The
Collaborative-Care Model
Pain to Performance advocates for a collaborative-care pathway in which medical, surgical, rehabilitative, and non-medical services remain scoped but connected through clearly defined roles, planned transitions, and relevant professional communication.
Page Contents
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Introduction
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How the Model Works
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Defined Professional Roles
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Points of Entry
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Example Pathways
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Practical Requirements
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Value-Based Alignment
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Connect With Pain to Performance
Downloads
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Introduction
The Collaborative-Care Model is a practical framework for connecting the different stages of an individual’s spine-care and return-to-function pathway. The model does not require every individual to work with every professional. It applies when a patient’s needs extend across medical evaluation, surgical care, licensed rehabilitation, self-management, and preparation for higher physical demands.
Each professional retains responsibility for their own area of practice. The purpose of collaboration is to create clearer transitions, preserve useful information, and reduce the likelihood that the patient is left to independently reconcile disconnected recommendations or determine what should happen next.
This page explains how that collaboration can function. Referral suitability and pathway-specific criteria remain available on the Best-Fit Referrals and individual referral pages.
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How the Model Works
Collaboration does not require every provider to manage the entire pathway. It requires each provider to clearly understand their own role, the role of the other professionals involved, and when responsibility should transition.
Defined Roles / Positions / Deliverables: Each professional remains responsible for the portion of the pathway that falls within their education, licensure, expertise, and scope.
Planned Staged Transitions: When the patient is expected to move from one phase of care into another, the next step can be identified before the current phase ends.
All Relevant Information Moves Forward With the Patient, Through the Spine-Care Continuum: this includes, surgical history, rehabilitation findings, precautions, mechanical observations, functional limitations, and remaining goals can be communicated to the professional assuming the next responsibility.
Communication Flows Reciprocally: Pain to Performance will communicate assessment findings, progress, limitations, or meaningful changes back to the appropriate referring / attending medical, surgical, or rehabilitation professional.
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Defined Professional Roles
Medical and Surgical Team: The medical and surgical team remains responsible for medical diagnosis, diagnostic investigation, medical risk assessment, treatment decisions, surgical candidacy, operative care, postoperative medical oversight, and concerns requiring further clinical investigation.
Physical Therapist and Licensed Rehabilitation Provider: The rehabilitation provider manages the clinical and functional priorities appropriate to the episode of care. This may include postoperative rehabilitation, symptom management, foundational movement, early loading tolerance, therapeutic exercise, and preparation for discharge.
Pain to Performance: P2P contributes detailed mechanical and functional assessment within a defined non-medical scope. Our role may include patient education, daily movement and exposure management, spine-sparing strategies, individualized corrective exercise, physical rebuilding, and preparation for occupational, fitness, recreational, or athletic demands.
The Individual: The individual remains an active participant throughout the pathway. Their responsibilities include communication, adherence, self-management, tracking relevant responses, and reporting meaningful changes in symptoms or function.
Other Involved Professionals: Primary care physicians, physiatrists, chiropractors, pain-management providers, athletic trainers, and other professionals may contribute within their respective roles when their involvement is appropriate to the individual’s presentation.
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Pain to Performance's Points of Entry
Pain to Performance's expertise may enter at different episodes of spine-care continuum depending on the objectives of the medical and surgical team and the individual's most urgent point of need.
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When continued conservative management has been recommended and greater mechanical clarity may be useful;
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When a spine surgeon wants additional mechanical and functional context while determining the appropriate next step;
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Before surgery to document relevant preoperative symptom behavior and functional tolerance;
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after postoperative physical therapy has been completed;
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after surgery when formal physical therapy was not prescribed and the individual is medically appropriate;
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after rehabilitation when basic function has returned but higher physical demands remain;
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or when an active individual requires a structured return to work, exercise, fitness, recreation, or sport.
Review the Five Referral Pathways
5 | Collaborative-Care Pathways
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Alignment With Value-Based Care Principles
The Collaborative-Care Model is aligned with several practical principles associated with value-based care:
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the appropriate service provided at the appropriate stage;
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clearly assigned professional responsibility;
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person-centered goals;
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continuity across transitions;
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useful professional communication;
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avoidance of unnecessary duplication;
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and attention to meaningful functional outcomes.
Pain to Performance does not present this framework as a formal reimbursement or shared-risk model. It is an operational approach intended to support more connected, accountable, and person-centered care within the respective boundaries of each professional involved.
For a more detailed discussion of the care-delivery rationale behind this read the Pain to Performance Position Statement
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Requirements for Collaboration
Collaboration can remain proportionate to the individual’s needs. In some cases, a report and clearly defined handoff may be sufficient. In others, periodic communication may be warranted.
What the Model Requires for Effective Collaboration:
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clearly defined professional roles;
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agreement regarding which professional currently holds responsibility;
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appropriate authorization for communication;
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relevant information moving forward with the individual;
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a defined point for transition into the next phase;
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and communication when the presentation changes or exceeds the receiving professional’s scope.
What the Model Does Not Require
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all professionals to work within one organization;
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a formal contractual referral agreement;
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every patient to see every type of provider;
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the surgeon or physician to approve every coaching decision;
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the rehabilitation provider to remain involved indefinitely;
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Pain to Performance to participate during the immediate medical or postoperative phase.
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Connect With Pain to Performance
A clinician does not need to establish a formal collaborative arrangement before recommending Pain to Performance.
The first step may be as simple as:
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giving an appropriate individual Pain to Performance’s information;
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requesting a brief professional conversation;
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discussing a de-identified clinical scenario;
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or planning a future post-rehabilitation handoff.
Request a Professional Conversation
How to Connect a Patient
Review Best-Fit Referrals