Over the years, the idea of incorporating maintenance care has garnered a lot of attention among chiropractors.
Maintenance care is long-term, wellness-based services such as regular adjusting, stretching, and massage, in addition to or in place of care for acute conditions.
While many believe maintenance care provides significant, measurable benefits to patients, others think it doesn’t offer any real value because patients may be paying for services they simply don’t need.
“Acute care has, at its core, the expectation of significant improvement in both subjective and objective symptoms, and that’s according to Medicare,” says Mark Sanna, DC, a practice management consulting and coaching expert who focuses on preparing chiropractors to become the primary providers of prevention and wellness services in today’s healthcare arena. “Maintenance care, on the other hand, is a level of care at which we do not expect any type of symptoms to significantly improve; our acute care has achieved its maximum effect, and once we have reached that plateau and patients level off, it is maintained at that particular level,” he says.
The case for care
According to two research studies published in 2011, there is solid evidence in support of the value of maintenance care. The first, published in Spine, concluded that “SMT (spinal manipulation therapy) is effective for the treatment of chronic non-specific LBP (low-back pain).” To obtain long- term benefit, this study suggested maintenance spinal manipulations after the initial intensive manipulative therapy treating an acute condition.1
The second study, published in the Journal of Occupational and Environmental Medicine, provides additional support for the value of chiropractic maintenance care for post injury low-back pain patients. The study cohort was 894 injured workers, who were followed for one year.
Physical therapy was shown to have the highest percentage of reinjured workers, followed by those receiving standard medical treatment (or no treatment at all).2
“The lowest incidence of repeat injury was found among those workers who had received chiropractic maintenance care.”
In a summary of study findings published at ChiroACCESS, the results of surveys given to chiropractors have verified the profession’s belief in the value of maintenance care. The authors conclude: “Furthermore, during the last decade there have been a dozen peer reviewed papers on the subject…it is heartening to see medical research corroborate the studies and beliefs of the chiropractic profession.”3
So, what do today’s chiropractors think about maintenance care? Is it helping patients maintain a demonstrably higher quality of life? Is long- term wellness care providing opportunities for building a patient base and revenue that otherwise would not have been possible and, if so, is that a good thing? Here, we asked three professionals their opinions about and experience with incorporating maintenance care into a chiropractic practice.
Validating patient values
Jay S. Greenstein, DC, CCSP, founder and CEO of a large integrated practice group, says the decision to transition to a maintenance care practice model should depend on your patients’ goals. Greenstein’s practice consists of six chiropractic, physical therapy, and rehabilitation clinics; a wellness company for post-rehabilitation; a clinical research foundation to study best outcomes; a consulting company that does business and leadership coaching for chiropractors; and clinical training and partnerships with technology companies to help them grow in the physical therapy and chiropractic marketplaces.
“There are chiropractors who practice the maintenance care philosophy, and there are those who don’t, but it should all depend on patients’ values,” Greenstein says. “Patients who appreciate the impact of regular chiropractic care should find healthcare providers who align with those values. Of course, there are those patients who only want to see a chiropractor on an as-needed basis, too.”
Greenstein points out that maintenance care—a prevention-focused wellness service—is different from supportive care, which involves ongoing care for a chronic condition. He also says that the two abovementioned studies provide solid evidence for the benefits of the former.
“There has been good evidence that looks at the impact of maintenance care and shows it to improve outcomes, but we still need more evidence,” Greenstein says. “The challenge we face as health- care professionals is that there is not an overwhelming amount of evidence right now.”
For chiropractors considering transitioning to a maintenance care model in their practices, Greenstein cautions against two things: “Sometimes, when chiropractors are recommending maintenance care, it is a financial decision,” he says. “It’s not a good idea to provide this care strictly for financial benefit.
Watch out for financial motivation— your reputation will catch up with you.” He stresses the importance of developing a reputation for providing services with integrity.
“Also, at the end of the day, it’s about providers making evidence-based recommendations that align with patients’ values, and if patients trust that provider that deepens the relation- ship,” he says. “This is opposed to saying, ‘You need to come in’ as a scare tactic, because that damages the profession and provides nothing of value to the patient.”
Greenstein also recommends that you do your homework before turning to maintenance care in your practice.
First, make a study of the current evidence, and then explain it to patients. Collect your own individual data as well to show that maintenance care offers benefits. This is a significant opportunity for chiropractors and you have a chance to own the wellness space. “But that requires a certain amount of evidence, so anything you can do to contribute to demonstrate the value of wellness and maintenance care will benefit the entire industry and the patients we serve,” he says.
A nuanced approach
Nicole L. Ingrando, DC, founder of North Orlando Spine Center in Longwood, Florida, is a proponent of maintenance care in the chiropractic practice, but only when it makes sense for the patient in question.
“When we were in school, there used to be polar-opposite thoughts: That the majority of patients we see will be acute—and that is absolutely the case—but on the other side of the coin were chiropractors saying that even though the patient feels better, it is financially beneficial to us to have them keep coming in,” she says.
