Review #2-3-4 – The Case for Successful Execution: Hips and Knees Priority Action Team

1. Review #2-3-4 – The Case for Successful Execution:Hips and Knees Priority Action Team Presentation to the Strategic Advisory GroupApril 14, 2008

2. Acknowledgements This work would not have been possible if it were not for the commitment of the: • Hips and Knees Priority Action Team (PAT) • Hips and Knees Task Teams

3. Agenda • Approach • Key Drivers of Change • Overview of the Recommendation • Implementation Planning • Implementation Strategy • Evaluation of Decision Criteria • Recommendations

4. Approach

5. Approach The Hips and Knees PAT was identified as a Quick Start opportunity in the Integrated Health Service Plan. The PAT completed the following activities to fulfill the associated objectives: • Refreshed quantitative data • Reviewed inventories of services and practices • Conducted additional best practice research • Developed a proposed model of integrated service delivery • Implemented a community engagement strategy • Engaged Task Teams to develop specific components of the overall recommendation

6. Population or Program Integration Process Quick Win Process Health System Integration Methodology

7. Mission Statement The hip and knee replacement delivery model strives to: • Ensure that individuals have timely, appropriate and equitable access • Incorporate best practices and evidence-based care • Utilize a common multidisciplinary pathway spanning the entire continuum of care • Enable services to be standardized, and delivered efficiently in a coordinated manner

8. Vision Within the next five years, measures will show achievement of the following elements in the evidence-based care and management of hip and knee replacement patients: • Clearly defined continuum of care available to all patients resulting in positive clinical and functional outcomes • Individuals have equitable timely access to services • Reduction in surgical wait times • The patient, family and/or their support system is an active participant in their care and self management • Demonstrated improvement in consumer satisfaction measures • The model delivers high quality best practice care

9. Values The Values of the Hips and Knees PAT are aligned with those of the South West LHIN and are as follows: • Accountability • Collaboration • Coordination • Efficiency • Effectiveness • Competence • Integration • Evidence-based practice

10. Key Drivers of Change

11. Rationale for Change • Wait times are higher than the provincial benchmark • Demand is expected to grow significantly • System-wide capacity issues continue This presents a challenge that demands change

12. Target Population The model will benefit individuals who: • Have osteoarthritis requiring Secondary Prevention and education • Require hip or knee replacement surgery The typical client profile for total hip / knee replacement: • Approximately 2/3 of patients are over the age of 61 with the average patient age being 68 years • 60% of patients are women • 80% of patients have osteoarthritis • Over 80% of patients are overweight or obese (meaning that they have a Body Mass Index greater than 25)

13. Key Drivers Rise in individuals requiring surgery • Overall population growth • Aging of the Baby Boomer generation • Rising incidence of obesity Rise in individuals requesting surgery at an earlier age • Improvements in the expected life of materials • Increased consumer awareness Rise in complexity of surgeries • High rates of chronic disease • Longer length of stay and additional resources

14. Current State

15. Current State Challenges System-wide capacity issues • Health human resources shortages • Bed shortages Lack of common approach throughout system • Multiple referral processes and wait lists • Timing and content of patient education materials • Approach to assessment and care • Length of stay by hospital • Timely pre-planning for Post-Acute care • Availability of Secondary Prevention and Post-Acute Care • Communication and coordination across providers • Sharing of patient health information across providers

16. Overview of the Recommendation

17. High-Level Recommendation Create an integrated model of care to improve service delivery efficiency and effectiveness, resulting in: • Decreased wait times • Enhanced quality of care • Equitable access Fundamental goal is to ensure LHIN-wide consistency in service delivery by incorporating evidence-based research and lessons learned into the design of the model

18. Building Blocks Framework Step 3 – • program or population. state design. • Target Population Mission, Vision, Values and Goals Oversight of System Scope of Services Performance •System Level Design Joint Oversight • •Service Level Design Performance Management • Approach to the flow of clients and Financial Accountability • information through the system • Entry and Access • Approach to Assessment Care Coordination • • Information Flow and Requirements Linkages to and fit within the Continuum •

19. Future State An Integrated Model of Care

20. Scope of Services Key Components of the Model: • Standardized Referral Process • Central Registry • Assessment and Education Centres • Secondary Prevention • Pre-Admit / In-Hospital Care • Post-Acute Care

21. Standardized Referral Process Who will provide the service and where? • Patients may be referred by a family physician, nurse practitioner or other physician • Through Family Medicine practices, Family Health Teams, Walk-in clinics, long-term care facilities, urgent care clinics or emergency departments How will the service be provided? • A standardized referral form will incorporate patient choice and streamline the intake process to expedite patients to receive appropriate services What resources are required? • Creation, design, printing and distribution of new referral form • Recommend creation of electronic form to eliminate errors and redundant data entry

22. Standardized Referral Form Introduces a common referral process Key features: • Easy to use • Ensures that all necessary data is collected • Reduces possibility of errors or omissions Content includes: • Patient choice • Requested surgery • Diagnosis and symptoms • Special needs • Medications and assistive devices

