Allied Health Professionals delivering one stop foot Rheumatology clinics by direct access to services

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1 Allied Health Professionals delivering one stop foot Rheumatology clinics by direct access to services Dr Mhairi Brandon Consultant Physiotherapist Glasgow Royal Infirmary Empowering allied health professionals (health and care) 9 th December, 2014 London

2 AHP VISION for "one-stop foot rheumatology clinics by direct access to services NHSGGC catchment area over 1.2 million people Interface of primary and secondary care to ensure a seamless pathway of care across both sectors NHS Scotland Political Drivers Framework for adult rehabilitation / AHP National delivery plan 18 week RTT Improve the patient journey to reduce number of hospital visits (including diagnostic imaging) Direct Access to services and fast track to specialist rheumatology AHPs. Case management to prevent unnecessary hospital admissions NHSGGC One-stop clinics Research Interdisciplinary AHP team to develop a clinical - academic partnership Physiotherapists Podiatrists Sonographers Orthotists

3 Foot disease prevalence The foot will be involved in almost all patients with inflammatory arthritis Point prevalence ~60% Disease course prevalence ~90% Grondal et al 2008, van der Leeden et al 2008, Otter et al 2010 Swelling Active disease Stiffness Joint damage Deformity

4 Turner et al, 2010; Turner et al 2008; Turner et al, 2008a; Turner et al, 2008b Disease mechanisms Greater understanding of disease mechanisms has supported advances in targeted foot therapy Dr Debbie Turner, ARUK Senior Lecturer in Podiatry, GCU Inflammation Altered mechanics Foot-related impairment & disability

5 18 WEEK RTT One Stop Foot Clinics 18 Week RTT One-Stop Foot Clinics One-stop Visit reduce patent journey from 24 wks wait and 5 visits to 4 wks and 1 visit lean thinking - bottom-up approach Diagnostic musculoskeletal ultrasound imaging (MSUS) imaging and interventions remove the bottle neck of the waiting times arthrocentesis and MSUS guided injection therapy Direct access early bird from 7.30 / designated helpline / self referral /GP referral preventing hospital admissions bypassing A&E e.g. gout, joint sepsis

6 Interdisciplinary Training and Education A clinical /academic partnership Undergraduate Placements (physiotherapy, podiatry, occupational therapy [vocational rehabilitation]) Postgraduate 10 PG Cert Ultrasound (5 podiatrists, 2 physiotherapists, 2 physicians, 1 nurse) 10 CPD placements in injection therapy (8 podiatrists, 2 physiotherapists) PhD students Foot and Ankle Research Group Glasgow Caledonian University 6 (4 rheumatoid arthritis, 1 juvenile chronic arthritis, 1 psoriatic arthritis) International visitors Centre of Excellence Centre for Rheumatic Diseases 8 (Norway, Australia, Romania, Singapore, Holland) Other activities 20 Peer Reviewed Journal Articles Hosted British Society for Rheumatology Ultrasound AHP Session Spring 2013

7 Advancing AHP Practice Learning new skills

8 Interdisciplinary Team Clinical Academic Partnership Team Structure Core Staff Physiotherapy Principal physiotherapist (lead clinician) Dr Mhairi Brandon (sonographer/ injection therapist/ microscopy) Physiotherapy advanced practitioner Lorraine Friel (injection therapist /exercise/ hydrotherapy) Physiotherapy assistant practitioner Sharon Morrison (lower limb casting / exercise classes) Podiatry Podiatry senior lecturer/ practitioner Dr Debbie Turner (sonographer/ injection therapist/ orthotics) Podiatry advanced practitioner Associated Staff Vocational Rehabilitation Independent prescriber Violet Butters (supplementary prescriber/ injection therapist) will be Independent prescriber from March 2014 Susan Webster (occupational therapist when required) Sister Moira McDonald (when required)

9 Interdisciplinary One-Stop Foot Clinic Assessment/MSUS Imaging Interventions: injections /casts /orthotics Person Centred Care Rehabilitation/Exercise

10 Inflammatory Arthritis: A Diagnostic Dilemma

11 MSUS in Clinical Practice Advancing practice for AHP sonographers (physiotherapists, podiatrists, radiographers) MSUS imaging is inexpensive, non-invasive, non-ionising and readily accessible in the clinical setting (AHP departments/clinics) MSUS imaging as an additional diagnostic tool MSK stethoscope is a useful adjunct to the routine clinical examination MSUS Imaging has been shown to be a useful assessment tool for the detection of bone and soft tissue foot abnormalities. ankle joint tibialis posterior tenosynovitis

12 Audit : MSUS and injection therapy Foot Clinic (n=2000 interventions) Joints Assessment of Inflammatory arthropathies (RA, PSA, OA, Gout) Doppler imaging - grading synovial hypertrophy (743) Joint injections - hind, mid foot forefoot (703) Joint effusion aspiration (RA, gout) (79) Tendon tenosynovitis (151) Achilles tendonitis (103) Nerve Mortons neuroma /other (299) Other plantar fasciitis (35) ganglion / bursitis (9) Surgery onward referral to foot surgeon (31) MRI Imaging/ Bone scan 9 MRI / 2 bone scan(11)

13 Foot Clinic Assessments and Interventions Assessments MSK ultrasound 77% Biomechanical / Gait assessment 54% Pressure studies 39% Vascular assessment 6% Neurological assessment 4% Treatments Orthotics 67% Footwear 29% CS Injections 37% (17% previous unguided recent injection) Below knee casting 8%

14 Future Developments: One-Stop Clinics Capacity New one-stop Clinics - 6 will be replicated across city partnership acute and primary care clinicians (mobile team) the patient experience was very positive but further evaluation is required to capture feedback on access and clinic locations across the sector areas. Patient experience and impact data increase the capacity for new patients by 50% to over 2000 patients per year reducing the number of appointments required from 5 to 1 Robust impact data will be collected during the rollout process within Glasgow for 6 one-stop facilities Develop one-stop methodology Replicate model for rheumatological conditions of the hands involving the occupational therapists and vocational rehabilitation Scoping of skill mix required for future service including clinical specialist orthotists and assistant practitioners Training and Education Engage with NHSNES and Universities to increase training capacity and funding for MSUS course linking with advanced practice (national shortage of sonographers) Investment in training and education across the various professional groups. Vocational rehabilitation and occupational therapists

15 Future challenges Think differently

16 Advances in clinical understanding Effective Interventions Disability Impairment Disease mechanisms Enabling technologies

17 Research Community Institute for Applied Health Research Infrastructure AHP Expertise Investment Training & Mentorship The Centre for Rheumatic Diseases

18 Acknowledgements Glasgow Royal Infirmary Foot Clinic Lorraine Friel, Advanced Physiotherapy Practitioner Violet Butters, Advanced Podiatry Practitioner Sharon Morrison, Assistant Physiotherapy Practitioner Rheumatology Day ward Moira McDonald, Lead Clinical Nurse Specialist (microscopy) Susan Webster, Clinical Specialist Occupational Therapist (vocational rehabilitation) Glasgow Caledonian University Ankle and Foot Research Group Professor Jim Woodburn / Dr Debbie Turner Doctorates Dr Gordon Hendry Dr Mhairi Brandon Dr Ruth Barn Dr Lisa Newcombe Dr Kym Hennessy Dr Kellie Gibson Dr Elaine Hyslop