patient flow collaborative learning session 3

Department of Human Services

Patient Flow Collaborative Learning Session 3

WHOLE SYSTEM ACCESS

Bellarine Room 1

Felicity Topp and Mary Mitchelhill


Breakout session 1Bellarine Room 1

9.40 – 10.35

Sue HucksonNational Institute of Clinical Studies, Program Manager

9th February, 2005

Improving care for mental health patients in Emergency Departments

Questions

?

Morning TeaMorning Tea

Meet us back here for Modernisation of Orthopaedic Outpatient

Services

at 10.50



10.50 – 11.45

Leonie OldmeadowVictorian Travel Fellow

9th February, 2005

Modernisation of Orthopaedic Outpatient Services

BackgroundBackground

Byles S and Ling R (1989): Orthopaedic Outpatients-A Fresh

ApproachPhysiotherapy 75 (7): 435-437

Travel Fellowship 2004Travel 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

Impression?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, effectiveFeasible for the Victorian healthcare systemNeeds leadership, support, and evidence

‘‘Physio Direct’Physio Direct’

• telephone triage

• decreases unnecessary GP visits

The first ‘physiotherapy The first ‘physiotherapy surgical practitioner’surgical practitioner’

• screening, theatre and post-operative care triage

• frees surgeon and registrar time for other surgery

What is a physiotherapy-led What is a physiotherapy-led screening clinic?screening clinic?

An additional ‘access filter’ in the patient’s journey, from GP referral to consideration for orthopaedic surgery

‘‘Old’ system of triageOld’ system of triage

GP

surgery

surgeon consult

Physio +

Discharge GP

Referral letter

100%

20%

40%

40%

urgent

soon

intermediate

routine

New system of triageNew system of triage

GP

surgery

surgeon consult physio

discharge

Physio screening

clinic

70%

30%

L

E

T

T

E

R

Manual physio

Physical reconditioning

Pain mgmt

Injection therapy

orthotics

70%

20%

10%

surgeon

Where?Where?In Consultant outpatient clinicsIn Consultant outpatient clinics

Where? In physiotherapy Where? In physiotherapy outpatient departmentsoutpatient departments

Where?Where?In Future: ‘interface’ primary In Future: ‘interface’ primary

multiprofessional team• consultant/physio

specialist from hospital• GPwSI• plus ? others

Who provides the screening Who provides the screening service?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)

CSP/ESP tasks ?CSP/ESP tasks ?• assessment• tests• diagnosis

• discuss with patient

• agreed management triage

• review

• free doctors time

Hip/knee screening clinic-Hip/knee screening clinic-case studycase study

‘‘Top- 10- tips’ for Top- 10- tips’ for implementationimplementation1. Medical ‘champion(s)’ critical (expect resistance)2. Work with GP’s3. Extension to scope of practice, and its limits,

agreed to by Consultants and physiotherapists4. Agreed clinical algorithms and protocols to support

new way of working5. Inform patient re seeing a physiotherapist, right to

request surgeon6. Patient to ring for appointment (decreases DNA)7. Data collection, including cost-effectiveness, from

outset. Implement research activity8. Establish close links with follow-on services 9. Copy letter management plan to patient and GP10. Start small- big cultural change

Questions

?

Team Presentations11.45– 1.00

Lee’s Cluster Bellarine Room 1

•Austin Health

•Melbourne Health

•Peninsula Health

•Southern Health

•Ballarat Health

Tabletop presentationsTabletop 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

Session formatSession 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….


Time Activity Rotation1200-1210 10 minutes

Peninsula presents to AustinSouthern presents to Melbourne ABallarat presents to Melbourne B

1210 –1220

10 minutes

Austin presents to Peninsula

Melbourne A presents to Southern

Melbourne B presents to Ballarat

1220 – 1230

10 minutes

Peninsula presents to Melbourne A

Southern presents to Melbourne B

Ballarat presents to Austin

Rotation 1

1230 – 1240

10 minutes

Melbourne A presents to Peninsula

Melbourne B presents to Southern

Austin presents to Ballarat


Time Activity Rotation1240 - 1250

10 minutes Peninsula presents to Melbourne B Southern presents to Austin

Ballarat presents to Melbourne A

Rotation 2

1250 - 1300

10 minutes Melbourne A presents to Ballarat

Melbourne B presents to Peninsula

Austin presents to Southern

LunchLunch

Meet us back here for

Orthopaedic Outpatients Revolution

at 2.00


Orthopaedic Outpatients RevolutionRelieving the Orthopaedic Outpatients Bottleneck


2.00-2.45

Damian ArmourVictorian Travel Fellow

9th February, 2005

IntroductionIntroduction

• 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

The Challenge – The Challenge – Access to Ortho OutpatientsAccess to Ortho Outpatients

