Many Hands

January 29, 2015
What's the best way to deliver athletic training coverage and sports medicine care in the 21st century? A large-scale model, outlined here, may be an answer.
By Mitch Bellamy

Mitch Bellamy, MS, ATC, is the Assistant Director of Sports Medicine and Athletic Training at the Vanderbilt Orthopaedic Institute, where he has been employed since 2004. He has previously worked at Belmont University and Marshall University and can be reached at: [email protected].


Every athlete should have access to an athletic trainer while participating in sport. Among sports medicine professionals, that statement is neither controversial nor debated. We all know that athletes who do not have access to athletic training services are at a greater risk for injuries and miss out on many health-related services.

The question of how to best deliver that access is not as straightforward. In a time of tight budgets, ensuring every athlete has sports medicine coverage can be difficult. There is not one perfect model or easy, inexpensive solution.

Here at Vanderbilt Sports Medicine, a division of Vanderbilt University Medical Center's Orthopaedic Institute, we've developed a way to provide athletic training services to a large and varied population in a somewhat nontraditional way. The model has been 20 years in the making, and it won't work everywhere, but it has proven to have many benefits for both athletes and the athletic trainers who work with them. It may also be the wave of the future.

HOW IT WORKS
Vanderbilt Sports Medicine began when the leadership of the Vanderbilt University Medical Center (VUMC) approached the athletic department at Vanderbilt University with a proposal to provide sports medicine coverage for its teams. Previously, University athletics employed its own athletic trainers and utilized an outside physician group for medical consultations.

VUMC would supply a team of athletic trainers to cover all traditional services, from injury prevention to rehabilitation. The partnership would also allow athletes to receive care from faculty members in the Department of Orthopaedic Surgery and Rehabilitation as well as other clinical departments at VUMC. The idea was approved and is basically the same model we still use today.

The intra-university partnership with Vanderbilt athletics proved to work well, and Vanderbilt Sports Medicine has grown in many ways since then. We began offering services to local high schools in 1995, and then added everything from youth to pro teams. When Kurt Spindler, MD, became Director of Sports Medicine in 1991, he was just the second faculty member in the division, which handled about 1,100 annual patient visits. Today, there are 14 faculty members, more than 40,000 annual visits, and $1.5 million awarded in research funding.

In addition to Vanderbilt athletics, Vanderbilt Sports Medicine now provides coverage to Belmont University athletics and 28 high schools in middle Tennessee. It is also the official sports medicine provider for the Nashville Predators (NHL) and the Nashville Sounds (Triple-A affiliate of the Milwaukee Brewers), as well as the Tennessee Secondary School Athletic Association (TSSAA).

The top of our organizational structure uses a paired leadership model consisting of myself as a director-level athletic trainer and Dr. Spindler as our Physician Medical Director, who is also the Director of the Division of Sports Medicine. We work in partnership to oversee the program, which entails making sure everything runs smoothly day to day and that we are providing top-notch services to all of our athletes and patients. Our big-picture focus is on clinical care delivery, quality assurance, and maintaining relationships with the community and coaches.

In my role, I perform administrative oversight for our athletic training services, which includes monitoring and evaluating the care we are providing, business development, strategic planning, budgeting, coverage when needed, and staffing. I also work with our leadership team of five athletic trainers who are responsible for specific units: Vanderbilt athletics (Head Athletic Trainer, Assistant Manager), Belmont athletics (Head Athletic Trainer), and high school outreach (two Assistant Managers, each of whom oversees a county). Our staff athletic trainers are assigned to one of these teams.

Each unit also has a physician leader who works with Dr. Spindler and our team of doctors. All are fellowship trained and their expertise covers several different sub-specialties, including orthopedic surgery, pediatrics, internal medicine, emergency medicine, and primary care. Staff physicians perform preparticipation physicals, hold clinics in the athletic training rooms to evaluate injured and sick athletes, cover games, and are on-call around the clock.

