Transforming Musculoskeletal (MSK) Care in Ontario: A Comprehensive MSK Access to Care Program. London Middlesex Primary Care Alliance March 28, 2018

Transcription

1 Transforming Musculoskeletal (MSK) Care in Ontario: A Comprehensive MSK Access to Care Program London Middlesex Primary Care Alliance March 28, 2018

2 Objectives Provide an overview of the Provincial MSK Strategy Context for action/case for change Why MSK populations first? Patient Pathway: hip and knee OA and low back pain patients Standardized provincial program elements Local planning and implementation flexibility South West LHIN project initiation update Next steps/key planning milestones Primary Care survey results & feedback received to date Discussion 2

3 Patient Story Impact of Waiting for Ortho Surgery Patient Healthcare Forum Patient Story/ 3

4 Overview of the MSK Strategy 4

5 Case For Change: Hip and Knee Replacements Wait Times Patients in the South West LHIN waited between 245 days and 757 days for their hip replacement consultation and surgery in Q3 Patients in the South West LHIN waited between 224 and 817 days for their knee replacement consultation and surgery in Q3 5

6 Case For Change: Lower Spine Surgical Consultation Wait Times LHSC Spine Surgery Consultation (Wait 1) Wait Time (days) FY 2016/17 Q1 FY 2016/17 Q2 FY 2016/17 Q3 FY 2016/17 Q4 FY 2017/18 Q1 FY 2017/18 Q2 FY 2017/18 Q3 Mean 90P Low back pain patients in the South West LHIN waited an average of 160 days, and 9 of 10 patients waited as long as 592 days for spine surgery consultation in Q3 2017/18. Generally, less than10% of patients referred for spine surgery consultation are surgical candidates. This results in patients waiting months in the wrong queue. 6

7 Case For Change: Why are hip and knee wait times so long? Funding Referral Patterns? Imbalance of Supply and Demand? QBP Funding Does Not Match Demand for Service Primary Care Preference for Certain Surgeons Inflated Demand Versus True Raw Demand Due to multiple referrals for single patients Funding Incents reinvestment to a Maximum amount Backlog of Open Cases is consistent and Allocations don t address the population waiting Clinical Appropriateness of patients on open case wait lists OA Prevalence in the South West Are our Patients Really different? Clinical Appropraitenes of patients on open wait lists Ortho Surgeons per capita in The South West Patient Demographics Hospitals Prioritize OR time/ global budget to other case types b/c allocations are set Process Changes ( e.g. Intentional Movement of patients From wait 1 to wait 2 lists Backlog of Open Cases is consistent and Allocations don t address the population waiting Filing Cabinet of Patients Not Documented In WTIS or Novaris ( Surgeon s Cushion) Patients choose to wait longer for a certain surgeon Patients Shop Different Lists Reporting/Waitlist Management? Data Quality and Gaming Out of LHIN patients in contrast to LHIN patients going elsewhere Variation between providers impacts reported wait times Long Wait Lists Encourage Early Referrals No Central Intake in current State enables historical reference patterns Community Resources unknown to providers Prevention/Self- Management Long Wait Times (Total Hip and Knee) Lack of standardized conservative Management Prevention Strategies We know our referral patterns and reporting/waitlist management practices directly contribute to long wait times. Through the implementation of the MSK program we will endeavor to understand if our funding meets our local population demands 7

8 What actions are required to improve Ortho wait times? 8

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14 South West LHIN Project Initiation Update Local project governance structure has been developed (Steering Committee, Clinical Advisory Board and Working Group) with all tables launched in December 2017 Executive Sponsors of the initiative are Cathy Vandersluis, VP of Surgery at London Health Sciences Centre and Sue McCutcheon, Director of Regional Programs at The South West LHIN. Project Core Team members laisse with provincial colleagues on a regular basis to inform and receive updates on standardized tools and resources to be used across the province Engagement strategies with Primary Care, Community Support Services, Allied Health Professionals, and Surgical Teams are taking place to influence and inform the local direction Technology: Novari e-request has been confirmed as the Central Intake software for this and future coordinated access models in the South West LHIN Provincial work is underway to expand the use of ereferral from Primary Care to facilitate referrals for patients to specialist and community resources. MSK has been identified as a priority pathway for early ereferral implementation. 14

15 Next Steps/Key Planning Milestones Job postings for Advanced Practice Leaders to champion the assessment component of the pathway will be posted by March 31 st. A staggered recruitment approach will be used for Assessors and Central Intake Administration. Determination of the location of the Assessment Centres across all sub-regions in the South West LHIN Further engagement with Primary Care and Allied Health to inform final referral forms Support for building new forms into EMRs will be enabled by Partnering for Quality Implementation and central intake go-live in Q2, 2018/19 15

