AHP Musculoskeletal Service Redesign. Judith Reid MSc MMACP Consultant Physiotherapist in MSK NHS Ayrshire and Arran

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1 AHP Musculoskeletal Service Redesign Judith Reid MSc MMACP Consultant Physiotherapist in MSK NHS Ayrshire and Arran

2 Local Drivers Routine referral practice Via acute care, duplication Long waiting times for AHP services Fragmented uncoordinated care Inconsistencies across Ayrshire and Arran Chronicity and re-referral Lack of alternative management options National review of spinal services

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4 Insanity: Repeatedly doing the same thing and expecting a different outcome Albert Einstein

5 The Quality Strategy 2010 Shifting the Balance of Care Policy Drivers Extend the scope of services provided by non medical practitioners outside acute hospital Improve capacity and flow for scheduled care Health Works Better Together Programme Achieving Sustainable Quality: A 20:20 vision 2011 Joint Effects 2011 AHP National Delivery Plan 2012 National Review of Spinal Services

6 Our Vision Improve Community Based Access AHP team, Physiotherapists, Occupational Therapists, Podiatrists, Orthotists Targeted Treatments, improved outcomes Process of Escalation Access to Investigation and/or secondary care services Right Person, Right Time, Right Place

7 Summary of Pathway STAGE ONE Patient presents with back pain disorder Red Flag, Cauda Equina Screening URGENT ORTHOPAEDIC REFERRAL STAGE TWO GP management Enablement of self help Working Health Service STAGE THREE Referral process Orthopaedics STAGE FOUR MSK TRIAGE AND TREATMENT Rheumatology Other Acute Services DISCHARGED Pain Services

8 Process of Escalation Patients failing to progress / improve Complex presentations Clinical supervision and support Advanced Practitioner Clinics Shadowing, peer review, education Timely access for patients Further Investigations Referral onwards

9 Escalation on Pathways ALL primary care sites Further investigations Onward referral Advanced Practitioners Pain Champions MDT Foot and Ankle Clinic Education

10 Improve Outcomes? Business Orthopaedic Referrals Surgical Conversion Quality EQ5D5L Condition specific Person Centred Survey and focus group techniques Safe Clinical presentation mapping Datix/complaints

11 Impact of Low Back Pain Pathway Pre Low back pain pathway, back pain accounted for 40% ESP capacity Post implementation 10% of capacity SAVING 945 new patient appointments per annum In general, MSK pathway is better than hospital consultants and GPs at delivering well thought out cases for surgery Consultant Orthopaedic Spinal Surgeon

12 The Pathways Mapping Redesign Event(s) Engagement sessions National guidance Evidence / Clinical guidelines Sharing Good Practice Consultation.. Pathway leads AHP Management Frameworks Launch events Education sessions Review Process

13 Reconfiguration Electronic Referral Process template Single Point of Access for MSK team Single Waiting List Electronic Triage by core team Appointing to most appropriate clinician Seamless transition within pathway

14 New name, unfamiliar Challenges tradition Board area Lots of change, timing What and why Relationships with stakeholders Of which there are many! Communication..

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16 Milestones Establish Programme Board Sept 2010 Back Pain Pathway April 2011 Stakeholder Event April 2011 Community ESP clinics May 2011 Comms Strategy July 2011 Stakeholder Event Oct 2011 Centralised Referral Management Hub / Transition to Trak/PMS Aug 2012 Implementation of Pathways Oct 2012

17 Referrals per pathway NHS 24 Hip Knee Elbow, Wrist and Hand Foot and Ankle Shoulder Spinal = Back, Neck & Thoracic

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19 The new model GP Directed Protocol driven TRIAGE TOOL WHSS 5% out Self Referral Directed from other sources NATS - Developed by expert panel - Safe: Identifies red flags Ability to identify Low Risk (self-management) MEDIUM / HIGH RISK HUB Referral 30% out * * Local MSK Hub - e-vet - Appoint - Auto-letter generation (patient informed within 5 days) Physio Clinical assessment, EQ5D and outcome measures Podiatry Clinical assessment, EQ5D and outcome measures Occupational Therapy Clinical assessment, EQ5D and outcome measures Equally Well Employability Services Mental Health Pain Services Leisure Rheumatology Vocational Services Older People Services Orthopaedics Community Pharmacy Dietetics Self Management First appointment