An important aspect of our model is the relationship between the athletic trainers and physicians. Athletic trainers do not need to go to one doctor for an orthopedic concern and then another for a general medicine issue. Instead, the team coalesces to provide care. Our staff's love of sport and commitment to the welfare of the athlete keeps the group aligned and the program successful.

To best serve our clients, we have developed separate coverage models for each level of competition. This allows us to provide services based on what each type of team needs.

Professional Organizations: Our team of physicians is responsible for the coverage of the two professional sports teams we have agreements with. These organizations contract with us for physicians to cover their games but utilize their own staff of athletic trainers.

Collegiate: The unit that covers Vanderbilt athletics functions as a traditional collegiate athletic training staff and does not provide services outside of Vanderbilt athletics. Their athletic training rooms are located within Vanderbilt athletics facilities. However, what makes this model unique is that the athletic trainers report up through Vanderbilt Sports Medicine and Vanderbilt University Medical Center instead of the University athletic department. (See "Ensuring Integrity," below.)

At Belmont, athletic trainers work out of traditional collegiate athletic training rooms located at the school. The group functions the same way as Vanderbilt's does, with athletic trainers reporting to Vanderbilt Sports Medicine.

High School: For our high school clients, we provide practice and game coverage for athletes and coaches during the school year. Treatment can range from something as simple as a bandage for a cut to rehabilitation for an ACL tear. Our high school athletic trainers perform clinical duties at VUMC in the mornings and are on-site at the high schools in the afternoon.

We provide one athletic trainer per high school. Each school is then grouped with three others and assigned a lead athletic trainer who oversees all four. This system enables us to quickly manage any staffing problems or conflicts, and complicated issues are quickly brought to an experienced leader. It also identifies a clear communication path for our team. Overall, we have found the structure provides nice flexibility for our staff, while still giving the high schools consistency in their health care providers.

Community Sports: Recently, one of our largest growth areas has been athletic training services for youth sports. With the potential for serious injuries occurring in youth sports and an increase in concussion awareness, local league administrators frequently seek to ensure their athletes have access to on-site medical care. This spurred us to create the Vanderbilt Sports Medicine Events Management Team, which is a fee-for-service model allowing local groups to obtain sports medical coverage with certified athletic trainers for any type of competition.

We currently have agreements in place with more than 35 youth organizations throughout middle Tennessee for a variety of sports including soccer, lacrosse, and football. Along with covering games, we assist in the development of site-specific emergency action plans and offer CPR/AED certification courses for coaching staffs. The Events Management Team is a way for us to serve as a community resource while also reinforcing our role as a comprehensive sports medicine provider.

We believe this outreach helped us secure our role as the sports medicine provider for the Tennessee Secondary School Athletic Association (TSSAA). In this relationship, Vanderbilt supplies athletic training coverage for Tennessee's state high school championship events.

COMMUNICATION & COLLABORATION
The key to covering all of the above schools and events is our team approach. This allows us to provide familiar faces to our athletes and coaches and maintain continuity of care. But it also requires that we communicate well among ourselves.

To do this, we have set up specific systems. Each team holds regular staff meetings connecting information at all levels. In addition, leaders from each group meet regularly to review, discuss, and update policies and procedures in areas such as post-concussion return-to-play and heat-related illnesses.

But some flexibility is necessary, too. We try to create an atmosphere where we have a foundation of protocols that pertain to everyone, but also allow each team to create its own identity and culture to meet the needs of its constituents.

Having such a large staff provides synergy and leads to exciting new ideas. Tom Bossung, MEd, ATC, Head Athletic Trainer for Vanderbilt athletics, says that the chance for dozens of athletic trainers to work for the same organization and learn from each other makes Vanderbilt Sports Medicine special.

