Introduction Rachel Hamilton, GP Tideswell Surgery Chris Rowlands, Transformation, NDCCG Bernie O Donnell, Commissioning Manager

Transcription

1 MSK QUEST 14 June 2017 Introduction Rachel Hamilton, GP Tideswell Surgery Chris Rowlands, Transformation, NDCCG Bernie O Donnell, Commissioning Manager Background MSK spend Activity flow Current MSK pathway and locations Business case scope Future pathway Next steps

2 MSK activity & spend Specialty Non-elective Episodes Elective & Daycase Episodes Activity March 16/Feb 17 Outpatient / Physio First Appointment Outpatient / Physio FU Appointment Annual cost Trauma & orthopaedics ,650,095 Pain management ,023,763 Rheumatology ,046,891 Physiotherapy ,129,760 Grand Total ,850,509 Totals 148,666 episodes/patient contacts directly attributable to MSK services 8.7% of CCG allocation spent on activity directly attributable to MSK services Activity & spend excludes MSK activity/expenditure in primary care (30% of all GP appointments), prescribing, A&E/MIU activity, 111/OOH activity, podiatry, medical NEL admissions with an MSK contributing condition etc. Potential (RightCare data) opportunity to reduce spend on MSK by 4m+ per year (including 3m+ on elective activity)

3 % Total Activity MSK activity flow 50.0% % Elective inpatient & daycase activity by Provider 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Chesterfield Royal Hospital Barlborough NHS Treatment Centre Stepping Hill Hospital One Health Group Ltd Aspen - Claremont Hospital Sheffield Teaching Hospitals Royal Derby Hospital Macclesfield District General Hospital Bmi - Thornbury Hospital Spire Regency Hospital Bmi - The Alexandra Hospital Series2 43.1% 12.9% 11.7% 7.5% 5.8% 4.7% 2.6% 2.5% 2.0% 1.8% 1.2% 4.2% Other

4 TO TREAT: PROVIDED BY: SERVICES OFFERED PROVIDED/OFFERED / North Derbyshire CCG Current MSK Pathway options Patient presents with MSK condition (Triaged by Practice and/or sees GP/ANP/Other Clinician; some selfreferral to Physiotherapy also available) Self Care Primary Care Extended Role Physiotherapist Primary Care Management Physiotherapy (General) MSK Service Further Investigations Lifestyle Services Community Services Routine referral to Secondary Care Specialist Service Red Flag/Urgent Referral Verbal advice Written information Signposting (e.g. decision aids) No further action Patient/Carer Voluntary Sector Web-based All Diagnosis Verbal/written advice then self care Course of therapy Signposting (e.g. decision aids) Pain Management Joint injections Can onward refer (e.g. MSK service, investigations, Consultant etc.) Physio aids Royal Primary Care Review of condition Pain Management Joint injections Written information Signposting (e.g. decision aids) Education Collaboration with Integrated Care Services for patients with comorbidities 35 GP Practices GP ANP ESP/Physio Practice Nurse All Diagnosis Verbal/written advice then self care Course of therapy Signposting (e.g. decision aids) Education Some Pain Management Joint injections Can onward refer (e.g. MSK service, investigations, Consultant etc.) Physio aids (some) DCHS (DCHS sites & in GP Practice) Private Providers ESP (in-house/ CRH) Voluntary Sector (Education only) All Diagnosis Verbal/written advice & self care Course of therapy Signposting (e.g. decision aids) Education Rehab. Classes Can onward refer (e.g. MSK service, investigations, Consultant etc.) Some Pain Management Joint injections Physio aids DCHS (DCHS sites) Voluntary Sector (Education only) X-ray MRI Ultrasound Neurological Other All main Acute Providers DCHS Private Providers Live Life Better weight loss and stop smoking services Derbyshire County Council lead DCHS Integrated Care Services for patients with comorbidities; includes: Integrated Community Core Team Occupational Therapy Falls Prevention Equipment/Aids Voluntary Sector Podiatry Orthotics Advice/ Education DCHS Voluntary Sector St. John s Amb. (Falls P. Service) GP Practice DCC Equipment Provider To Orthopaedics Rheumatology Neurology Geriatrics Neuro Surgery Pain Management Other For Advice/opinion Management Resulting in: Advice & discharge Continuing management Surgery CRH Sheffield Teaching Stepping Hill East Cheshire Kings Mill Private Providers Other NHS Simple acute soft tissue Simple acute spinal Simple to moderate Chronic MSK Simple to moderate acute soft tissue Simple to moderate acute spinal Moderate Chronic MSK Simple to moderate acute soft tissue Minor acute spinal Minor to moderate Chronic MSK Moderate to Complex acute soft tissue Simple to Moderate Acute spinal Moderate to Complex Chronic MSK Moderate to Complex Chronic MSK Complex/Severe Chronic MSK Acute MSK condition 4

