Patient Flow Collaborative Learning Session 3

1. Patient Flow Collaborative Learning Session 3 WHOLE SYSTEM ACCESS Bellarine Room 1 Felicity Topp and Mary Mitchelhill

2. Improving care for mental health patients in Emergency Departments Breakout session 1Bellarine Room 1 9.40 – 10.35 Sue Huckson National Institute of Clinical Studies, Program Manager 9th February, 2005

3. Questions ?

4. Morning Tea Meet us back here for Modernisation of Orthopaedic Outpatient Services at 10.50

5. Modernisation of Orthopaedic Outpatient Services Breakout session 2Bellarine Room 1 10.50 – 11.45 Leonie Oldmeadow Victorian Travel Fellow 9th February, 2005

6. Background Byles S and Ling R (1989): Orthopaedic Outpatients-A Fresh Approach Physiotherapy 75 (7): 435-437

7. Travel Fellowship 2004 The role of physiotherapy-led screening clinics in managing wait lists and hospital demand for orthopaedic outpatient services Leonie Oldmeadow DPhysio, M.Clin Ed, Grad Dip Physio

8. Impression? Outcomes • demand on OSOC decreased (by 50%-70%) • 90% patients very satisfied with new screening service • few wait >13 weeks for specialist outpatient appointment • conversion-to-surgery rates increased from 20% to 70% • wait elective surgery approaching 6 months • < 4hr wait A&E ‘minor injury’ Conclusions Widespread, well accepted, effective Feasible for the Victorian healthcare system Needs leadership, support, and evidence

9. ‘Physio Direct’ • telephone triage • decreases unnecessary GP visits

10. The first ‘physiotherapy surgical practitioner’ • screening, theatre and post-operative care triage • frees surgeon and registrar time for other surgery

11. What is a physiotherapy-led screening clinic? An additional ‘access filter’ in the patient’s journey, from GP referral to consideration for orthopaedic surgery

12. ‘Old’ system of triage 20% urgent soon intermediate routine surgery 40% GP Referral letter surgeon consult Physio + 100% Discharge GP 40%

13. New system of triage Manual physio Physio screening clinic Physical reconditioning Pain mgmt Injection therapy L E T T E R 70% GP orthotics 70% 30% surgeon surgery surgeon consult 20% physio 10% discharge

14. Where?In Consultant outpatient clinics

15. Where? In physiotherapy outpatient departments

16. Where?In Future: ‘interface’ primary multiprofessional team • consultant/physio specialist from hospital • GPwSI • plus ? others

17. Who provides the screening service? • Clinical specialist physiotherapists/ extended scope of practice (CSP/ESP) • qualified to request x-rays, blood tests, MRI, CT, bone scans, surgery (arthroscopy, arthroplasty, spinal)

18. CSP/ESP tasks ? • assessment • tests • diagnosis • discuss with patient • agreed management triage • review • free doctors time

19. Hip/knee screening clinic-case study

20. ‘Top- 10- tips’ for implementation • Medical ‘champion(s)’ critical (expect resistance) • Work with GP’s • Extension to scope of practice, and its limits, agreed to by Consultants and physiotherapists • Agreed clinical algorithms and protocols to support new way of working • Inform patient re seeing a physiotherapist, right to request surgeon • Patient to ring for appointment (decreases DNA) • Data collection, including cost-effectiveness, from outset. Implement research activity • Establish close links with follow-on services • Copy letter management plan to patient and GP • Start small- big cultural change

21. Questions ?

22. Team Presentations11.45– 1.00 • Lee’s Cluster Bellarine Room 1 • Austin Health • Melbourne Health • Peninsula Health • Southern Health • Ballarat Health

23. Tabletop presentations The aim of this session is to; • Promote discussion • Share “Peer to Peer” practical experiences of innovation • Increase energy for change and shared learning • Spread ideas between teams

24. Session format • 2 teams per table • Team A has 10 minutes to share experiences with team B • Whistle blows • Team B has 10 minutes to share experiences with team A • Rotation 1 • Continued….

