Temora Virtual Fracture Clinic:Telehealth for Fracture Follow-up in Murrumbidgee LHD

Presented by Duncan McMaster- Physiotherapist

Acknowledgements• The traditional custodians of the land in which we live and work, the

Wiradjuri people. We acknowledge the value of culture and beliefs and try to be reflective as we develop health services that positively affect everyone.

• Presentation adapted from Annie Nichols and Ellen McMaster’s previous presentations

• Gloria the patient who kindly agreed to share her story

• Jill Ludford and MLHD Executive for supporting innovation initiative through the Edison Program

• The project team – extensive

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Murrumbidgee Local Health District Temora Virtual Fracture Clinic

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BackgroundTemora is located around a hours drive from WaggaSpecialist Orthopaedic team is located in WaggaWe were successful in getting approval + support to trial the Temora virtual Fracture ClinicWagga specialists telehealth to staff and patient at Temora

Project Overview

• Problem identified• Patient journey was mapped• Idea of the Virtual Fracture clinic in MLHD • Project team identified• Stakeholder map completed• Scope of project identified. • Consultation with stakeholders and planning.• Set up – working with staff at Wagga and at Temora, Telehealth

implementation manager, EMR team, communicate with GP’s.• Implementation commenced (October 2018 – current)• Evaluation

Identifying the problem

• Patient story• Time of travel

• Unsure of where to go

• Difficulty parking

• Lots of traffic

• Long waiting times at Wagga clinic

• Waiting in full waiting room

• Cost to travel

• Burden on family

• Traveling home late in afternoon/ night

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Patient Journey Mapping

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Patient Diagnosis:Acute Fracture [#]

Clinical Care

Does the patient require

Orthopaedic review or

management ?

GP: Clinical Management of

Fracture

Referral to physiotherapy with

specific and appropriate fracture

management instructions

ED Dr/GP contacts WW Orthopaedic Registrar for advice/treatment options

Via 02 59431000

Yes

• Day: Friday• Time: 1230hrs.• Ortho Team to consult and develop

clinical management plan with each patient

• XRAY

Patients not appropriate for referral to Temora VFC • Ortho Assessment required • Out of scope • Need for special equipment

MLHD FRACTURE CLINIC @ WW

No

Murrumbidgee Local Health District Temora Virtual Fracture Clinic

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Data Collection & Review: Wagga Wagga # Clinic Attendances by Home Location 2017/2018 [Fin.year]

Location Presentations

Ardlethan 3

Ariah Park 7

Barmedman 5

Condobolin 4

Cootamundra 16

Harden 10

Lake Cargelligo 26

Murrumburrah 7

Springdale 3

Stockinbingal 2

Temora 16

Trungley Hall 2

Tullibigeal 2

West Wyalong 17

Wombat 4

Wyalong 3

Young 16

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Our Team

• Annie Nichols- Temora Physiotherapist and Project Lead

• Ellen McMaster- MLHD Allied Health Rural Generalist Pathway supervisor

• Duncan McMaster- MLHD Allied Health Rural Generalist Pathway supervisor and Wagga Wagga Base Hospital Orthopaedic Senior Physiotherapist

• Shane Delves- Telehealth Implementation

• Annie Williams- A/Director, MLHD Strategy & Planning

• Orthopaedic Specialist team in Wagga

• Administration staff in Wagga and Temora

Murrumbidgee Local Health District Temora Virtual Fracture Clinic

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Project Scope

In Scope Out of Scope

Simple uncomplicated fractures – referral from Orthopaedic Consultant/registrar

Complicated fractures that may require further intervention

Follow up consultations Initial consultations for fractures

Patients within 80km radius of Temora Pathological fractures/complex patient

To run in conjunction with WWBH fracture clinic

Fractures requiring surgery/ post-op

Patient Diagnosis:Acute Fracture [#]

Murrumbidgee Local Health District Temora Virtual Fracture Clinic [TVFC]

SERVICE:• Align with Wagga

Fracture Clinic times ( Friday 1300-1500hrs)

• Contact with Wagga Ortho team as needed

• Physio coordinated• Nurse• AHA• Ortho team Wagga on

standby via VC (PEXIP platform)

• VMO on call

ED Dr/GP contacts WW Orthopaedic Registrar for advice/treatment options

Via 02 59431000

Clinical Care

ED Dr/GP completes Care Coordinator clinical

assessment and REFERRAL

Does the patient require

Orthopaedic review or

management ?