“At the time, I violently opposed that last view, because it is hard to sell a patient on something they don’t necessarily need,” she continues. “After all, if you were to actually look at the statistics on why patients go to a chiropractor, there is always a complaint attached to it. There is something dominating and dictating their life negatively.”
These days, however, Ingrando sees the benefits that maintenance care can provide, on the condition that the treatment is customized to each patient (so that they see the positive impact such therapy can offer).
“The body will always require maintenance, but maintenance care must be individualized,” she says. “Knowing what to strengthen and what to treat is highly variable for each patient. Can patients do it on their own? Absolutely. But we as chiropractors can teach them what to do so that they can continue to ask their bodies to do what they want them to do.”
Ingrando still defies one thought about maintenance care that she says ultimately damages the healthcare provider-patient relationship.
“I am not a proponent of the economics of maintenance care,” she says. “People don’t want to be sold something they don’t need. I wish the insurance companies would cover
maintenance care more, because the better we maintain ourselves, the more we can avoid unnecessary surgeries. But to tell patients that they will not be healthy if they don’t get cracked by me regularly is not ethical. I’m not a fan of selling them something they really don’t need.”
According to Ingrando, personalized care for every patient begins with one simple change: taking the time each patient needs to realize the benefits of therapy, whether it be maintenance or acute care.
“The biggest advice I have for chiropractors considering maintenance care would be to create a business model that allows you to spend more time with patients,” she says. “A cookie- cutter approach to helping patients, even with maintenance care, will probably not be effective. Everyone requires different stretches and different strength exercises.
“We will have, at any given time, pain that we can treat, and if we can help patients and empower them, why wouldn’t they tell the world?” she adds. “But patients do not want to be scared into dependency, they want to understand their pain.”
Sanna sees one of the drawbacks of maintenance care arising with chiropractors themselves.
“One of the pitfalls of maintenance care is that chiropractors don’t understand the difference between it and acute care,” he explains. “While maintenance care is extremely beneficial for patients, no insurance covers it, and a lot of chiropractors are confused about this, especially with Medicare patients. They wonder, ‘Why is maintenance care not covered?’”
In the long run, from a provider’s perspective, maintenance care is a tremendous benefit as it can help people ward off problems down the road. “Patients are less likely to go into an assisted care facility, and they are more self-reliant and less likely to use prescription drugs. So chiropractors have to learn when patients are showing significant improvement in signs and symptoms and when they have reached that plateau for benefits in acute care. That’s when it is time to move to maintenance care,” Sanna says.
An interesting correlation exists between patients who have insurance and those who embrace the benefits of chiropractic maintenance care. In other words, these patients are one and the same.
“Some patients who do have insurance might also have a $5,000 to $10,000 deductible, so they are making much more educated decisions about where to spend their healthcare dollars,” he explains. “When someone has made their own investment to pay for acute care, they want to protect that investment by undergoing maintenance care.” He encourages chiropractors to let patients know about wellness care right in the beginning of the acute episode of care. Let them know the long-term health benefits of undergoing maintenance care so that they can maximize their healthcare dollars.
Those looking to implement a maintenance-care model in their practices need to establish criteria for care that support these types of services. “The criterion for acute care that DCs utilize is pain; when the pain goes away, the patient goes away. We know in the healing process that it could take weeks or months once pain has gone away for the patient to achieve full function,” Sanna says.
Therefore, he recommends that chiropractors have criteria for care beyond pain relief. This can include using outcome assessment questionnaires, measuring flexibility and range of motion, assessing posture and working to restore the curvature of the spine, and then retraining muscles.
The ability to communicate the benefits of maintenance care to patients is important as well. “Once you have established criteria for care, then we want you to be able to communicate those criteria to patients in plain language, in a way that is understandable and motivates patients to see the benefits of maintenance care,” Sanna says.
A model of stability
Maintenance care has long-term benefits for the patient, but it is also wonderful for the business side of a practice. As Sanna sees it, “If you have an acute care practice, the average patient comes in for less than 12 visits and you’re on a never-ending treadmill to find more new patients.” When he has someone who sees the “big picture” of health, that patient may see him 80 to 100 times over their lifetime, and that makes for a stable practice. In addition, these patients refer him to others and become part of his practice family. The value and stability of your practice can be vastly improved with this type of model.
Ultimately, it’s up the individual chiropractor to determine whether implementing a maintenance-care and wellness practice model is a good idea. Start by evaluating your personal values with regard to healthcare and listen to your patients’ desires. These seem to be the essential determiners when evaluating whether maintenance care is an appropriate practice model for you.
Amy Stankiewicz is a freelance writer based in Cleveland. She has written for trade publications for more than 15 years. She can be contacted at email@example.com.
1 MK, Machaly SA. Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome? Spine. 2011;36(18):1427-37.
2 Cifuentes M, Willetts J, Wasiak R. Health maintenance care in work-related low back pain and its association with disability recurrence. J Occup Environ Med. 2011;53(4):396-404.
3 ChiroACESS. “Medical Research Supports Chiropractic Maintenance Care.” http://www.chiroaccess.com/Articles/Medical- Research-Supports-Chiropractic-Maintenance- Care.aspx. Published April 2011. Accessed February 2017.