Falls Prevention: a positive effect of the Osteoarthritis Chronic Care Program (OACCP) Matthew Williams Snr Physiotherapist, Musculoskeletal Coordinator Royal North Shore/Ryde Hospitals Danella Hackett Snr Physiotherapist, Musculoskeletal Coordinator Fairfield Hospital May 2016
Outline Rationale behind an OA MDT program The Osteoarthritis Chronic Care Program (OACCP) Falls in OACCP participants Case Studies
OA At a glance 1 in 5 people currently suffer from OA, this will increase to 1 in 4 by the year 2050. The risk of disability due to knee OA alone is greater than that due to any other medical condition over the age of 65. (Framingham Study Guccione et al., 1994) The incoming silver tsunami see s an aging population with unprecedented obesity and sedentary characteristics. Individuals with OA have a 30% greater chance of falling. Individuals with OA have a 30% greater chance of falling.
A need for change Internationally, nationally and state wide a need for better management of musculoskeletal conditions was recognised, especially those individuals awaiting elective joint replacement In NSW 2010: The Agency for Clinical Innovation (ACI) established a proposed model of care to cater for this cohort and the OACCP was born. 4
Musculoskeletal Network Implementation progress as at March 2016 ORP OACCP Legend: Green - implemented Orange underway Red no activity Site FLC hours Medical support in team Site Coordination with MDT Patient cohort RPAH Full-time Yes - Rheumatology Fairfield Yes Waitlist Concord Rotating registrar All medical team - Endocrine Nepean Yes Waitlist Nepean Full-time? Don t know if Gustavo was Gosford/Wyong Yes Waitlist replaced - Geriatrics POW Full-time buy with other Yes - Endocrine RNSH/Ryde Yes Waitlist endocrine nurse duties Wagga 16 hrs/week No GP model, not working Manly Yes but very limited hours Waitlist RNSH/Ryde Full-time Yes Endocrine and Rheumatology Hornsby Yes but very limited hours Waitlist Hornsby 4 days/week Yes - Rehabilitation Sutherland Yes limited hours Waitlist Manly 2-3 days Yes Rheumatology Bowral Yes but limited hours Waitlist Newcastle Part-time Yes Rheumatology Newcastle? Model has moved to community? so unsure Port Kembla Full-time Yes Rehabilitation Port Macquarie Yes Waitlist Coffs Harbour 3 days Yes Rheumatology Coffs Harbour Yes Waitlist Lismore Full-time Yes Geriatrics Hunters Hill Private?? Tweed Heads Full-time Yes Endocrinology Murrumbidgee PHN Yes Waitlist Grafton 0.6 FTE Yes unsure specialty Broken Hill Yes Waitlist St No FLC Endocrine all medical team Coffs Harbour GP leadership with MDT Pre-waitlist Vincent s Grafton Coordinator but model???? Waitlist Broken Hill In set-up mode? RNSH Coordination of GP referred Pre-waitlist patients Liverpool/Fair In planning mode Rheumatology, orthopaedics, Orange In set up mode not signed off Waitlist field rehabilitation all involved Canberra Full-time No still working on the model Armidale In set up mode not signed off? Western NSW LHD, Southern NSW LHD, Western Sydney LHD Sydney LHD, Western Sydney, Western NSW, Illawarra Shoalhaven LHD, Southern NSW
Osteoarthritis Chronic Care Program (OACCP) The OACCP offers a comprehensive, evidence based and integrated model of care that improves the interdisciplinary coordination of treatment for individuals with OA. Objectives: Reduce pain Enhance function Improve quality of life Slow disease progression Encourage self management
How have the Objectives been implemented Client Centred - What does this really mean? Client Choice, Client Control First ask then offer Wait til 8 Targeted education and individualised goals
Program structure (Fairfield) Commenced in 2009 and assisted ACI Musculoskeletal network in the development of the OACCP Team Senior PT Musculoskeletal Coordinator, Level ½ Physio part time and Orthopaedic CNC We can refer to Occupational Therapy and Social Work within the hospital as these patients are seen as an inpatient by these service providers
Who else can the patients access? Other referrals: Diabetes Osteoporosis Cardiac/Pulmonary Rehabilitation Smoking Cessation programs Psychology Allied Health Get Healthy Service Falls specific: Able and Stable program Falls Clinic Stepping on Staying active and on your feet Booklet Falls network handouts including those in other languages Walking aids Occupational therapy review
Program Structure (RNSH) Patients invited from elective joint replacement list and referrals from orthopods and rheumatologists. Initial Appointment with Msk co-ordinator involving a holistic assessment, OA education, exercise program and referral to services within and outside of program. Attendance at MDT clinic Follow up with Msk coordinator every 3 months for reassessment -? Escalation for surgery, or removal from WL. Linking up with community based programs and support networks to further assist self management.