20 Number of referrals MATS referrals

21 Impact...6 months on Decreased demand on acute services, sustained at 25% Increased Appropriateness of Surgical Referrals Streamlined the Patient Pathway

22 2500 Orthopaedic Outpatient Waiting List Total Waiting Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13

23 MSK Waiting Times Series1 Series2 Series3

24 Waiting Times Persistent Lack of capacity/resource Year on Year increase in referrals of 6% Lost capacity during transition to PMS Non Attendance Loss of patient Focussed Booking Underutilisation of Existing Capacity

25 Patient Appointments % of added, removed Additions, Removals, Balance / / / / / / / /2013 Added Removed Balance % Added, Removed 35% 81% 87% 98% 78% 77% 87% 116% Months 2012/13 140% 120% 100% 80% 60% 40% 20% 0%

26 DNA (Non Attendance) pre go live post go live OT Podiatry Physiotherapy

27 Test of Change Netcall Remind Plus Patient Focussed Booking Analysis of Non Attendance STarT Score / Stratification Age

28 STarTBack, Hill et al 2008 High 24% Medium 28% Low 48% Risk of Chronicity / Poorer Outcome Population Targeted Treatments New to Review Ratios Identify Development Needs

29 Stratified Intervention No intervention stated Advice only Leisure services Physiotherapy management Rehab class Functional Restoration Programme Pain class Combined clinic Refer back to GP

30 Chronic Pain Service Improvement Group Opportunities Funding 50,000 a year for 2 years from Scottish Government to facilitate service redesign formulation of MCN Clinical psychologist job plan Recommendations Integration of MSK and pain management pathways Appointment of additional multidisciplinary team staff Development of pain management programme

31 Quality Data EQ5D5L Condition Specific Measures Change in EQ5D VAS Decline 11% Profiles ISQ 24% Correlation Health Economist Improvement 65% Further Evaluation

32 Things that worked well Person Centred Improved journey for patients Potential to deliver improvements in patient experience and outcomes Improved access to second opinion and onward referral Improved learning and development opportunities Data to support ongoing developments Things that didn t work so well GPs not fully aware of pathway or have limited understanding Confusion caused by continuing duplication of referrals Lack of admin/clerical support compromised compliance and clinician time Volume of paperwork overwhelming

33 Challenges Administrative Processes IT restraints DNA rate Communication, Communication, Communication...

34 Ayrshire & Arran Musculoskeletal (MSK) Redesign Programme April 13 update Programme Goal Improve access to the most appropriate MSK management and treatment pathways: better clinical outcomes and experience. Impact on Orthopaedic Demand Oct NovDec Jan Feb II Programme Activity Achievements Data indicates 34% reduction in Orthopaedic referral rate Increased capacity of Complex Case Clinics now on all sites including Arran Multidisciplinary foot and Ankle clinic established, runs at ACH with Orthopaedic Surgeon, Podiatry, Physiotherapy and Orthotic input Physiotherapy Clinical Specialist appointed to support ongoing Pain Service Development Current Focus DNA rates remain high (approx 18%) following transfer to PMS with loss of patient focussed booking Increased waiting times for MSK Working with Business Intelligence to establish robust reporting of National Standardised KPIs Full analysis of risk factors to DNA and explore opportunities for new ways of working Re-introduce Opt in / patient focussed booking Promote uptake of MATS service Full analysis of demand / capacity Pathways go live MSK Centre Opens 6 month report Vetting / Triage Workshop European Care Pathways Poster Presentation October13 February 13 May May 13 20/21 June 13 If you require any further information please contact: Judith Reid, Consultant Physiotherapist in MSK - Judith.Reid@aapct.scot.nhs.uk> All Previous Flash Reports are situated on the following Athena Website:

35 Opportunities and Developments Making best use of Capacity Improving uptake of MATs Need to test different management models, improve effectiveness and efficiency. Single appointments for low risk patients Greater engagement with leisure services, community services and voluntary organisations Enhanced support for high risk patients

36 Our Vision Improve Community Based Access AHP team, Physiotherapists, Occupational Therapists, Podiatrists, Orthotists Targeted Treatments, improved outcomes Process of Escalation Access to Investigation and/or secondary care services Right Person, Right Time, Right Place

37 Thank You for Listening Any Questions? Contact:

38 European Care Pathways conference Supporting safe, effective, person centred care, through the use of care pathways Grand Central Hotel, Glasgow 20 th and 21 st June 2013 Follow the conference on twitter at #ecpc13