16 Primary Care Survey Results received to date (n=32) 16

17 Location of Respondents 3.13% 3.13% 9.38% 28.13% 56.25% Grey Bruce Huron Perth London-Middlesex Oxford Elgin 17

18 Physiotherapy What % of your patients with hip or knee OA do you refer for physiotherapy? 50.00% What % of your patients cannot afford physiotherapy? 40.00% 40.00% 30.00% 30.00% 20.00% 20.00% 10.00% 10.00% 0.00% % 60-80% 40-60% less than 40% 0.00% % 60-80% 40-60% less than 40% Does your community have easily accessible physiotherapy facilities (location, cost )? 40.63% 59.38% Yes No 18

19 Knee Osteoarthritis Injections Do you recommend injections cortisone and/or HA injections to your patients with knee OA? 0.00% % Yes No 40.00% 30.00% 20.00% 10.00% 0.00% What % of your patients with knee OA receive injections cortisone and/or HA? 9.38% 18.75% 34.38% 37.50% 0.00% % 60-80% 40-60% less than 40% I do not recommend injections 19

20 Hip Osteoarthritis Injections Do you recommend injections - cortisone and/or HA injections to your patients with hip OA? 41.94% 58.06% What % of your patients with hip OA receive injections - cortisone and/or HA? 60.00% 51.61% 50.00% Yes No 40.00% 30.00% 19.35% 20.00% 9.68% 12.90% 6.45% 10.00% 0.00% % 60-80% 40-60% less than 40% I do not recommend injections 20

21 Community Programs Does your community have free or affordable community exercise programs (through community centres, gyms, arthritis society.)? Community Exercise Programs Available 45.16% 54.84% Yes No YMCA VON Arthritis society Memorial Boys and Girls Club SMART exercise program Tai Chi for Arthritis Senior's Centre Centre for Activity and Aging Healthline Do you refer to or provide your patients with self-management programs/tools (through the Arthritis Society, the 32.26% 67.74% Yes No Self Management Tools and Programs Chronic pain self management group Arthritis society Fowler Kennedy Bioped Sole Science SW LHIN self management 21

22 Discussion 22

23 What We ve Heard So Far From Our Primary Care Partners (PCP) Clear messaging is needed regarding the volume, extent and locations of assessments performed by the interprofessional team. Develop and communicate roles and responsibilities for PCP, Assessors and Surgeons. Consider algorithm about when to provide cortisone vs. knee replacement. Desire for this program to provide education to PCPs and other providers (i.e. Chiropractors, Inter-professional teams, Community Programs) [about the referral process and inclusion criteria?] Negate conflicting medical measures being recommended to PCPs ( i.e. Opioids). Today, PCPs are having to send multiple x-rays/mris due to 6+ month waitlists. Current referral process is cumbersome for PCPs, i.e. PC is currently the gatekeeper for requesting and communicating appointments to patients. 23

24 What We ve Heard So Far From Our Primary Care Partners (Continued) Wait times for people who need replacements are too long & a plan is needed to address the backlog of surgeries. I have many newcomer clients for whom having an interpreter funded for their [assessment] sessions is important. Wait times may be reduced by unnecessary referrals. Cost of bracing, orthotics, physiotherapy is a major barrier for our CHC clients and many others I expect. Make [publish] a list of family physicians doing injections to help with wait times. 24

25 Discussion What early advice/feedback would you offer the MSK Team to achieve success in implementation? How would you like to be communicated with, using what mechanism s? How do you support your non-surgical patients today? What education/supports would be beneficial to you in PC? 25

26 Appendix A Additional MSK Program Information 26

27 LHINs with CIACs have seen a greater improvement in their wait time for hip and knee replacement surgery (Wait 2) A comparison between LHINs with CIACs and without CIACs demonstrates significantly lower wait times in LHINs with CIACs. CIACs have also contributed to a greater percentage of change in wait time since 2007/08, decreasing by 27%. 90 th percentile wait time 07/08 15/16 Change (days) % Change LHINs with CIACs % LHINs with no CIAC % CIACs with high participation rates (volumes of patients going through the CIAC vs other process) are providing patients with faster access to consultation (Wait 1) and surgery (Wait 2), while CIACs with low participation rates have less of an impact on wait times. Wait times in the Champlain LHIN (where the CIAC model is mandatory for primary care physicians making hip and knee referrals), wait times have shown significant improvement and are among the best of CIAC sites. 27