RNSH OACCP Multidisciplinary Team Person with OA Physiotherapist Dietician Occupational Therapist Social Worker Rheumatologist Orthotist Community Groups Exercise - strengthening, aerobic conditioning, hydrotherapy Weight management, optimal nutrition Joint protection, need for assistive devices, lifestyle/ functional adaptations Assist with coping, self efficacy, catastrophising Monitor and advise pharmacologic interventions with GP or pain clinic Need for insoles, motion control shoes, braces
Comorbidities
Falls in OACCP participants Approximately 1 in 3 people report having a fall in the preceding 12 months prior to OACCP contact Approximately 1 in 5 patients who have knee OA and 1 in 2 patients who have hip OA are at increased risk of falls
Case Study Mrs A 75 Year old Female awaiting R THR PmHx: HTN, Hypercholesterolaemia, Osteoporosis (last BMD 5 years previous), L THR 20 years ago and revised 5 years ago Falls history - 2 falls in last 6 months, last one was a week prior to initial assessment # rib BMI 29.5, TUG 10.7 secs, repeated STS in 10 secs (failed) Patients goal was that she wanted to improve her mood
Pre Final Follow up 3/12 STS test 5 6 4 Tandem Stance 8 15 15 TUG 13 7 11 Number of falls Management Referred to Able and Stable and given Staying Active and on your Feet booklet Followed up with GP and BMD was completed 1 year ago she was found to have osteopenia and had her osteoporosis treatment changed at this time. 2 0 0
Patient still presently awaiting surgery as was deferred secondary to some other surgery she needed to have first. At last contact she really enjoyed the exercise program, was still completing the exercises Mood had improved to some degree although she still felt some isolation secondary to her difficulty with public transport due to her hip problem
Case Study Mr SB Category C L TKR 63yo male with 4 year history of left knee pain progressively worsening PHx: R knee osteotomy 06 R TKR, R THR 08 PMhx: DM2, bilat ear canal recon 93 X-ray: Severe medial T/F joint OA
On examination: VAS 2/10 Restricted knee ROM, quads inhib, TUG 21.1 sec, 6MWT 322m Gait: Wide BOS, shuffled steps, slow to initiate. History of increasing falls (5 in last 3/12) BMI 35.27 Waist circumference: 123cm Flat affect mild depression score on DASS Vacant facial expression Referrals: Rheumatologist, Dietician, Orthotist, SW, Hydrotherapy, Falls prevention. ACTION: Contact GP? Parkinson s Disease referred to neurologist diagnosis confirmed. Placed on levodopa
Outcome 3 month review: TUG from 21.1 to 11.5sec 6MWT 322m up to 397m Nil reports of falls. Patient had an early call up to surgery due to a cancellation and had a successful knee replacement mobilising independently with a walking stick.
The road ahead.. OA is a sleeping giant which is expected to effect 1 in 4 Australians by the year 2050 with a significant proportion of these at high risk of falls. A proactive, multi-disciplinary approach with an emphasis on exercise and ideally positioned in primary care is imperative in tackling this increasing burden.