Dermatology and Rheumatology Collaboration: Improving Outcomes and Satisfaction
Formally-Combined Rheumatology-Dermatology Clinics:
Despite being relatively new to the psoriatic disease landscape, combined Rheumatology-Dermatology clinics have shown significant promise as it relates to patient outcomes, provider satisfaction, and patient satisfaction. A formally-combined clinic consists of rheumatology and dermatology providers who work together, in a shared space, and see patients together on the same day. Essentially a “one-stop shop” for patients, it is a streamlined approach to care delivery and often results in more timely initiation of treatment strategies that can halt further joint damage or cutaneous involvement. Patient convenience is an obvious benefit to this approach, but there are some other advantages:
1. Having experts in both disciplines collaborating in real time enhances patients understanding of the complexity of their disease--which in turn increases treatment compliance.
2. Each discipline can proficiently manage their respective domain, rather than attempting to manage beyond their scope of expertise.
3. All aspects of the disease are addressed simultaneously and considered when creating a tailored treatment plan.
These real-time combined clinics primarily exist at academic health centers, which further offer an enhanced learning experience to trainees as well as private practice dermatologists and rheumatologists. This collaborative educational approach has positive downstream benefits as it aids in better preparing providers to recognize the nuances of the disease as well as various management approaches. In short, earlier identification of PsA, enhanced comorbidity screening and education of psoriatic disease, and more timely initiation of biologic drugs are some of the positive outcomes associated with combined Rheumatology-Dermatology clinics.
Barriers to establishing a formal Rheumatology-Dermatology clinic mainly center around logistics as it relates to scheduling, co-pays, and reimbursement. These formal clinics meet either weekly or monthly, thus limiting the number of available visits. Coordinating the schedules of various providers and patients to meet on a weekly or monthly basis can be tedious and is often the main limiting factor. Due to the collaborative, multidisciplinary approach, visits tend to be longer and thus do not allow the same number of patients to be seen in a given day, thus it is viewed as a cost inefficient model to healthcare administrators focused on revenue generation. Insurance reimbursement also proves to be challenging with many payors still requiring patients to submit two separate copays.
Neighboring Collaboration Between Rheumatology and Dermatology Clinics:
Most of us do not practice in a formal combined Rheumatology-Dermatology clinic but we understand the importance of collaboration as it pertains to psoriatic disease. My clinic includes neighboring groups of rheumatology and dermatology providers who specialize in psoriatic disease. We see patients asynchronously but have established a strong referral system between our respective groups. It is often comforting to patients to hear that they are being referred to a fellow specialist and that they will not need to wait months to be seen. In our dermatology practice we have identified the following best practices when it comes to caring for our psoriasis patients:
1. We never let a psoriasis patient leave the exam room without asking about their joints. A large majority of patients who develop PsA present with skin findings first, so joint symptom screening happens at every visit, without exception. A positive joint screening triggers an automatic referral to rheumatology.
2. We empower our patients with knowledge through educating them about psoriatic disease comorbidities. The importance of establishing care with a PCP is stressed to the patient so that screening for common comorbidities such as hypertension, diabetes, hyperlipidemia and cardiovascular disease can be addressed at recommended intervals.
3. Last, but certainly not least, all our patients are screened for depression, as we know that depression, anxiety and suicidality affect a greater proportion of our psoriatic patient population compared to their non-psoriatic counterparts.
Outside of the exam room, our group promotes collaboration and communication across specialties. We prioritize education of trainees, physicians, advanced practice providers and nurses through clinic-based education--but also through participation in formal educational programs sponsored by organizations such as the Rheumatology Nurses Society, Dermatology Nurses Association, Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network, and the National Psoriasis Foundation.
Local and Remote Rheumatology and Dermatology Collaboration
For the majority of dermatology and rheumatology providers, collaboration is neither in real-time, nor on the same hall or building. Referrals can take weeks to months, and may be many miles away. In these all-to-common scenarios, cooperation and coordination is still possible but it will require communication. Do you know the providers at the referral sites? Have you driven to their clinic(s) to introduce yourself to the MDs, NPs, PAs, and staff? Putting a face to the voice on the phone is important! This worthwhile endeavor initiates a team mentality. Exchange contact information, talk about the consultation process in your clinic, and gain a better understanding of their patient volume and schedule restraints. Never criticize referral wait times, but rather, ask about labs, tests, and information you can obtain prior to the referral--so that the initial evaluation can be more thorough and effective. Invite them to visit and tour your facility and make a commitment to add “urgent” evaluations to your schedule within 1-2 days.
Additionally, perhaps you and your local rheumatology provider can connect on the phone (or Zoom) bimonthly or monthly for a 20-minute grand round session? Difficult patients and upcoming referrals can be discussed? Collegial respect can be built, education increases for both parties, and patients love knowing that while a referral could be months away, their case will be discussed within the next few days or weeks. These types of endeavors may not work in every town or city, but the key is to think creatively about building relationships with key referral sites. You may have to be the initiator and you will likely need to be pleasantly persistent in establishing professional communications. Everyone is busy, but our patients deserve it and will ultimately benefit from these collaborative efforts.
In summary, caring for patients with psoriatic disease is best achieved through a collaborative, patient-focused approach. This can be achieved through formal Rheumatology-Dermatology clinics or informal collaborations between rheumatology and dermatology providers. The systemic, multisystem nature of psoriatic disease and its comorbidities warrants each of us to look at our respective practices to see where the gaps in care delivery exist and how we can better collaborate. Closing these gaps can minimize delays in diagnoses and maximize patient outcomes, ultimately improving the lives of our patients with psoriatic disease.
Veronica Richardson ANP-BC, DCNP is a dermatology certified nurse practitioner at the Perelman Center for Advanced Medicine at the University of Pennsylvania in Philadelphia, PA. She sees general dermatology patients and has passion for NP/PA education. Outside of work she enjoys spending time with her husband snowboarding, paddleboarding and traveling.