Miller 432253

Digitally signed by Richard T.

Miller 432253 Date: 2019.05.03 21:33:02 -05'00'

Rajani Potu 361440

Digitally signed by Rajani Potu 361440 Date: 2019.04.24 12:45:27 -05'00'

Jeffrey L.

Hastings 457520

Digitally signed by Jeffrey L.

Hastings 457520 Date: 2019.05.24 09:19:34 -05'00'