5 North Derbyshire DCHS MSK Physiotherapy Services & MSK Service based at New Mills HC & MSK Service inc. chronic pain, injection & Classes based at Walton Hospital (MSK outreach at Wheatbridge & Staveley) GP Practice based Services at: Wheatbridge Health Village, Brimington MC, Brimington Surgery, Newbold Surgery, Holme Hall Surgery Service at Dronfield HC Service at Eckington HC and Killamarsh MP Service at Staveley Clinic Service at Thornbrook Surgery Service At Shirebrook HC & MSK Service inc. chronic pain & injection based at Cavendish and Buxton Hospitals Service at Eyam Surgery MSK Service at Bakewell Agricultural Centre Service at Welbeck Road HC & MSK Service inc. injection based at Ashford Therapy Unit & MSK Service inc. injection based at Whitworth Hospital Service inc. chronic pain & classes at Clay Cross Hospital Service at Tibshelf HC 5

6 North Derbyshire Private Provider & other Physiotherapy/MSK Services 3VH Service focussing on Rheumatology (offers service to all NDCCG patients but based in the High Peak) Chapel-en-le-Frith Mobile Physiotherapy Patients (Housebound patients only) Barlborough and other private MSK surgical providers also provide some (mainly but not exclusively) post-op physiotherapy Royal Primary Care and Creswell GP Practices also provide Physiotherapy triage/treatment as part of their core primary care service provision Whitehouse. Referrals from 3 GP Practices (Tideswell, Arden House, Evelyn MC) CRH Extended Role Physiotherapy Practitioner for Services. CRH Pain Management Department Devonshire. Referrals from 3 GP Practices (Buxton, Stewart, Elmwood) Claremont based at Bakewell MC mainly for postop/other patients referred to Claremont (Sheffield) GC 2 Extended Role Physiotherapy Practitioner for Physiotherapy/MSK Services. 6m pilot 2016/17 6

7 What next for Marjorie? It could be any of the following options. GP requests X- ray GP prescribes Pain Management GP discharge to self care with advice/ signposting GP with T&O interest manages care Referral to General Physiotherapy (DCHS or CRH) Referral to Pain Management Services (CRH, DCHS) Referral to MSK Service (DCSH or CRH) Referral to another English T&O provider Referral to BMI Thornbury Marjorie is a 60 year old lady who has recently retired from teaching and lives in Newbold, Chesterfield. She is a keen gardener but has noticed increasing pain in her left knee when she tries to kneel or walk for longer distances. She is concerned that her knee pain will prevent her from continuing with her hobbies. She presents to her GP who suspects she is suffering from osteoarthritis. Referral to Claremont Referral to One Health Referral to Sheffield MSK CATS Referral to CRH T&O Referral to Barlborough

