Finding Your Fabrication Match: In-house, Central Fabrication, or Both

When it comes to in-house and central fabrication, Carmen Miller, CPO, has seen the good, the bad, and the ugly. During her first 18 months as a practitioner, she worked at a clinic that did most of its fabrication in-house, with clinicians sacrificing patient-care time by spending a large chunk of their day in the lab. There, she grew in her skills, and alongside technicians, was able to help patients who needed an emergency repair or get patients who had come from a long distance fitted in a single day. A year ago, she moved to her current position at Unified Medical Equipment Solutions, Arkansas. There, almost all devices are fabricated at a central fabrication facility. This means she has more time with her patients and, overall, feels the quality is superior. It also means that she has experienced delays in the fabrication process and in setting patient appointments because she never quite knows when a device will be ready. “I was nervous to embrace central fabrication at first,” she says. “With prosthetics especially, I was hesitant to relinquish that modification control. Now I’ve gotten used to it.” Seeing fabrication both in-house and outsourced, Miller says the choice for clinics depends on several factors including the availability of skilled technicians or a good working relationship with a reliable central fabricator. Both solutions have merit, she says, and depend largely on the clinics themselves and the resources available to them. The choices that Miller has seen in her career are not unique. Every practice must decide which fabrication route, or routes, work best for them. To help understand what goes into the decision between in-house or central fabrication, we spoke to a variety of practices about the choices they made and why they made them. Finding Peace With Central Fabrication After experiencing both sides of the fabrication debate, Miller says she is happy with the central fabrication process, even with its drawbacks. “I was nervous to embrace it at first,” she says of central fabrication. “With orthotics, I knew I could get better outcomes from a central fabricator than myself. But with prosthetics, I was hesitant to relinquish that control. Now I’ve gotten used to it and have established relationships with our fabricators.” She now has more time for her patients and doesn’t have the stress associated with doing the work in-house. “If I mess up in-house, that’s coming out of my bottom line,” she says. “Whereas in central fabrication, I put in the order, and if something gets messed up, that’s not reflected in my numbers. I like having the pressure of the uh-oh moments taken off of me.” Also, she says, she has seen better quality come out of the central fabrication facilities she uses. The in-house technicians she used to work with weren’t as professional, she says. “I think the quality of the product can get compromised from in-house from the perspective where it’s not great, but it’s also not the worst,” Miller says. “Whereas central fabricators have to maintain their professional relationship, and I feel like the quality of goods is a lot more guaranteed and a lot more of a priority.” She says it made sense when Unified Medical Equipment Solutions chose to use central fabrication facilities. Their clinics weren’t close enough to collaborate on fabrication and didn’t have the money to pay for in-house technicians and equipment at each site. “We’re spread out enough and small enough that it doesn’t justify the logistics of trying to maintain our own in-house fabrications,” says Miller. “Also, from a financial perspective, it’s wiser to maximize our time with the patients and not have to block up an entire afternoon to catch up on modifications.” She works with several central fabrication facilities based on her needs, she says. Over time, she’s found that different facilities have better quality depending on the device. There are drawbacks, she acknowledges. When she worked at an in-house clinic, she knew exactly when the definitive devices would be ready and could schedule patients accordingly. Now, patients have to wait until the device arrives before they can even make an appointment, which, depending on their schedules, can draw out the process. Also, she says, when she had a patient who was coming from far away, she had the ability to block off a portion of the day, cast the patient, and fit his or her first check socket all in one appointment. “So, things like being able to expedite things from a fabrication standpoint is something that I miss having the option to do,” Miller says. “But overall, I feel like it’s made my life a lot easier and streamlined.” A Mixture of Both Rashi Jha, CPO, AlliedOP, New Jersey, is glad her practice uses both in-house and central fabrication. Orthoses are almost always sent to a central fabrication facility, and she has found that this solution saves time on AlliedOP’s high-load prosthetic work. It also gives her the control she likes when it comes to fabricating prostheses, which are done in-house. “The pro to in-house prosthetics is that we’re modifying the molds ourselves,” she says. “I get to see it being done from cast to finished work. If there’s something I need to change, I can run downstairs and get it changed.” This approach also works well because the practice has two very experienced technicians who have a great working relationship with the clinicians, Jha says. Practitioners and technicians communicate formally, such as when employees have a preliminary meeting about a patient, and also informally throughout the day through calls and text messages. Jha says the turnaround time is quick and dependable. She knows she can schedule a patient to come back in a few days for a check socket or diagnostic socket and a little over a week for a definitive device. In an emergency, it can be even faster. Just recently, she had a patient in a definitive socket that was causing severe blistering. That same day, she and the technicians were able to get the patient into a walkable check socket to move around the house. Jha says they do not have that same turnaround reliability with their outsourced orthoses. Generally, it takes them about two to four weeks to get the device back, quality check it, and fit the patient into the schedule to pick it up. “I feel like I don’t have an exact answer for turnaround time for orthotics because different vendors are used depending on the prescription.” The in-house fabrication approach does mean sacrificing some patient time. On Mondays and Thursdays, Jha only sees patients for half of the day so she can use the remainder on fabrication. “It gets really hard scheduling sometimes,” she says. “The front desk will ask if I can get someone in during those times, and I can’t. It definitely gets annoying with scheduling.” Overall though, she says their approach is a good combination. “I wouldn’t say one way is better than the other,” she says. “What we have right now is pretty good, I’d