25. Session format

26. Session format

27. Lunch Meet us back here for Orthopaedic Outpatients Revolution at 2.00

28. Orthopaedic Outpatients RevolutionRelieving the Orthopaedic Outpatients Bottleneck Breakout session 3Bellarine Room 1 2.00-2.45 Damian Armour Victorian Travel Fellow 9th February, 2005

29. Introduction • Victorian Travelling Fellowship Program • Relieving the Orthopaedic Outpatients Bottleneck • NHS Initiatives • Overview of the Orthopaedic Assessment Service. • Barwon Health • Improving Access to Orthopaedics • State-wide focus

30. The Challenge – Access to Ortho Outpatients

31. Victorian Travelling Fellowship • Awarded in Aug 04 • Travel to 9 NHS sites in Nov 04 • Intended Learning • New models of Outpatient Care • use of Primary Care to ease demand on Secondary Care. • Referral Pathways for GP’s. • Consultant Physiotherapists (ESP’s) & GPwSI • Change Management. • How did they engage the Consultants? • Funding Models.

32. Victorian Travelling Fellowship • Stockport NHS • Aintree Hospitals • Whiston Hospital • Royal Liverpool Hospital • University Hospital of North Staffordshire • Somerset Coast PCT • Royal Bournemouth Hospital • Southampton Health Community • Modernisation Agency 2 1 3 4 5 9 6 7 8

33. Fellowship Summary • Multiprofessional Triage Team / Orthopaedic Assessment Service (OAS) • Benefits • More timely access for patients referred with musculoskeletal problems. • Orthopaedic Consultants see a higher ratio of new patients in their clinic who are likely to require surgery. • A clear and documented framework is developed for patients with musculoskeletal disease. • Physiotherapy and other allied health professionals are provided with a significantly enhanced career path.

34. Fellowship Summary • Risks • Downstream impact on the capacity of the referral alternatives. • Physiotherapy, Podiatry, Pain Clinic etc • Elective Surgery • GP resentment • Seen as solution for all musculoskeletal issues.

35. Stage 1 – GP Referral GP sees patient with an Orthopaedic/musculo-skeletal condition and ‘refers’ them into the OAS. Specialist physiotherapists review all referral letters to identify the appropriate care pathway Appropriate treatment not clear from referral Appropriate treatment clear/unambiguous from referral Patient referred directly to Orthopaedic consultant Patient referred directly to pain management Patient referred directly to physio for treatment Patient referred directly to Orthotics Patient referred directly to podiatry, rheumatology Patient referred directly back to GP Stage 2 – Face to face physiotherapy triage assessment Patient has an assessment in a locality based clinic by a specialist physiotherapist to identify appropriate care pathway. Patient referred directly to Orthopaedic consultant Patient referred directly to pain management Patient referred directly to physio for treatment Patient referred directly to Orthotics Patient referred directly to podiatry, rheumatology Patient referred directly back to GP OAS Overview

36. GP Referral • Standardised GP referral template. • Desirable for ease of triage but not a prerequisite for success. • Barwon Health already has a generic Medical Director referral template with a high take up rate. • GP Communication Plan crucial to implementation. • Prevent backlash “Expect to see a Surgeon” • Prevent all musculoskeletal issues being referred.

37. Triaging • There are varying levels of GP referral triage undertaken: • Referral Management • NHS - implementing a centralised referral management system • a precursor to the implementation of the “Patient Choice” system • Paper Triage  • Generally by an experienced Physiotherapist. • Some sites still had Consultants triaging • Allocated to non-consultant resources after a “transition phase”. • Undertaken in conjunction with agreed guidelines (include ‘red flags’). • Clinic Assessment  • Undertaken if paper assessment not adequate for decision • A face-to-face assessment by Primary Care resources. • Communication is made with the GPs about the ongoing care.

38. Clinic Structures • Multidisciplinary • Physiotherapists are the core resource • General Practitioner with a special interest in Ortho. • Other resources would include Podiatrists, OTs, Rheumatologists etc. • Timeframe • Assessments run for a period of 30 minutes • 20 min patient consultation / 10 min multidisciplinary discussion. • Patient Numbers • Each clinician sees 6 new or 5 new/2 review.

