Using Quality Improvement Methodology to Develop a Multi-Disciplinary Clinic for Patients With IBD Living in Rural Regions

Introduction: A goal of inflammatory bowel disease (IBD) management is to provide a multidisciplinary approach. Barriers include lack of resources outside of IBD centers and access to these specialty centers. Patients living in rural regions are particularly impacted by these barriers. Our aim was to create a comprehensive telehealth care model for patients living in rural regions called RADIUS (Rural Advanced Practice Providers Delivering IBD Care in the United States). Methods: We identified community-based rural practices in northern New England who were interested in a telehealth-based “hub and spoke” IBD model (Figure 1). The initial iteration of a RADIUS visit included consultation with an IBD specialist and nurse coordinator and then optional visits later with an IBD psychologist, dietician, and pharmacist if deemed necessary. As part of Plan, Do, Study, Act (PDSA) cycles we conducted qualitative interviews with RADIUS patients and providers. Based on feedback, the next iteration included multidisciplinary appointments with the full team for all patients during a one-time 2-hour virtual visit. We also added one-on-one mentoring sessions between the IBD specialist and referring providers on a bimonthly basis to review all shared patients and quarterly webinars providing didactic teaching and case reviews with all providers. Results: To date, 161 patients (Table 1) with IBD have been seen at the Northern New England RADIUS hub. Six spoke sites in Maine and Vermont include 18 referring providers. Wait time between referral to a RADIUS visit is within 1 month as compared to 6 months for non-RADIUS IBD referrals. Average disease duration at time of referral has decreased from 32 years at RADIUS inception to 6 years currently. IBD-specific medication changes were made in 56% of patients. Qualitative referring provider and patient feedback was highly supportive of the new RADIUS care model. Conclusion: The RADIUS hub and spoke model has created an expanding rural health network providing comprehensive, multidisciplinary IBD care virtually to patients in Northern New England, while also collaborating with and educating Advanced Practice Providers. Using quality improvement methodology, we have co-developed a model with referring providers and patients to optimize the IBD care experience. Based on the early success of RADIUS, a second hub site has opened in Portland, Oregon with additional sites opening in 2023 in Colorado and Tennessee.Figure 1.: Iterative process to develop RADIUS (Rural APPs Delivering IBD Care in the United States) program with hub and spoke map of Northern New England. Table 1. - Patient Demographics in the RADIUS (Rural APPs Delivering IBD Care in the United States) Program Characteristics Age Median 49 years (range 17 – 85) Sex 57% female43% male Crohn’s disease n = 106 patients (65.8%)Disease location:Ileal: 27 patients (25%)Colonic: 35 patients (33%)Ileocolonic: 42 patients (40%)Ileocolonic and upper GI tract: 2 patients (2%)Perianal disease: 25 patients (24%)Disease Behavior:Inflammatory: 52 patients (49%)Stricturing: 34 patients (32%)Penetrating: 10 patients (9.5%)Stricturing and penetrating: 10 patients (9.5%)Perianal disease: 25 patients (24%) Ulcerative colitis n = 52 patients (32.3%)Disease locationProctitis: 2 patients (4%)Left sided: 19 patients (36%)Extensive: 31 patients (60%) Other IBD IBD unclassified: 2 patients (1.2%)Collagenous Colitis: 1 patient (0.6%) Rurality classification for RADIUS patients Small town/isolated rural: 44%Large rural town: 41%Urban core: 8%Suburban: 7% Distance from patient’s home to hub site Median: 130.6 milesFarthest: 306.5 miles Patient’s home state Maine: 61%Vermont: 30%New hampshire: 9%