8 Business case scope Stages of the MSK Pathway (Summarised) Self-Care Patient does not access NHS services May access private services (e.g. physiotherapy) May access web-based or written information Self-referral to lifestyle services Primary Care GP Practice Collaboration/advice/ Joint working Advice & discharge to self-care Further review or may consider onward referral (proposed secondary care referrals via MSK CATS service; pathway for 2ww referrals dependent on referral management model) Diagnostics Pain Management Joint injections Written information/signposting/education Collaboration with Integrated Care Services for patients with co-morbidities Referral to lifestyle services IN SCOPE General Outpatient Physiotherapy Accepts referrals from GP/other clinician or self-referral Rehabilitation treatment (e.g. following hospital stay) Course of treatment for simple acute MSK conditions Advice & discharge to self-care, further review or may consider onward referral Diagnostics Written information/signposting/education Collaboration with Integrated Care Services for patients with co-morbidities Patient aids (some) Referral to lifestyle services MSK CATS Service Accepts referrals from GP/other clinicians but no patient self-referral without triage Referral management service with clinical triage of referrals Course of treatment for simple chronic/more complex MSK conditions Advice & discharge to self-care, further review or may consider onward referral Diagnostics Written information/signposting/education and use of patient decision making-aids Collaboration with Integrated Care Services for patients with co-morbidities Patient aids (some) Rehabilitation Classes Onward referral where appropriate for specialist opinion/intervention Referral to lifestyle services Specialist Services Secondary Care (Orthopaedics, Rheumatology, Neurology, Pain Management Service, other) Community Services (Podiatry, Orthotics, Equipment) Specialist review and decision/advice on further management Collaboration/advice/ Joint working

9 MSK CATS Pathway Patient presents with MSK condition Assessment/Triage by GP practice or potentially other Community Services Investigations Red flag / Urgent or Emergency Simple acute soft tissue or spinal Simple Chronic MSK Moderate acute soft tissue or spinal Simple to moderate Chronic MSK Moderate to complex acute soft tissue or spinal Moderate Chronic MSK Moderate to Complex MSK LTC Self Care Primary Care Management Lifestyle Referral if indicated Patient self-referral to OP Physiotherapy, Podiatry or Lifestyle Services Primary Care Management Lifestyle Referral if indicated Podiatry MSK Pathway Symptoms not resolved Symptoms resolved Symptoms not resolved Other MSK LTC MSK CATS Service Referrals sent to single point of entry via e-rs Options include: Diagnostic investigations Pain Management Course of therapy Clinical Assessment and pathway tailored to patient s needs Joint injections Education Rehabilitation Classes Verbal/written advice for self care Review options & signposting (e.g. decision aids) Onward referral (e.g. Orthotics, Equipment) Symptoms resolved Symptoms not resolved and unable to manage with self care or in primary care PLCV referral criteria met? NO Address issues YES or not relevant Onward referral to: Orthopaedics, Pain Management, Neurology, Neuro-Surgery, Rheumatology or other relevant specialty

10 Patients Mark is a 35 year old who is a keen 5 a side football player. He has developed heel pain after a training session that is causing him pain when he tries to run. He self refers to physio via a contact telephone number advertised (at his local GP surgery/websites ) The physio diagnoses him with achilles tendonitis and advises on a personalised rehabilitation program (stretching and strengthening exercises). The physio also refers him on to orthotics for some heel raiser insoles to help prevent a recurrence of the problem. After 6 weeks Mark s pain is much improved and he manages to return to football.

11 Patients Remember Marjorie - 60 year old, retired from teaching, keen gardener but has increasing pain in her left knee when she tries to kneel or walk for longer distances. Concerned her knee pain will restrict her hobbies. She presents to her GP who suspects she is suffering from osteoarthritis. Her GP discusses the condition and talks through the management options with her, giving her a link to the online right care patient decision aid tool that Marjorie works through when she gets home. After reading about the different options Marjorie self refers to physiotherapy. She is not keen on surgery but struggles with her weight and is not confident with performing the exercises given to her. The physio refers her to the local OA knee class, where as part of a small group she is given information and practical advice and support on managing her arthritis. Through undertaking the group exercises she develops more confidence and starts performing them herself at home. She finds the peer support of the group a great help. With her improved confidence and increased levels of activity she manages to lose some weight and finds her knee pain is much more manageable.

12 Patients Keith is a 75 year old gentleman with a 6 month history of increasing pain in his right hip despite some previous physiotherapy input. He has found it increasingly difficult to walk in to town or drive without pain. The pain also stops him from sleeping well. He presents to the GP who notices a significant reduction in the range of movement at his hip and arranges an x-ray which confirms osteoarthritis. Due to the amount of functional limitation his GP refers him the MSK CATS service. The referral is triaged by the extended scope practitioner who agrees that a direct referral to orthopaedics is appropriate and an appointment is made with the consultant who lists him for a hip replacement. Keith receives early mobilisation post operatively and is discharged home after 2 days with transfer of physiotherapy to the community team. After 6 weeks Keith can stop using crutches and has already noticed significant improvement in his pain and function.

