title: Within-team Patterns of Communication and Referral in Multimodal Treatment of Chronic Low Back Pain Patients by an Integrative Care Team.
abstract: BACKGROUND
  Nonspecific chronic low back pain (CLBP) is a highly prevalent and costly public health problem with few treatment options that provide consistent and greater than modest benefits. Treatment of CLBP is shifting from unimodal to multimodal and multidisciplinary approaches, including biopsychosocially-based complementary and integrative care. Multidisciplinary approaches require unique levels of communication and coordination amongst clinicians; however, to date few studies have evaluated patterns of communication and decision making amongst clinicians collaborating in the care of challenging patients with CLBP.
  
  
  METHODS
  As part of an observational study evaluating the effectiveness and cost-effectiveness of an integrative, team-based care model for the treatment of CLBP, we used multiple qualitative research methods to characterize within-team cross-referral and communication amongst jointly-trained practitioners representing diverse biomedical and complementary disciplines. Patterns of communication and coordinated care are summarized for 3 cases of CLBP treated by multiple members (≥3) of an integrative medical team embedded within an academic hospital.
  
  
  RESULTS
  Patients were aged from 36 to 88 years with varied comorbidities. Qualitative content analysis revealed 5 emergent themes regarding integrative patient care and treatment decision in this clinic: (1) the fundamental importance of the clinic's formal teamwork training; (2) the critical communicative and collaborative function of regular team meetings; (3) the importance to patient care goals of having the varied disciplines practicing "under one roof"; (4) a universal commitment to understanding and treating patients as whole persons; and (5) a shared philosophy of helping patients to help themselves. These key themes are all interconnected and form the foundation of the clinic's culture.
  
  
  CONCLUSIONS
  Our qualitative findings provide context for current trends in enhancing patient-centered, coordinated, and team-based care; efforts towards better understanding interprofessional communication; overcoming barriers to successful collaboration; and identifying best practices for fostering clinical teamwork and a strong team identity. Our findings also support the need for further qualitative research, in combination with quantitative research, for evaluating the effectiveness and cost-effectiveness of resource-intensive integrative models for the treatment of chronic conditions.
authors.affiliation: Osher Center for Integrative Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts (Dr O'Connor), United States.
authors.forename: Bonnie B
authors.initials: BB
authors.lastname: O'Connor
authors.affiliation: Samueli Institute, Alexandria, Virginia, and Department of Nutrition, Harvard School of Public Health (Dr Eisenberg), United States.
authors.forename: David M
authors.initials: DM
authors.lastname: Eisenberg
authors.affiliation: Division of Preventive Medicine, Brigham and Women's Hospital (Dr Buring), United States.
authors.forename: Julie E
authors.initials: JE
authors.lastname: Buring
authors.affiliation: Osher Center for Integrative Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts (Ms Liang), United States.
authors.forename: Catherine L
authors.initials: CL
authors.lastname: Liang
authors.affiliation: Osher Center for Integrative Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts (Ms Osypiuk), United States.
authors.forename: Kamila
authors.initials: K
authors.lastname: Osypiuk
authors.affiliation: Osher Center for Integrative Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts (Dr Levy), United States.
authors.forename: Donald B
authors.initials: DB
authors.lastname: Levy
authors.affiliation: Osher Center for Integrative Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts (Dr Wayne), United States.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Wayne
keywords: Clinician communication; back pain; collaborative care; coordinated care; qualitative research