OASIS Osteoarthritis Service Integration System

1. OASISOsteoarthritis Service Integration System Provincial Arthroplasty Collaborative Learning Session #3 October 2006

2. Agenda • Overview OASIS Program • Primary Care Participation • Listing of Community Services • Education • Knowledge Transfer • Questions/Discussion

3. Background • Second most costly disease category in Canada • Estimated 3 Million Canadians with symptomatic OA (Arthritis in Canada) • 40-50% patients suffer intermittent pain, with 10% suffering extreme pain (Krueger) • Increasing prevalence of OA associated with aging = expected increase in incidence of arthritis within next decade

4. Gaps in Care • Fragmentation of current services – limited coordination between care providers • Lack of coordinated capacity to respond to evolving demands • Waitlist and wait time pressures (consults and surgeries) • Gaps in care for non-operative patients • Lack of knowledge regarding resources and supports available

5. Gaps in Care (Cont’d) • Limited emphasis on prevention and health promotion • Prevailing model of hospital/acute focus rather than system wide/patient focus • Rising consumer expectations of care • Demographic trends – need to develop capacity

6. OASIS Program(OSTEOARTHRITIS SERVICE INTEGRATION SYSTEM) • Services • Multi-disciplinary assessment of treatment & education needs • Personalized action plans • Listing of resources available in public and private sectors • Tools for self-management • Coaching & group education • Coordination of referrals (optional) Target Populations • Patients in early and advanced stages of osteoarthritis of the hip and knee: • - Non-operative cases • - Surgical candidates • - Individuals seeking information on options Source of Referrals • primary care physicians • orthopedic surgeons • rheumatologists Benefits • Enhanced Relationship with Primary Care Physicians • Improved access to services • Skills in self-management • Improved quality of life and health outcomes • Collaborative Partnerships • Improved use of system resources & expertise • Linkages with other Chronic Disease Initiatives

7. Purpose Statement To design a coordinated early access system that will ensure equity and fairness for patients waiting to be assessed and treated for osteoarthritis and to provide them with a multi-disciplinary assessment of their condition and the education and tools necessary to manage their condition non-operatively, as well as pre and post surgery, as the case may be.

8. Goals of OASIS • Limit the development and progression of OA • Slow onset of complications that can cause severe disability • Reduce avoidable declines in health • Reduce variations in care

9. Program Objectives • Improve access, patient flow, quality and efficiency of services • Build capacity of system to meet escalating demands • Minimize time of patient suffering and disability • Build the continuum of care • Make cost-effective use of system resources & expertise • Enhance roles of the multidisciplinary care team • Link multiple arthritis initiatives

10. Features of OASIS Program • Focus on continuum of care – from prevention through medical supports to surgical intervention and post-operative care • Target populations • Information Only Cases • Non-Operative Cases • Surgical Cases • Multidisciplinary needs assessment teams • Personalized action and referral plans • Timely education and information • Patient navigation through the system

11. Features (cont’d) • Focus on needs of individuals, families, care-givers and communities • Complex and long-term partnerships • Builds on related initiatives • Focus on assessment, triage and education

12. OASIS Services • Multi-disciplinary assessment • Action Plan • Inventory of Resources/ Service Supports • Liaison with PCP • Liaison with Surgeon • Case tracking and follow-up with PCP • Clinical patient navigator

13. Service Delivery Structure • Assessment Clinics • Regional Education teams • Partnerships • Interactive Website

14. Tools and System Supports • PCP Screening / Referral Tool • Multi-disciplinary assessment tools • Triaging Criteria • Care Pathways • Telephone & Video Conferencing • Website

15. System Benefits • Enhanced access to services • Multi-disciplinary Teams will redistribute workloads; efficient use of staffing expertise and associated resources • Improved patient flow • System wide savings – increased productivity and quality of life • Rationalization of system wait lists • Coordination point for related OA initiatives

16. Patient & Care Giver Benefits • Systems in place to support education & development of self-management skills • Client awareness • Client support and motivation • Individualized management plan

17. Multiple Stakeholders • Clients and caregivers • Primary Care Physicians (PCPs) • Allied Health Professionals • Orthopedic Surgeons • Rheumatologists • Community Organizations • Education Partners

18. Primary Care Participation • Pivotal role in coordinating access to services • Relationship with clients & understanding of client history and medical needs • Limited time & resources to identify service options • No time to support client navigation through the system

19. Benefits of OASIS for Primary Care • Equitable access to services based on need rather than entry into referral queue • Access to first available surgeon • Up to date inventory of public and private sector services • Standardized referral forms and assessment tools • Client skills in self-management • Personalized action plan for all clients • Linkages with other chronic diseases • Alignment with other CDM initiatives

20. Engagement Strategies • Participation in planning for system re-design & implementation processes • Focus Groups – testing ideas • Leadership of Depts. of Family Practice • Multiple Vehicles for Communications and Engagement • Beta-testing tools and processes • Communications & feedback loops • Evaluation – impact on physician practice • Soft launch and incremental up-take

21. Incremental Participation • Primary Care Physicians with clients waiting for surgical CONSULT • New referrals in early and advanced stages of osteoarthritis • Referrals for information only • Initial focus on Vancouver Coastal residents

22. Multiple Stakeholders • Clients and caregivers • Primary Care Physicians (PCPs) • Allied Health Professionals • Orthopedic Surgeons • Rheumatologists • Community Organizations • Education Partners

23. Listing of Community Services • Background • Purpose • Key Features • How Did We Do It? • Where are we Now?

24. Listing of Community Services – Background • Focus groups – patients, physicians and allied health • Gaps identified: • Lack of information regarding available resources • Pockets of Information • No central location / coordination