13 Patients Sandra is a 65 year old with a 3 day history of low back pain and numbness to her calf. She has noticed that she seems to be dragging her foot when she walks. She presents to her GP who notes that she has a history of breast cancer 10 years ago. Examination reveals numbness and weakness as she has described. Due to the red flags in her history, the GP arranges a 2ww appointment with the spinal surgeon who performs an MRI scan. Due to the red flags the referral bypasses the triage stage of the MSK pathway and an appointment is booked directly. Thankfully there are no signs of spinal metastases on the MRI scan but Sandra does have a large disc prolapse causing her symptoms. The surgeon advises her that there is a 50-60% chance of improvement if managed without surgery over the coming 4 months. She decides to watch and wait and by the time of her follow up appointment her symptoms have almost completely settled. She is discharged with some physiotherapy follow up in the community.

14 Paul s symptoms have settled well and is informed he can self-refer again via physiotherapy if his symptoms were to return. Patients Paul is a 37 year old who has been diagnosed with carpal tunnel syndrome for the last 4 months. He makes an appointment to see his GP as his symptoms of intermittent numbness and pins and needles to his left hand haven t settled and his symptoms are waking him up at night. He has had some initial physiotherapy and tried using a splint for 12 weeks without any benefit. His GP refers him to the MSK CATS service. After the referral is triaged The extended scope practitioner phones Paul to get some more information On discussion, it transpires that although persistent, Paul s symptoms are mild and he is not keen on surgery An appointment is made with the extended scope practitioner who performs a steroid injection The extended scope practitioner arranges to phone him up at 3 months to review his progress

15 Pathway agreed MSK CATS Service mandatory compliance and extended general outpatient physiotherapy service in primary care Single pathway with mandatory compliance Supporting referral management system implemented; working in partnership with new PLCV referral process Expanded MSK CATS service to deliver the pathway and triage all referrals No direct outpatient referrals to secondary care providers for orthopaedic referrals from GPs, consultant to consultant or other clinicians (excludes trauma/fracture clinic or post non-elective stay) GP/Clinician education and awareness programme No changes to general outpatient physiotherapy services General outpatient physiotherapy services infrastructure improved to include expanded capacity and enhanced self-referral options (telephone, web-based, marketed, standardised model) Designed to support additional activity in order to support primary care capacity and enable patients to access the right services more quickly. Could be expanded to include other relevant specialties (e.g. rheumatology, pain management)?

16 Enablers Redesigning of existing services Existing commissioning model NDCCG wide service All MSK specialities Contracted medical input to the core service MSK specific referral management hub

17 Outcome measures for the project Improve health outcomes for patients with an MSK condition and support them to make the right treatment choice Ensure that all patients have equity of access to MSK services and are supported to make an informed choice on their treatment options Develop and implement a consistent and more clinically effective MSK service across NDCCG; incorporating both specialist MSK services and general outpatient physiotherapy Ensure that GPs and other clinicians are supported to make the right choice and access the most appropriate services to manage the patients MSK condition Implement an MSK referral management service which requires clinical triage of routine cases before a referral to secondary care is made Minimise the number of patients who are referred to secondary care for assessments and treatments when there may be more appropriate clinical options available Timescales, flexibility and commissioning model

18 Next steps Task/Milestone MSK Pathway and PLCV business case approval and authority to proceed are confirmed (Governing Body 22 May 2017) Project resources and level of investment are confirmed and in place Target Completed Mobilisation plan and service specification developed and agreed with provider(s) June 17 Share plan with other Derbyshire CCGs and understand/confirm their and STP approach to managing the MSK pathway July 17 Communication, engagement and education plan development and sign-off June 17 Communication, engagement and education plan implementation From June 17 Mobilisation plan implementation to support launch September 17 Providers develop plans, capacity and infrastructure September 17 Implement PLCV referral management infrastructure and systems From July 17 Agree, develop and implement standard patient information and shared decision tools September 17 Implement roll-out of phase 1 October 17 Implement roll-out of phase 2 April 18