say.” Outsourcing Almost Everything and Loving It As an orthotic technician himself, Jason Auyer, CPO, decided to have in-house techs when he and his wife cofounded Alliance Prosthetics and Orthotics, Georgia. His hope was that he would build up a small team of technicians who could manage themselves and do the bulk of the fabrication work while collaborating closely with clinicians. Unfortunately, finding and retaining technicians proved to be more difficult than he anticipated and, more and more often, he was doing the fabrication work himself. “I was spending more time doing technical work than seeing patients,” Auyer says. “It wasn’t the best use of my time.” He set out to find the holy grail of fabrication facilities—one that he could collaborate closely with, have a quick turnaround time, and be able control the costs. After trial and error, he says he found the perfect place for him: O&P Solutions, Georgia, located an hour’s drive from both of Alliance’s clinics. He says he can depend on them to get the work done expertly and quickly. In emergency cases, he says their longstanding partnership means he can occasionally ask for a rush order—a favor he makes sure he doesn’t take advantage of. “When something is rushed, we can meet them halfway or they can sometimes drive to our office; if we didn’t have that ability, it would be more challenging.” After building up their business relationship, Auyer says the central fabrication facility does the bulk of Alliance’s fabrication business. “It’s a mutually beneficial situation,” he says. “They are getting my business, and I get a great service and can better take care of my patients.” After searching for a facility, he says he chose O&P Solutions because of its nearby location and because he had already worked with some of its technicians and knew their work. “The quality was great,” he says. “We started with a few things and then turned to them more and more once we had that collaboration. We now give them the majority of our business, and because of that, they can give me better pricing.” In turn, he says, his clinics are easy for them to work with. They always do their best to fill out the paperwork appropriately, and they have his cell phone if there are ever any questions. “They don’t have to waste their time waiting for us to call them back,” he says. With other facilities, the back-and-forth attempt at communication could delay the process for days, he says, and it could take time for him to make his way through customer service and get to the person making the decisions. Now, he says, the technicians working on the devices call him directly. Getting to this point has taken time, he says. Alliance and O&P Solutions have both had to learn the other’s processes and preferred way of working, he says. Alliance knows the information O&P Solutions needs on its work orders and what kind of casts lead to the best end-product. “We want to call a place and have an instantaneous, great, perfect relationship with no problems,” he says. “But getting there takes time.” Creating Their Own Central Fabrication Facilities With 50 clinics across 12 states, Bionic Prosthetics and Orthotics Group has expanded significantly over the past few years. Headquartered in Indiana, the company needed a fabrication solution that could support its extensive network. They wanted a solution that would free up clinicians to focus on patients and get the most use out of their expert technicians, who can be tough to both find and train, says Tony Gutierrez, CP, national clinical specialist. As the business grew, Bionic created a space dedicated to fabrication near its headquarters so the technicians they had could serve multiple clinics. As they continued to grow, so did their fabrication needs. The business now has five fabrication spaces, spread out across the country and each with a different specialty. This way, Gutierrez says, they have the benefits of the expertise of a central fabrication facility while still having control over the devices produced. “When you have your own people, it helps with quality control and specialization, and you can have that oversight that is needed sometimes,” Gutierrez says. Bionic has been working to make its fabrication centers as efficient as possible. One way is by utilizing fused deposition modeling (FDM) 3D printing to fabricate the large volume of diagnostic sockets and flexible sockets that technicians had been fabricating by hand. Gutierrez says they saw the 3D printing potential when they were able to digitally modify and design a prosthetic socket in about 15 minutes and then utilize their printer to fabricate the diagnostic socket overnight, thus freeing up technicians to work on other, more complicated pieces. “We realized we were bogging our technicians down with a large volume of pieces, when, instead, we could make them experts in something else,” he says. “We saw the efficiencies in our fabrication process rise and the skill set of our technicians rise. They were able to focus on the complex projects while the relatively easy ones were becoming automated.” Getting to this point has taken time, Gutierrez says. Bionic invested early and heavily into 3D printing, and there was a lot of trial and error as they figured out the best technologies, processes, and materials to use. They now use 11 printers to help fabricate lower- and upper-limb prosthetic sockets, AFOs, and spinal orthoses. “When people asked how we did it, I say it took a lot of work and about five years of failure to figure out our process,” he says. Thus far, they’ve had the most success in 3D printing PETG clear plastic check sockets and flexible inner sockets that are used for lower- and upper-limb amputation levels. They have also been working toward using the printing processes to create devices with a long-term use. He says that their processes have become so refined that other clinics are outsourcing to them for their sockets. “Once our clinicians and outside groups realize the efficiencies of a digital workflow, we’re seeing more and more buy-in to improve the patient care process,” he says. Their solution of spread-out fabrication labs does come with some drawbacks, Gutierrez says. Emergency fabrication can be a struggle at times, he says. “Many of our clinicians have the ability to repair some things on-site, but not everyone has the tools or the skill sets to do that,” Gutierrez says. “That’s when we rely on some rush logistics and try to get it done in a timely manner and get it back to the patient as fast as we can. It is a challenge. It’s not like when your car has an issue, and you can get a rental. There’s no rental prosthesis.” Thankfully, he says, with their focus on a digital workflow and printing, their clinics already have a digital file for the patients and can often quickly make a long-term use printed socket to use in the interim while the technicians work on repairing the final product. Maria St. Louis-Sanchez can be contacted at msantray@yahoo.com. All photographs courtesy Getty Images/unsplash.com.