"Even though my staff members and I work with Vanderbilt athletics, Belmont's staff is on another campus, and the high school outreach athletic trainers focus on their schools, we can come together under the umbrella of Vanderbilt Sports Medicine," Bossung explained in the Winter 2012 edition of Vanderbilt Orthopaedia. "This allows us to share ideas and form our own support groups. It makes us better medical professionals."

For example, the sport of lacrosse has grown in middle Tennessee, and we have become the sports medicine provider for several high school club teams. In the beginning, we utilized the knowledge and skills of one of our collegiate athletic trainers who had experience in lacrosse to help us review common injuries and helmet-removal techniques to ensure we were prepared.

Individuals on our staff also hold in-services for any new treatment technique, taping protocol, or evaluation skill they have learned. This provides continuing education opportunities and opens up best practice ideas to our entire athletic training staff.

Our work has also been boosted through collaborations with the information technology and research arms of VUMC. For example, we worked with them to develop an online documentation tool accessible from a computer, tablet device, or smartphone. Using drop-down menus, free text data fields, or dictation, an athletic trainer can record injury reports and daily notes, providing a confidential record of care. This has allowed our outreach athletic training staff to become more efficient and improved our overall documentation as a staff.

Another advantage of being employed by a medical center is the use of the electronic medical record (EMR). "Being able to utilize and access our athlete's EMR allows us to communicate with other providers across VUMC to make better decisions in the patient's plan of care," says Mollie Malone, MEd, ATC, Assistant Athletic Trainer and the Assistant Manager for Vanderbilt athletics. "This minimizes repeat and unnecessary testing."

And athletes and/or their parents then have access to our portal, My Health at Vanderbilt. This enables a patient to communicate with their health care provider, view their medical records, and quickly see any test results.

We have also benefited by the introduction of the CoachSmart app, a joint effort between Vanderbilt Sports Medicine and Monroe Carell Jr. Children's Hospital at Vanderbilt, which provides on-the-field information about lightning strikes in the area, as well as heat index information. The app also offers a FAQ section for coaches, athletic trainers, and parents on topics such as heat-related illnesses, proper treatment for sprains and strains, and warning signs related to concussions. Leveraging the resources of the Medical Center creates unique collaborations and deepens the professional tools available to our athletic trainers.

For Vanderbilt athletes specifically, we've used the many resources of a large medical center to create a Health Enhancement Committee. Members come from a variety of positions in the athletic department and on the sports medicine staff such as team physicians, athletic trainers, a dietitian, a sport psychologist, and athletic administrators, including the life skills coordinator. The goal of this group is to recognize any student-athlete issues that arise and address them through a multidisciplinary approach.

STAFF BENEFITS
What is it like to work for such a large sports medicine group? The biggest plus is being surrounded by all the resources of a large medical center. Our athletic trainers have avenues for professional development and opportunities to be involved in many areas of medicine.

To start, in addition to traditional practice and game coverage, our high school outreach athletic trainers are utilized in outpatient rehabilitation and physician clinics. These opportunities allow each athletic trainer to be involved in the entire care process, not just a part of the on-field or in-arena support team.

Another benefit for our high school athletic trainers is reasonable work hours due to our team coverage approach. Having a large staff gives our athletic trainers the ability to take time off during athletic seasons. In addition, we have resources available when coverage is needed for large tournaments. An athletic trainer assigned to the host school does not have to be on-site for the entire tournament. Instead, other staff members take shifts.

To make sure individuals don't get lost in the crowd of our large organization, our leadership team communicates regularly with all athletic training staff members. Every athletic trainer is evaluated annually on their performance, receiving structured feedback from management, coaches, and peers. This formal conversation provides an avenue for staff to discuss professional and developmental goals.

In addition, each member of the athletic training team completes annual competencies and quality assurance training in:

- concussions
- sideline emergency training
- general medical conditions (e.g. asthma, anaphylaxis)
- dental injuries
- environmental injuries (lightning and heat related)
- spine boarding and helmet removal
- injury documentation
- yearly team physician and sports medicine educational sessions.

