Enhancing clinical and economic outcomes

1. Enhancing clinical and economic outcomes Physiotherapy Screening & MD Management in Orthopaedics and Neurosurgery David Smith, Maree Raymer David_Smith@health.qld.gov.au 0407 767 632 SOPD Innovation Workshop Wednesday 27th November 2013

2. Significance of MSK conditions 31% of Australians Disability & productivity loss $4.1 billion 4th largest contributor to direct health costs (2004/2005)

3. Non-operative Management eg. PT, ongoing R/V Triage (Cat 1,2,3) Elective Surg. Wait List (Cat 1,2,3) Initial SOPD Consult GP Referral SOPD Wait List (Ortho or N/S) Discharge to GP Traditional Pathway (Ortho or N/Surg) 10-25% • High demand – needs poorly met • ~60% not seen in time • Poor QoL & deterioration while wait • Most patients don’t need surgery • Inefficiency

4. Physio. Screening & MD management Non-operative Management eg. PT, ongoing R/V Triage (Cat 1,2,3) Elective Surg. W.List (Cat 1,2,3) Initial SOPD Consult GP Referral SOPD Wait List Deliver Select Discharge to GP Physiotherapy Screening Clinic Redirect MD Non–surgical Management

5. N/OPSC & MDS Outcomes Services established State wide - 13 facilities Orthopaedics, 4 N/Surgery Activity (FY13) :5 532 new(4837 R/V) Management : 72% Referred to Non surgical Mx Waitlist Reductions : 27 – 54% 12% Managed, & Removed Wait list 65%

6. Discharge Patterns Remain SOPD waitlist Urgency ISQ Managed & removed SOPD wait list 23% 65% 12% Urgency Upgraded Safety Net

7. Red Flags Significant pathologies identified (> 40 in a sample between 2008 & 2012) • Neoplasms • spinal, soft tissue, pelvic • lung, thyroid • Fractures – hip and pelvis • Auto immune conditions and Inflammatory conditions incl. MS • Cerebral Vascular anomalies • Sub-arachnoid cysts • Cord Compression req. emergency decompression. • Parkinson’s Disease

8. Stakeholder satisfaction

9. Research Projects to maximise effectiveness Project 1 : Optimising patient selection : develop a prediction model to identify early those patients likely to be successful or unsuccessfulwith non surgical management Project 2 : Cost effectiveness analysis : fully informed cost effectiveness analysis and identification of the optimal mix of services between traditional and physiotherapy led service model

10. Progress : economic analysis Pilot study completed OPSC & MDS model likely to be highly cost effective Results tempered by uncertainty in some parameters Prospective study required to apply this economic model in a fully informed prospective analysis Prospective multi - site study underway √ Grant funding awarded (AusHSI) √ Central and site specific ethics approvals in place √ Patient Recruitment underway with > 400 patients enrolled

11. Summary to date N/OPSC & MDS = expert physiotherapy assessment (advanced role) and comprehensive MD management for selected Cat 2 & 3 patients Well established in 13 facilities in Orthopaedics and 4 Neurosurgery – delivering > 5 500 new SOPD app’ts p.a. Overall very well received by surgeons, GP’s and patients Patient outcomes and health system benefits clearly demonstrated → more timely, efficient and cost effective services which maximise value of the workforce

12. Lessons Learned The patient and planning • Placing patient experience & patient choices at centre of planning, both for flow and treatment options. • Tangible patient benefits have to be demonstrated. • Abiding by guiding principles helps check direction & integrity when changes may be demanded. Support • Sustained Executive buy-in essential : actions > words. • Ongoing Executive support required to overcome barriers and resistance to change. • Continual advocacy and networking for success. • Executive doesn’t stop at HHS but also Systems Manager.

13. Lessons Learned cont’d Innovation and problem solving • Willingness to work backwards from a problem to a solution with a blank page vs more of the same. • Understanding the problem from its root cause more important than focussing on the secondary effects or barriers. • Taking a good idea and making better is innovation. Workforce • Enabling staff to work towards full potential is extremely motivating; helps to maximise value of both physiotherapy and medical workforce. • Ongoing workforce development required for sustainability and expansion. • Higher level roles/responsibilities demand advanced/ higher level skills.

14. Lessons Learned cont’d Measures, data & relevance • Reporting measures that are meaningful across a range of domains resonate with different stakeholders eg. patient outcomes, stakeholder impacts, organisational and cost impacts. • Data collection built in. • Understand different stakeholders have different motivating factors for success. • KPI’s aligned with funding and priorities. Continuous improvement & change management • Building in an ethos of continual improvement and flexible responsiveness to changing environment is essential. • Resourcing for improvement and research is critical. • Must be able to adapt to changing political environment, (both small p and big P) – opportunities and challenges. • If something no longer works – accept it, make it work or make any necessary change.

15. Opportunities Demand > N/OPSC capacity = scope for expansion at existing sites to better match patient need Sites that currently don’t have this model could adopt & benefit Cost efficiency potential Broader MSK service reform - Adopt similar approach to Chronic pain, Rheumatology Other 1st contact models: ED, Urology/Gynae etc Challenges Not working to full scope –– enable and progress to extended scope incl. access to imaging, pathology and prescribing How to best work/integrate with ML’s Inconsistent application of triaging and integration of N/OPSC with medically led clinics in SOPD Changing perceptions re: timing and role of referral to SOPD VMO factor Regional/Rural service access Workforce supply and skills development National Categorisation Guidelines David_Smith@health.qld.gov.au 0407 767 632