28 CIAC Success To-date LHINs with CIACs have seen a greater improvement in their wait time for hip and knee replacement surgery and patients going through CIACs experience shorter waits In the Champlain LHIN, where the CIAC model is mandatory for primary care physicians making hip and knee referrals, wait times are better than in LHINs where CIACs are not mandatory. 90 th percentile wait time 07/08 15/16 Change (days) % Change LHINs with CIACs % LHINs with no CIAC % Comparison of CIAC vs Other Models Wait 1 Volume and Days Hip and Knee Replacement Surgery - Q3 2016/17 CIAC Wait 1 Volume Other Models Wait 1 Volume CIAC Wait 1 Days Other Models Wait 1 Days 100% Volume Proportion CIAC/Other 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Hamilton Niagara Haldimand Brant Central West Toronto Central Central Champlain North Simcoe Muskoka North East Source: Wait Time Information System, Access to Care at Cancer Care Ontario North West th Percentile Wait 1 (Days) 28

29 ISAEC Pilot Care Pathway Community Providers LBP Patient Primary Care Provider (granted referring privileges after LBP training) ürecommendations for ancillary support (when indicated) Specially trained Advanced Practice Physiotherapists and Chiropractors Specialists Community Programs, Physiotherapists, Chiropractors, Psych Counseling, Occupational Therapists, Registered Massage Therapists, Acupuncturists. Spine Surgeons, Rheumatologists, Pain Specialists, Physiatrists ü (Updated) Tailored Treatment Plan and resources for ongoing selfmanagement ü Central referral intake and patient bookings # ü (Updated) Consult Note and Patient Treatment Plan and other resources ü Streamlined access to networked spine specialists and diagnostic services* (when indicated) Diagnostic Services üdi Referral, etc. (when indicated) MRI, etc. * Spine Surgeon and Imaging arranged by ISAEC. ü ISAEC follow-ups for patients assessed to be Complex 29

30 ISAEC Pilot* Successes to Date: Since November 2012, ISAEC has consistently demonstrated positive results in terms of delivering accessible, evidenced-based, patient-centred LBP services. Key achievements include: Provided services to over 6,000 patients, including referral to APCs in under two weeks; High rates of patient and provider acceptance as evidenced through high satisfaction rates (patient at 99% and provider at 96%); Improved patient outcomes with reduction in chronicity six months following ISAEC treatment; Significant built-in knowledge transfer to participating PCPs, who reported a two-fold increase in their confidence in treating/ managing LBP. Greater than 96% of patients referred for ISAEC surgical consultation by their ISAEC APC were surgically appropriate, and less than 7% of ISAEC patients have gone on to imaging or specialist intervention. * ISAEC pilot sites are in Toronto, Hamilton and Thunder Bay 30

31 Appendix B Additional Survey Responses (N=32) 31

32 Knee Osteoarthritis Injections Do you inject your knee OA patients, or refer them out? 0.00% 43.75% 56.25% Inject myself Refer out I do not recommend injections If you refer out, who do your refer to? 45.16% 9.68% 16.13% 22.58% 6.45% Other family medicine colleagues Sport and exercise medicine physician Rheumatologist Orthopedic Surgeon Other Average wait times Weeks Other family medicine 10 Sport and exercise medicine 5 Rheumatologist 18 Orthopedic Surgeon 6 Other 12 Physiatrist 32

33 Hip Osteoarthritis Injections Do you inject your hip OA patients, or refer them out? 21.74% 8.70% 69.57% Inject myself Refer out I do not recommend injections % of Respondents that refer to specialists 29.63% 11.11% 3.70% 14.81% 37.04% 3.70% Other family medicine colleagues Sport and exercise medicine physician Rheumatologist Orthopedic Surgeon Other I do not recommend injections Average wait times Weeks Sport and exercise medicine physician Orthopedic Surgeon Other Radiology 33

34 Hip Osteoarthritis Injections Do you inject your hip OA patients, or refer them out? 20.00% 10.00% 70.00% Inject myself Refer out I do not recommend injections If you refer out, who do your refer to, and what is the wait time? (select all that apply) 30.77% 10.26% 7.69% 12.82% 35.90% 2.56% Other family medicine colleagues Sport and exercise medicine physician Rheumatologist Orthopedic Surgeon Other I do not recommend injections Average wait times Weeks Sport and exercise medicine physician Orthopedic Surgeon Other Radiology 34

35 Bracing Stores Does your community have specialized bracing stores (eg. Shoppers Home Health, Athletic World.)? Bracing Stores 25.81% 74.19% Yes No Lifemark Shoppers Home Health Wreck Room Right Fit Fowler Kennedy Bioped Med e Ox Physio Clinics Foot by Foot 35