Working in a world-renowned sports medicine program also pushes us to be the best health care professionals we can be. All of our physicians are involved in research and serve as faculty members in the Vanderbilt School of Medicine, while holding leadership positions locally and nationally. Through their example, staff athletic trainers are expected to not only stay current in their field but be educators and innovators.

For example, athletic trainers are provided the opportunity to partake in a career advancement program (CAP). Under CAP, each athletic trainer must complete additional requirements in patient care, advocacy, professional development, teaching, and research.

Athletic trainers also participate in physician conferences and medical resident lectures augmenting their knowledge base of musculoskeletal problems, treatments, and research. In addition, each year athletic trainers complete continuous quality improvement (CQI) projects, which usually have some research component to them. This evidence-based medical research may change our patient care practices and gives our staff a unique opportunity to present their findings to peers and other professional organizations.

One of our most recent outcomes from a CQI project was the development of our collegiate concussion protocol. It provides sports-specific return-to-play procedures for college athletes and was a collaboration among athletic trainers, sports medicine physicians, and VUMC's Department of Neurosciences. The creation of this protocol would not have been possible without the resources from VUMC coming together.

MEETING THE CHALLENGES
Of course, any model has its drawbacks, and being part of a large organization can present challenges. Decision-making related to Vanderbilt athletics typically must flow through the dual channels of the VUMC and University athletics. Multiple levels of review can make for a long lead time when seeking to expand programs or pursue additional resources.

In addition, pressure points and perspectives can be very different for a hospital administrator and a university athletics director or coach. As a result, conflicts can arise over competing priorities. Our athletic trainers sometimes find themselves having to bridge the understanding gap between these different parts of the organization, while at the same time demonstrating their continuous commitment to the success of the athletic team.

Another hurdle is that funding is tied to the economics of medical care delivery. While Vanderbilt University athletics and Belmont University help fund their respective athletic training room staff, VUMC supports much of the administrative infrastructure and the high school outreach programs. Many health care entities have had to eliminate or reduce their sports medicine programs due to decreased revenue streams. Medical-related budgets are under tremendous pressure at a time when there is more and more recognition of the need for health care resources to support student-athletes at all levels.

Despite the challenges, we believe our model works well and can be a template for others affiliated with an academic medical center. It could also be implemented at smaller hospitals or through a group of practicing community physicians.

At the end of the day, though, it's the commitment of the athletic trainer to the athletes that makes or breaks a program. Athletes can achieve higher and higher levels of performance, and do so safely, in large part because of the services of athletic trainers. Whatever organizational structure is used, it all comes back to our dedication to serving the athlete.


Sidebar: ENSURING INTEGRITY
A study conducted by The Chronicle of Higher Education earlier this year found that return-to-play concussion decisions in football at many NCAA Division I schools were influenced by coaches. In a survey of 101 head athletic trainers, head football athletic trainers, and other sports medicine professionals from the NCAA's Football Bowl Subdivision (FBS), 53 said they had felt pressure from football coaches to return a student-athlete to play faster than they thought was in his best interest medically. In addition, 42 responded they had felt pressure from football coaches to immediately return an athlete to the field after suffering a concussion.

Having an athletic department's sports medical coverage run by a university medical center helps ensure that oversight issues do not get muddled. At Vanderbilt University, athletic trainers report directly to the Medical Center rather than someone in the athletic department.

Lori Alexander, Associate Director of Vanderbilt Student Athletics, believes this has been an important benefit to student-athletes. "It allows us to maintain the utmost integrity of care to our student-athletes," she says. "The sports medicine staff and physicians make the decisions regarding when a student-athlete can return to competition based on what is best for him or her, independent from when a coach may want them to return."

For a closer look at The Chronicle's study and story, visit: www.training-conditioning.com/2013/09/06/whos_the_boss/index.php.
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