< 1 Month

1-2 Months

2-3 Months

3-4 Months

4-5 Months

5-6 Months

6-7 Months

7-8 Months

8-9 Months

9-10 Months

10-11 Months

11-12 Months

> 12 Months Total

54 85 45 64 60 57 52 45 42 81 34 58 342 1,019

Routine Orthopaedic Outpatient Waiting list patients

Orthopaedic Outpatients Waiting ListPatients Awaiting their 1st Appointment

0

200

400

600

800

1000

1200

200312

200401

200402

200403

200404

200405

200406

200407

200408

200409

200410

200411

200412

Pati

en

ts

1 - Urgent 2 - Semi Urgent 3 - Routine

Victorian Travelling FellowshipVictorian 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.

Victorian Travelling FellowshipVictorian Travelling Fellowship1 Stockport NHS

2 Aintree Hospitals

3 Whiston Hospital

4 Royal Liverpool Hospital

5 University Hospital of North Staffordshire

6 Somerset Coast PCT

7 Royal Bournemouth Hospital

8 Southampton Health Community

9 Modernisation Agency

1

2

3

4

5

9

6 7 8

Fellowship SummaryFellowship 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.

Fellowship SummaryFellowship 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.

OAS OverviewOAS OverviewStage 1 – GP Referral

Patient has an assessment in a locality based clinic by a specialist physiotherapist to identify appropriate care pathway.

Stage 2 – Face to face physiotherapy triage assessment

Specialist physiotherapists review all referral letters to identify the appropriate care pathway

GP sees patient with an Orthopaedic/musculo-skeletal condition and ‘refers’ them into the OAS.

Appropriate treatment not clear from referral Appropriate treatment clear/unambiguous from referral

Patient referred directly back to GP

Patient referred directly to Orthopaedic consultant

Patient referred directly to podiatry, rheumatology

Patient referred directly to Orthotics

Patient referred directly to pain management

Patient referred directly to physio for treatment

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

GP ReferralGP 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.

TriagingTriaging

• 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.

Clinic StructuresClinic 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.


• 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).


• Clinic Outcomes– Not just Assessment– One Stop Shop

• Assessment / Advice / Discharge

Downstream ImpactDownstream 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.

Downstream ImpactDownstream 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.

Workforce Issues - Workforce Issues - Orthopaedic ConsultantsOrthopaedic 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).

Workforce Issues – Workforce Issues – GP’sGP’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.

Workforce Issues – Workforce Issues – PhysiotherapistsPhysiotherapists• 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

Workforce Issues – Workforce Issues – OtherOther

• 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.

Change ManagementChange 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.

Government InfluencesGovernment 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.

MeasurementMeasurement

• 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

OutcomesOutcomes

• 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

Barwon Health’s StrategyBarwon Health’s Strategy

Improving Access to Orthopaedics Steering GroupOrthopaedic Spokesperson GM Surgical Services Project Leaders (3)Orthopaedic Surgeon DND Surgical Services Chief Physiotherapist BM Surgical Services Project Manager ESAC

Project Manager (PT)

Outpatient AccessProject Lead - PhysioExec Sponsor - GMSSSurgeonDeb Schulz (Chief Physio)Lisa Adair (NUM OPD)Jeff Urquart (GP)

TheatreProject Lead - R CockayneExec Sponsor - DNDSSSurgeon – Mr WillamsAnos RepresentativeLee Rendle (ANUM Ortho)Haydn Lowe (ESAC)Audrey Williams (CSSD)

Inpatient AccessProject Lead - L Coleman Exec Sponsor - BMSSSurgeonHaydn Lowe (ESAC)Mick O’Donnell (NUM Ward)Rehab Rep

Focus AreasOP Waiting NumbersOP Waiting TimesPhysio led servicesBetter use of consultant time.

Focus AreasTurn around timesStart timesEquipment IssuesConsumables

Focus AreasLength of StayRehab PredictorPatient EducationBed Management in Ward

State-wide FocusState-wide Focus

1. Awareness of the Outpatient issue– “Can’t manage what you don’t measure”

2. Identify existing initiatives.– National & International

3. Coordinated/Consolidated focus– NHS Modernisation Agency– DHS Collaborative

ReferencesReferences

• Chartered Society of Physiotherapists (UK)– www.csp.org.uk/download/sep/pdf/csp_sep_ocos.pdf

• NHS Modernisation Agency– www.modern.nhs.uk/serviceimprovement/1339/1990/7700/Orthopaedics

GuidevFinal.pdf

Questions

?

Afternoon TeaAfternoon Tea

Meet us back in the Plenary for

Statewide strategic innovation

at 3.00

patient flow collaborative learning session 3

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