Consensus Terminology for Stages of Care:
Acute, Chronic, Recurrent, and Wellness

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

FROM:   J Manipulative Physiol Ther. 2010 (Jul);   33 (6):   458–463

Mark D. Dehen, DC, Wayne M. Whalen, DC, Ronald J. Farabaugh, DC, Cheryl Hawk, DC, PhD

Council on Chiropractic Guidelines and Practice Parameters, Lexington, SC, USA

OBJECTIVE:   As the chiropractic profession delineates its role in the emerging health care marketplace, it will become increasingly important that the scope of appropriate chiropractic care is clearly defined relative to overall patient case management. Therefore, the Council on Chiropractic Guidelines and Practice Parameters engaged in a multidisciplinary consensus process addressing the terminology related to "levels of care."

METHODS:   A formal consensus process was conducted in early 2009, following the RAND/UCLA method for rating appropriateness. Panelists were selected to provide a broad representation of the profession in terms of geographic location and organizational affiliation, and an attempt was made to include members of other professions, including representation from third-party payors. The Delphi process was conducted electronically in January-February 2009. A nominal group panel was conducted through an online meeting service using an experienced group facilitator. Twenty-seven panelists were selected; all but 3 were doctors of chiropractic. Six of the panelists had experience as consultants with third-party payors.

RESULTS:   Fifteen seed statements were circulated to the Delphi panel. Consensus was reached on all statements after 3 Delphi rounds, with further refinements made through the nominal group panel.

CONCLUSIONS:   By using a recognized formal consensus process, the Council on Chiropractic Guidelines and Practice Parameters has endeavored to establish a set of terms that are acceptable to the chiropractic community in order to facilitate their use within the broader health care community.


From the FULL TEXT Article

Discussion

This formal consensus process to clarify the terminology used by chiropractors related to common areas of patient care is important as such care becomes increasingly integrated into the mainstream. The chiropractic profession's history of developing outside mainstream medicine has fostered colloquialism and confusion, often to the detriment of our shared patients. Terms such as preventative/maintenance care, [17] defined as care to reduce the incidence or prevalence of illness, impairment, and risk factors and to promote optimal function, and supportive care, defined as treatment/care for patients having reached maximum therapeutic benefit, in whom periodic trials of therapeutic withdrawal fail to sustain previous therapeutic gains that would otherwise progressively deteriorate, [17] are chiropractic specific and not commonly used by other health care disciplines.

Therefore, for the purposes of this project, chiropractic care as it applies to the typical patient presentation was to be described using conventionally recognized terminology across the accepted continuum of care, from acute to chronic/recurrent on to wellness. Acute conditions were those having a relatively short but possibly severe course, for example, acute cervical torticollis. Chronic/recurrent conditions were those persisting over a long period, for example, lumbar degenerative disc disease with associated osteoarthritis and occasional sciatic leg referral. Wellness care was considered more related to enhancement of function and ability to perform daily activities. Our panelists were charged with identifying the common characteristics of each of these 3 primary levels of care. Medically necessary care refers to care that is generally reimbursable by third party carriers, for example, acute and/or chronic/recurrent care. Ongoing care in the chronic/recurrent population was discussed as potentially contraindicated, for example, if it delayed appropriate psychological care in the dependent personality patient.

In addition, providing context for chiropractic care in chronic/recurrent cases, as supported by contemporary research previously identified in the CCGPP's literature syntheses, [8-13] is important in establishing a chiropractic alternative for this expanding patient population. Concomitantly, while the definition of wellness care remains fluid, the historical chiropractic health care model of improving function, good nutrition and exercise endorsement are consistent with basic wellness tenets. Refining these terms with a chiropractic lens was felt to be important in order to standardize the delivery of such care.

In the face of the evolving health care market, with its demands for effective collaborative outcome-oriented patient management, there is a role for chiropractic integration. However, this historic lack of standardized common language is a handicap that needs to be addressed. Therefore, this consensus project is an initial step to close that gap. Currently, the CCGPP is involved in a new multidisciplinary consensus project to better outline documentation and parameters for chronic/recurrent care. Future research will also be necessary in the area of wellness care as that area of patient focus matures.

Limitations The chief limitation of this project was the lack of diversity in the consensus panel, which included only 3 non-DCs (one of whom was an RN) and only 2 International Chiropractors Association members. The CCGPP had hoped to attract a broader, more multidisciplinary panel. Our inability to do so may reflect the longstanding isolation of the profession, as well as the factionalism within it. Another limitation may be related to the number of source documents available to provide to the panel as background on terminology in use throughout the medical and research communities. Additional sources may have been useful for the panel to gain a broader understanding of common medical lexicon. We reviewed only a limited number of terms and perspectives centered on “levels of care.” There may be other terminology, definitions, or perspectives which were not considered, although efforts were made to include those most commonly used in the health care arena. Limitations imposed by the Delphi process, as well as the limited diversity of the panel members, may also have contributed to a bias in consideration of other definitions or terminology.


Conclusion

Achieving consensus on this terminology related to the spectrum of patient presentations is expected to facilitate their use within the profession of chiropractic, which, in time, may facilitate better integration of chiropractic care within the health care mainstream.


Practical Applications

• It will become increasingly important in the emerging health care system that the scope of appropriate chiropractic care is clearly defined relative to overall patient case management.

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