By
A NICU nurse from a local hospital brought her child to my clinic for a plagiocephaly evaluation. She explained that attending one of my cranial education presentations prompted her to have her child’s head shape evaluated. To my surprise, she told me that it was the first time that head shape deformities were presented to her NICU group, and there have been countless babies through their department with cranial deformities that went untreated.
Ultimately her child was diagnosed with plagiocephaly, underwent cranial remolding orthosis (CRO) treatment, and the outcome was excellent. From that point on, her department has been an excellent referral source and proponent for cranial remolding efforts.
Cranial remolding treatment saw a rapid increase in the 90s due to the Back to Sleep campaign from the American Academy of Pediatrics to reduce sudden infant death syndrome. As a result, most healthcare providers have accepted CROs as the gold standard for treatment of head shape deformities when conservative efforts have been exhausted. However, most medical professionals sending patients to cranial orthotists have limited knowledge about identifying and quantifying the level of severity and the appropriate treatment options. Too often the parents’ concerns are downplayed, or they are encouraged to try repositioning until it is too late to correct the deformity. So how can we better target our educational efforts to ensure that these referral sources are better informed? The lack of education around cranial deformities in medical colleges creates an opportunity for orthotists to share their knowledge on the subject and establish a sphere of influence within their referral network.
In this article, I will share how education of future referral sources benefits the entire team involved in the cranial remolding treatment process, the program I developed for education, and the results my program has gotten.
Becoming a Resource for Referrals
Throughout my O&P career, I have been fortunate to work with some amazing individuals at the top of their fields. One such individual was Tom DiBello, CO/L, FAAOP, who was my mentor as I cut my teeth in O&P. At the time, he was the owner of Dynamic Orthotics and Prosthetics, Texas, with multiple locations and a stellar reputation among referral sources, especially pediatrics. Tom had a genius approach to building an O&P practice that was not only successful but had a component that would provide sustainability. One day I asked him what made his approach different and his secret to success. He explained that being a great clinician with a solid business plan isn’t enough to be successful in today’s competitive environment. “Clinicians must become a resource for their referring physicians and therapists,” he said. “Anyone can sell a device; you must sell the value you bring to the team: service, professionalism, and clinical competency. One way to do that is by staying up to date on the literature and to teach and educate any time the opportunity presents itself, both formally and informally.”
Benefits of Education
Every few weeks, our clinical liaison and I attend luncheons and short meetings with referral sources to better inform them about our cranial remolding clinic. The efforts are educational but are most often part of new business development with the intention of expanding our referrals and increasing revenue. Staying true to Tom’s approach, it is imperative to meet with your referral sources to have such conversations, but I chose to expand my educational efforts to another level without the business development aspect. My goal was to have more time in a classroom setting where the content could be presented in a more organized and thorough fashion.
My initial instruction was to medical students in the department of Physical Medicine and Rehabilitation in the Long School of Medicine at the University of Texas. The content was well received, and interest in the education I was providing began to grow. Fast forward five years and I am now regularly instructing there for physical medicine and rehabilitation, physical therapy, and nurse practitioner students, and as a guest lecturer in the Department of Pediatrics, and soon in the School of Nursing.
The cranial remolding education program that started small is now integrated and part of the curriculum in the above departments; however, it is time-consuming and unpaid. Regardless, educating the students is rewarding, and interest has grown substantially as the programs ask for more of my time and commitment. The program is a hit.
This type of education provides a mutual benefit for the cranial orthotist and the referral source. Knowing the overall treatment protocols for cranial remolding gives any medical professional within a pediatric setting a skill that separates him or her from the competition. This makes it easier for concerned parents to find a team of specialists who can provide quality care in a timely manner. The resulting improvement of continuity of care is consistency in communication, resulting in earlier detection, improved compliance, and optimal outcomes, all thanks to a simple education program.
The Program
My program is separated into four modules. The depth of the content can easily be tailored based on the allotted time and the audience receiving the instruction. Based on staff/student availability, the modules are scalable for everything from a simple one-hour presentation to a multimonth residency program.