No

Yes No

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Yes

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GP: Clinical Management of

Fracture

Referral to physiotherapy with

specific and appropriate fracture

management instructions

TEMORA VIRTUAL FRACTURE CLINIC

ROLE:• Plan actioned by Temora

team• ED protocol for clinical

escalation• Cast application• Cast removal• CAM boot or equipment• Gait correction

/assessment/walking aids

• Rehab appointment• Post cast care

Physiotherapy Assessment and

indicated management align with GP

request

Initial Management at WWBH ORTHO WARD/CLINIC/ED

• Plan• X-ray Referral

Liaise with GP or if GP not available, Ortho

team

• Day: Friday• Time: 1230hrs.• Ortho Team to consult and develop

clinical management plan with each patient

• XRAY

Patients not appropriate for referral to Temora VFC • Ortho Assessment required • Out of scope • Need for special equipment

MLHD FRACTURE CLINIC @ WW

Booking toWWBH # Clinic

or TVFC through WWBH Outpatient Clinics

Clarification?

Patient chooses to

attend WWBH

Murrumbidgee Local Health District Temora Virtual Fracture Clinic

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Temora Virtual Fracture Clinic - Official Launch 7th Nov

Murrumbidgee Local Health District Temora Virtual Fracture Clinic

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Data Collection & Review: Temora Virtual Fracture Clinic Attendances by Home Location (From 12th Oct 2018 to Feb 2019)

Location Ortho Consult (Telehealth) Face to face consult

Ariah Park 2 2

Cootamundra 6 6

Temora 1 5

Stockinbingal 1 1

Young 2 2

Boorowa 1 1

West Wyalong 3 3

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Murrumbidgee Local Health District Temora Virtual Fracture Clinic

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Evaluation – Feedback

• “Quicker, more convenient”• How would you describe your telehealth consultation with the orthopaedic doctor?

“Excellent” • “Less time out of school” • “10/10”• How long after the scheduled appointment time did your appointment actually start?

“Started straight away”

Telehealth: What, where, who, when and why ?

WHAT WHERE WHO HOW WHY WHEN

Laptop, PEXIP + Integrated webcam+ iMEd imaging, + eMR

Wagga Ortho Doctor Usual clinics ExpertFracturemanagement

Clinic day+ email for patient ID

Wagga Physio (facilitates thinking about the VFC)

Usual clinics Assist Doctors with telehealth.Support Temora PT

Clinic day

Wagga Admin Usual clinics Set up Telehealth Booking pt’sthroughout week + Clinic day

Laptop + good webcam + eMR + xray + equipment + persistence & resilience

Temora (patient end)

PatientPhysioAHA(Nurse)(Radiographer)(GP)

VFC Provide a service closer to home when it is neededEg cast off and check xray, refer to physio.

Concurrently with Wagga clinic(Dr access)

Considerations for setting up project

• Case for change- important to selling to executive/ funding/ managers/ specialists

• Scope of practice – doctors aware of physios and telehealth capabilities

• Effective and thorough planning- avoid complications and difficulties which may reduce the chance of success

• Embed change- to increase sustainability

• EMR and processes – how to adapt the tools to fit the needs

• Knowledge and confidence - Staff upskilling and commitment to skill development and resources.

• Communicate with referrers for appropriate patients – including GP’s for scope of the service

• Workforce changes and availability/contingency planning

• Infrastructure: Considered privacy, acoustics, camera/sound, waiting room, consult area located near casting equipment/physio service

• Scheduling –timing with doctors (time to run clinic concurrently with Wagga)

• Scheduling patient/Dr/physio – how will it work? Need coordination even for a small scale.

Lessons Learned so Far….

• Feedback: Integrated camera and microphone on laptop not as good as when using the plug-in Webcam.

• Patients very happy to be part of the pilot and happy with the service. The patient knows the physio and specialist doctor are working together.

• The most important and hardest person to engage was the Orthopaedic specialist. This is an ongoing challenge. Importance to have in-scope and out of scope criteria and clear plans.

• Admin support or AHA support is needed due to clinics booking system/ setting up

• We are still working on identifying suitable patient processes at the Wagga end as the Virtual clinic is not embedded into practice yet – process of change has started but the physio at the remote location is still chasing up the ortho team with the list of potential follow-up patients every week.

Moving forwards

• Sustainability considerations include: • Embed systems/ processes into practice

• Transferability – Young, other

• Minimum staff requirement at rural site = physio (up-skilled in fracture management) AHA, radiographer, nurse availability at clinic time, admin support).

• Minimum staff support required at Ortho team location: Orthopaedic specialist, Registrars, Physiotherapist, NUM, Admin

• ? Option of a Telehealth Coordinator (Qld model) one per district. Coordinates patients/health professionals/room/equipment and scheduling for all telehealth patients so the clinicians can focus on the patient and clinical thought processing.

Questions ??

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