25. Listing of Community Services –Purpose To provide a central location for information on services (treatment and self-management supports) available in both the private and public sectors to serve individuals with osteoarthritis

26. Listing of Community Services – Key Features • Wide range of services, for example: • Rehab services • Nutrition • Transportation • Exercise • Education • Education • Core education - OASIS • Partners

27. Listing of Community Services –Key Features • Services reflect needs ranging from mild to severe OA • Contact information • Ability to sort by location, service type, etc. • Access to Information (I.e.: Website)

28. Listing of Community Services – How Did We Do It? • Task Group • Representation from various disciplines across VCH • The Arthritis Society • Gathered information on public and private sector services • Template for storing and retrieving information • Participation criteria • Consent for inclusion • Letters of intent • Maintenance Procedures

29. Listing of Community Services – Where Are We Now? • Receiving confirmations of participation • OASIS Website • Printed copies • Flyers / Brochures

30. Multiple Stakeholders • Clients and caregivers • Primary Care Physicians (PCPs) • Allied Health Professionals • Orthopedic Surgeons • Rheumatologists • Community Organizations • Education Partners

31. “Knowledge is power” Sir Francis Bacon English Author & Philosopher 1561-1626

32. Education • Education Team • Patient Modules • Provider Modules • Delivery Structure

33. Education – The Clinic Team • One-to-one sessions • Identify learning needs • Counseling/information specific to patient, including connection with peer support groups • Group education sessions (emphasis on prevention, health & self-management)

34. Education – The Regional Team • Group education sessions (emphasis on prevention, health & self-management) • In clinic • With partner organizations • Traveling education sessions • In a variety of venues • Build relationships with partner organizations • Evaluate education delivery – patient/provider satisfaction

35. Education – Patient Modules

36. Education – Self Management What is self management? • Self Management: what the client does, to the best of their ability, on a daily basis to manage their disease and the impact it has on their life. • Self Management Support: what the care provider does to build that person’s belief in themselves (self-efficacy) that they have the ability to manage their disease on a daily basis.

37. Act Plan Study Do PSDA Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement?

38. Education – Provider Modules • Orientation to OASIS • Evidenced-based osteoarthritis knowledge • Train the Trainer Sessions for teaching core program • Pharmacological & complementary therapy management • Change management skills • Nutrition & weight management • Exercise & Physiotherapy

39. Education – Delivery Structure • Staffing Model • Partnerships • OASIS Core Sessions • Education Venues • Teaching Modalities • Provider Education

40. Education – Next Steps • Identify Education available • Identify gaps • Partnering • Develop modules (core & specific) • Traveling education • Evaluation

41. Knowledge Transfer • Just a taste today • HA leadership team • Knowledge transfer sessions • May 2006 • October 2006 • Visit to each HA in 2007

42. FAQ What is the difference between CSI and OASIS? • CSI is a provincial initiative to address long surgical waitlists and wait times • Focus of CSI is on patients waiting >26 weeks for hip or knee surgery • OASIS is a new program launched at the same time as CSI – it services all OA clients in VCH, not just those having surgery at UBCH • OASIS focuses on assessing service needs and providing education for clients in all stages of the disease – not just advanced stage where surgery is required.

43. FAQ How can the OASIS Program be applied in rural settings? • Web-based screening and assessment tools available to primary care physicians and allied health • Assessment Clinics (staffed by multidisciplinary teams) that travel on scheduled basis into isolated communities • Inventory of local services (public & private) to participate and/or partner with

44. FAQ Physicians do not seem to be part of the multi-disciplinary team. • Physicians are an integral part of the multi-disciplinary team although not physically present at the time of the OASIS assessment. • Significant input and involvement in: • Development of approach and tools used in assessment • Criteria used for triaging / streaming clients • Orientation of OASIS staff in assessment techniques • Consultation regarding unique client situations • Participation in follow-up actions / referrals

45. FAQ Would OASIS not benefit from a “one-stop shop” approach? • A one-stop shop approach ideal for the client – where can see a range of specialists / experts in one location. • Logistically this model is difficult to implement and sustain as a distinct model – primarily due to competing priorities for experts time and resourcing requirements • Opportunity for OASIS to be more integrated into community health units

46. FAQ What is expected of other HAs with respect to OASIS? • Government announcement February 2006 was twofold: • Implement OASIS in VCH • Share model / learnings with other HAs • Other HAs to plan for “OASIS-type” models • One-size will not fit all – tailor to local needs

47. FAQ What is the relationship between OASIS and the Surgical Patient Registry (SPR) • For surgical candidates, the OASIS data collection process “ends” with a referral to the Orthopedic Surgeons for a consultation for surgery • Surgeons complete the SPR prioritization tool and forward along with booking information to OR Booking Offices • OASIS will extract a sub-set of data points from ORMIS re “dates” of referral, bookings, etc. for use in routine reporting and evaluation of waiting times, etc. • SPR focuses on all surgical cases; OASIS captures data only on those choosing to participate in the Program • Opportunity for sharing components of the data-set (both directions)

48. FAQ How does OASIS align with the Collaborative? • OASIS is a system redesign initiative – with emphasis on coordination of services across the continuum of OA care, a virtual “single point of entry” and needs-based access to service • The Collaborative is a vehicle to bring clinical staff together to share quality improvement initiatives at the front line that improve care delivery and care pathways, with particular emphasis on individuals in the acute episode of arthroplasty care • OASIS forms the conceptual umbrella of integrating services under which a range of services are delivered including arthroplasty care

49. Thank you and Questions