Finding Your Fabrication Match: In-house, Central Fabrication, or Both

3D Printing Diversifies for Success

OIG Report Addresses Continued Waste, Fraud, and Abuse in OTS Orthoses Medicare Benefit

OIG Report Addresses Continued Waste, Fraud, and Abuse in OTS Orthoses Medicare Benefit

RECENT NEWS

Get unlimited access!

O&P JOBS

Open Bionics hiring for CPO’s!

ABC Certified Prosthetist/Orthotist/ Resident – Memphis TN/Southaven MS

Part Time Certified Prosthetist

Are you sure want to unlock this post?

Are you sure want to cancel subscription?

The most important industry news and events delivered directly to your inbox every week.

Welcome Back!

Retrieve your password

Are you sure want to unlock this post?

Are you sure want to cancel subscription?

Finding Your Fabrication Match: In-house, Central Fabrication, or Both

Support authors and subscribe to content

Subscribe

Related posts:

3D Printing Diversifies for Success

OIG Report Addresses Continued Waste, Fraud, and Abuse in OTS Orthoses Medicare Benefit

OIG Report Addresses Continued Waste, Fraud, and Abuse in OTS Orthoses Medicare Benefit

RECENT NEWS

Get unlimited access!

O&P JOBS

Open Bionics hiring for CPO’s!

ABC Certified Prosthetist/Orthotist/ Resident – Memphis TN/Southaven MS

Part Time Certified Prosthetist

Login to your account

Reset Password

Signup to your Account

Are you sure want to unlock this post?

Are you sure want to cancel subscription?

Account Activation

The most important industry news and events delivered directly to your inbox every week.

Welcome Back!

Retrieve your password

Login to your account

Reset Password

Signup to your Account

Are you sure want to unlock this post?

Are you sure want to cancel subscription?

Account Activation