Terminology/Anatomy
In the initial module, we build the knowledge foundation through terminology, anatomy, and landmarks, as well as how the cranium grows biomechanically. The goal is to make sure that we communicate with consistency to ensure the correct diagnosis.
Cranial Remolding Overview
We want to ensure the evaluator has an idea about the frequency of cranial deformities and how often he or she will see these patients. This section covers the history of cranial shaping as well as the effects of the Back to Sleep program, supporting literature, and in what situations cranial deformities can occur more frequently. Other content includes the rate of growth and what ages are most effective for reshaping.
Evaluation/Clinical Identification
The third section breaks down the evaluation process and how to correctly identify the difference between positional deformities and craniosynostosis. This entails instruction on anthropometric measurements so the providers can make evaluations in their practices and interpret digital scans. The goal is to ensure the provider has enough knowledge to make an educated decision whether to send the patient for more in-depth analysis or try repositioning methods as a more conservative approach. We spend some time in this section on torticollis but reinforce that physical therapists will ultimately decide if therapy is required or not.
Treatment
Though the orthotist spends the most time with the patient for cranial remolding therapy, it is very important for the referral to know what the treatment entails. In this section we look at every aspect of treatment, from the proper diagnosis codes and prescription details to insurance coverage. We break down wearing schedules and overall treatment timelines that the parents can expect based on severity and age. Other topics include frequently asked questions about topics such as contraindications, compliance, skin issues, and various challenges that may be prevalent with remolding treatment protocols. For students who are passionate about cranial remolding, I have expanded the instructions to include rotations through my clinic for a hands-on approach and to better instill the content they have learned through the classroom instruction. I am currently in discussions with administration to launch a cranial remolding certification within the medical school that will require a set number of classroom hours along with clinical rotations that will result in added value to the student’s education.
Results
Since educating my referral sources, I have found that patients with positional deformities are being sent at a much younger age than before, which is a critical component in achieving the best results. For example, I am seeing patients at two to four months of age, which allows me time to reposition in hopes that conservative treatment can correct the deformity to within normal limits. In the past, patients were typically older than eight months of age, which eliminated repositioning and led directly to CRO treatment due to slower growth.
I also see patients for craniosynostosis evaluations under four months of age where before they may have been five to ten months of age. When craniosynostosis is present, most surgeons can operate endoscopically to remove the fused suture up to four months of age, however, patients older than four months will likely wait until ten or more months of age and have open cranial vault surgery, which presents more challenges.
Continuity of care is also a significant benefit to educating medical professionals as the foundation of knowledge is shared across the team. There is much overlap for team members when treating a positional deformity. For example, the physical therapist may be treating a patient for torticollis at the same time cranial remolding therapy is taking place with the orthotist. All of this is under the umbrella of treatment from the pediatrician who has referred both specialists. Former students who are now professionals often contact me to inform me of noncompliance or an improper fitting device because they share my goals for the treatment, further solidifying the importance for continuity of care.
Because my clinic is within the University of Texas Long School of Medicine, there is a sense of loyalty the students demonstrate as a result of receiving the content as part of their curriculum. They have a strong positive connection and commitment to the institution, often expressing this through positive word-of-mouth recommendations and a willingness to support its initiatives and reputation. As a result, they feel a sense of belonging and pride in being associated with our cranial remolding clinic and make referrals in the spirit of supporting the development and educational efforts that take place within my clinic, which is priceless.
Conclusion
Educating your referral sources ensures that the patients receive consistent and coordinated medical attention throughout their treatment. This leads to earlier intervention, more accurate diagnoses, continuity of care, and better outcomes. When referral sources feel confident in your expertise and integrity, they are more likely to recommend your services to others. This trust not only strengthens current partnerships but also attracts new clients, resulting in the longevity of your practice.
Jim Brookshier, MPO, CPO/LO, FAAOP, is a member of the Academy’s Craniofacial Society.