23. Central Registry Who will provide the service and where? • Referrals will go through one Central Registry (one number, one location) serving the entire LHIN How will the service be provided? • Referral forms will be forwarded to this single point of entry into system • Forms will be assessed for completeness • Form will be forwarded as appropriate in a timely manner • The Central Registry will utilize a single wait list to help ensure wait times are distributed appropriately across the LHIN What resources are required? • Available existing space • Office set-up including telecommunications • Creation of Central Registry database • Clerical and managerial support • Training

24. Assessment and Education Centres Who will provide the service and where? • Multi-disciplinary clinical assessment team • Three Assessment and Education Centres: • One within each planning area • Within an existing orthopaedic clinic at a surgical site How will the service be provided? • An initial consultation will be performed to: • Obtain required health information • Assess surgical status • Assess secondary prevention needs • Identify post-acute care needs • Educate the patient

25. Assessment and Education Centres (cont’d) What resources are required? • Available existing space and additional services upon consultation • Staffing requirements by full time equivalent (FTE): • 1.88 FTE - Advanced Practice Therapists • 1.88 FTE - Advanced Practice Nurses • 0.43 FTE - Clerical resource • 0.40 FTE - Managerial resource • Training

26. Assessment Summary Introduces a common approach to initial patient assessment Alleviates some of the work from the pre-admit clinic Content includes: • General assessment • Physical exam findings • Clinical history

27. Proposed Workflow forReferral, Central Registry and Assessment and Education Centres

28. Secondary Prevention Who will provide the service and where? • Various providers throughout the South West LHIN How will the service will be provided? • Assessment at earliest point possible: • Identify the Secondary Prevention needs of surgical and non-surgical candidates • Provide patients with available options and arrange care • Secondary Prevention service providers provide range of services to: • Improve patient's knowledge and empower the patient • Identify and address safety issues • Improve level of fitness and function • Enable patient to remain at work and/or at home longer • Improve overall quality of life and outcomes

29. Secondary Prevention (cont’d) What resources are required? • This model recommends enhancements to the role of Secondary Prevention to address gaps in provision and access What are the supporting guidelines and tools? • Common assessment tool • Common guidelines for provision of Secondary Prevention services

30. Pre-Admit / In-Hospital Care Who will provide the service and where? • Multi-disciplinary teams • Each of the surgical sites How will the service be provided? • Pre-admit clinic will be streamlined due to work done in advance at Assessment and Education Centres • Utilize common clinical care pathway and Teaching Checklist to ensure patient treatment is equitable and in accordance with best practices • Adherence to pathway in combination with the Assessment and Education Centres and Secondary Prevention should result in a standardization in the length of stay What resources are required? • Dependent on degree of variance between current practices and common care pathway

31. Common Collaborative Care Path Introduces a common approach to in-hospital care Outlines the key activities that should be completed each day from pre-admit, through to discharge Covers topics such as: • Diagnostics • Treatments and assessments • Medications • Teaching • Exercise • Discharge planning

32. Post-Acute Care Who will provide the service and where? • Three streams of post-acute care have been identified: • Outpatient rehabilitation / private clinic • Facility-based rehabilitation • Home Care • Services are provided by: • Physiotherapists, occupational therapists and others • A number of organizations utilizing a mix of public and private funding

33. Post-Acute Care (cont’d) How will the service be provided? • Early identification of most appropriate post-acute care stream • Utilize common guidelines • Pre-arrange with post-acute care service provider • Confirm initial assessment while patient is in-hospital • Post-Acute service providers will track patient progress against key milestones and outcome measures to determine transitions between streams and appropriate time to discharge What resources are required? • This model recommends enhancements to the role of Post-Acute Care to ensure access to all streams is equitable, in terms of both geography and funding.

34. Post-Acute Care – Guidelines Introduces a common approach to post-acute care Aids clinical staff in identifying which of the three post-acute care streams is most appropriate for patient Utilized early in continuum to ensure timely pre-arrangement of post-acute care services

35. Post-Acute Care - Milestones Introduces a common approach to Post-Acute Care Identifies separate milestones for: • Hip vs. knee replacement • Each Post-Acute Care Stream Indicates: • Week by week activities • Outcome measures • Guidelines for discharge

36. Supporting the model • Evidence-based review of literature and best practices • Common clinical guidelines, outcomes, indicators, education tools and care pathways • Processes, systems and communications that enhance flow of clients and information through the system • Oversight of System Performance

37. Education Tools • Research and best practices show that quality patient education can improve patient outcomes, anxiety and discharge planning resulting in lower healthcare costs and improved functional outcomes for the patients • The education tools will be • Introduced as early as possible • Standardized to ensure consistency • Based on best practices • Customizable for specific patient pathway • Accessible • Patient education materials will include • Model of Care Brochure • Hip and Knee Replacement Services Website • Patient Education Binder • Teaching Checklist

