Department of Human Services
Patient Flow Collaborative Learning Session 3
WHOLE SYSTEM ACCESS
Bellarine Room 1
Felicity Topp and Mary Mitchelhill
Department of Human Services
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
Department of Human Services
Breakout session 2Bellarine Room 1
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….
Session formatSession format
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
Session formatSession format
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
Department of Human Services
Orthopaedic Outpatients RevolutionRelieving the Orthopaedic Outpatients Bottleneck
Breakout session 3Bellarine Room 1
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.
Clinic StructuresClinic 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).
Clinic StructuresClinic Structures
• 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