39. Clinic Structures • Themed Clinics • Mixture of approaches • Themes/specialities vs generic in nature. • Types: • Lower Limb, Upper Limb, Spinal, Injection clinics • Some sites also ran a mixture of specialised and generic clinics. • Location • Primary care or secondary care settings. • Dependant upon responsibility for the service. • Logistical matters (e.g clinic space, access to diagnostic services).

40. Clinic Structures • Clinic Outcomes • Not just Assessment • One Stop Shop • Assessment / Advice / Discharge

41. Downstream Impact • OAS clinics will result in an improvement in waiting times for initial assessment.  • However implications are … • Waits for treatment clinics (e.g Physiotherapy, Podiatry and Pain Clinic) will increase. • Increased listing rates result in an increase to the elective surgery waiting list. • Patients receiving immediate assessment, advice and discharge within the OAS clinic will benefit without impacting on downstream resources.

42. Downstream Impact • A study within one of the sites indicated approximately: • 33% of GP referrals would receive immediate treatment and discharge. • 33% requiring a Consultant opinion. • remainder requiring other non-invasive therapy. • Other sites found that only 20% required a consultant opinion.

43. Workforce Issues - Orthopaedic Consultants • In NHS - full time with about 7 clinical sessions per week for their Trust. • High degree of subspecialisation. • Role in the OAS … • need to be willing reallocate traditional consultant tasks to other clinical resources. • flexible in relation to the management of their allocated time (swap clinics for theatre sessions).

44. Workforce Issues – GP’s • Play a key part in the OAS • as a referrer • as a participant in the clinics themselves • Utilisation of GPwSI’s was mixed. • Integration of a GP within the clinics assists in the relationship building with GP community. • The availability of a medically trained resource within the clinic provides a required level of clinical expertise.

45. Workforce Issues – Physiotherapists • Success depends on the ability of the organisation to successfully enhance the role. • Extended Scope Physiotherapist (ESP) • Injection Therapy • Ordering of X-Rays and Blood Tests • Ordering of MRIs • Listing for surgery • Competency development • Documented guidelines outlining the core competencies of ESP. • Orthopaedic Consultant Signoff • Society of Orthopaedic Medicine training course

46. Workforce Issues – Other • Other Allied Health Professionals • Podiatrist • Rheumatologist • Administrative Staff • Crucial in managing patient expectations • HMO’s • Reduced the need to work in clinic • Safe working hours.

47. Change Management • Ensure all stakeholders (esp. Surgeons and GPs) embrace the concept of the OAS. • Start the OAS small (e.g. with a particular body part) and expanding gradually. • Many sites started with new referrals as opposed to going back through the waiting list. • Documented procedures and protocols in addition to the continuing education of staff is critical.

48. Government Influences • Advances would not have been achieved without a comprehensive focus on the matter by NHS. • Outpatient Targets. No one waiting greater than…... • 21 weeks by April 2003, • 17 weeks by 2004, • 13 weeks by 2005. • Underpinned by a national outpatient service improvement collaborative and modernisation program. • Many of the sites visited recognised the evolving problem well before the targets were set.

49. Measurement • Patients by service type (e.g. back/spine, lower limb, upper limb) • Conversion rates for Surgery • Waiting Number and Waiting Times • Service Outcomes • Referral to Physiotherapy (Primary or Secondary) • Referral to Orthopaedic Consultant • Assessment, Advice & Discharge • Investigation (including type) and further review • Other Referral (Pain Clinic, Podiatry, Rheum) • DNAs

50. Outcomes • Patients • Improved Access:17 weeks for all referrals. • Patients satisfied with care. • Lower DNA / FTA Rates (6%) • Surgeons • Higher listing rates, better time utilisation. • 20 to 30% of referrals require a consultant opinion • Many now rely on OAS. • Physio’s/Allied Health • Enhanced Career Path