38. Education Tools (cont’d) Model of Care Brochure • Builds awareness of overall model of care and links to other resources • Available to health service providers directly involved in model of care • Available to community • Originators of referrals • Community agencies • Online Hip and Knee Replacement Services Website • Builds awareness and educates • Online version of patient education binder • Links to other resources • Provides opportunity for community feedback • Connects to South West LHIN and the Healthline websites • Reflects the design of existing sites such as myjointreplacement.ca

39. Patient Education Binder Primary patient education tool Valuable reference to patient, family, other support and health service providers Materials will be customizable as reflected by the draft table of contents which identifies: • Timing of receipt of materials • Type of content • General vs. joint specific • Standard vs. hospital specific • All patients vs. surgical patients only • Hip vs. Knee replacement

40. Teaching Checklist for Providers The Teaching Checklist for Providers would serve to: • enable communication between providers • reduce redundancy and conflicting messages • ensure key teachings are demonstrated at the appropriate point in time A checklist specific to the South West LHIN would be created: • Using the Grey Bruce Health Network Total Hip Replacement Checklist as a guide • Aligning with the final content of other education tools, guidelines and care pathways

41. Approach to Entry and Access How will individuals gain initial access? • Consultation with physician/nurse practitioner resulting in referral to Central Registry How will providers and clients learn that the program exists? • Emphasis placed on creating awareness among potential originators of referrals and potential patients through: • Community Engagement sessions • Distribution of detailed information, brochures and standardized referral forms to originators of referrals • Brochures widely available at physicians’ offices and various community agencies • Hip and Knee Replacement Services Website, with links from various health care websites What are the supporting tools? • Standardized referral form • All referrals sent to one Central Registry (one number, one location)

42. Approach to Assessment What is the approach to Assessment? • Determine surgical status of patient (Assessment Summary) • Determine the Post-Acute Care stream for surgical candidates (Post-Acute Care Algorithm Guidelines) • Determine Secondary Prevention requirements of all patients (Assessment tool to be developed) • Determine the education needs of all patients (Patient Education Binder)

43. Care Coordination • Make the patient (and their family or other support) a partner in care • Educate Patient • Inform and involve patient in decision-making process • Enable patient to be an active participant in their own care • Make patient accountable for their care • Provide linkages into other areas of continuum • Assess Secondary Prevention and Post-Acute Care needs as early as possible and re-confirm as necessary

44. Linkages To and Fit Within the Continuum • Overall improvement in communication • Increased awareness of model and the key transition point • Navigation process in place to support transition and appropriate fit between patient and provider • Consideration for additional communications between hospital and community health service providers • Improved navigation supported by: • Increased availability of patient health information • Guidelines, forms and clinical care pathways • Teaching Checklist • Patient Education Binder • Feedback loop to referring physician on patient assessment

45. Information Flow and Requirements

46. Joint Accountability and Oversight Ensure that the proper governance and accountability structures are in place between the South West LHIN and various health service providers during Pre-Implementation period: • Memorandums of Understanding • New Governance Structure In the long term, the South West LHIN may consider modifying existing funding mechanisms to drive desired behaviours • Service Accountability Agreements • Wait Time Allocation Funding

47. Accountability Council Implementation and Ongoing Monitoring Implementation Steering Committee Project Manager Implementation only Implementation Task Team 1 Implementation Task Team 2 Implementation Task Team X Joint Accountability and Oversight (cont’d) Hips and Knees Governance Structure

48. Joint Accountability and Oversight (cont’d) Hips and Knees Accountability Council • To serve as oversight role throughout implementation and beyond • Monitor and evaluate need for change and refine model as required • Membership represents the entire continuum of care and has the influence and authority to affect change in their organizations • Membership would consist of the following representation: • Senior Director level or above from South West LHIN • Member of the South West LHIN Board of Directors • Surgeon and a Vice-President or CEO from each of the surgical sites • Individuals with the authority to influence their health service organizations • Members from the Hips and Knees PAT for continuity

49. Joint Accountability and Oversight (cont’d) Hips and Knees Implementation Steering Committee • Support and direct the Implementation process • Involve individuals with an operational role from key health service provider organizations and members from the Hips and Knees PAT Implementation Task Teams • Operate for a limited time and in a facilitated environment • Focus on final conceptualization and design of specific components of model and then serve in advisory role during implementation Project Manager • Manage the entire scope of the project on a full-time basis • Coordinate and facilitate all project implementation activities

50. Performance Management Indicators High-Level performance indicators have been identified • Align with the Hips and Knees PAT Mission and Vision • Align with Provincial Wait Time Strategy mandate • Incorporate balancing measures (quality & efficiency) • Include baseline, transitional and end-state measures • Indicators and reporting requirements need to be confirmed with health service providers Service-level measures have also been identified • Task Teams have proposed these additional measures • Beneficial in monitoring and refining specific components of the model