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Enhancing clinical and economic outcomes
David Smith, Maree Raymer
[email protected] 0407 767 632
SOPD Innovation Workshop
Wednesday 27th November 2013
Physiotherapy Screening & MD Management
in Orthopaedics and Neurosurgery
Significance of MSK conditions
31% of Australians Disability & productivity loss
4th largest contributor to direct health costs (2004/2005)
0
1
2
3
4
5
6
7
CardiovascularDisease
Oral Health Mental Disorders Musculoskeletal
Exp
en
dit
ure (
$ B
illi
on
s)
$4.1 billion
Traditional Pathway (Ortho or N/Surg)
GP Referral
SOPDWait List
(Ortho or N/S)
Initial SOPD
Consult
Triage(Cat 1,2,3)
Discharge to GP
Non-operative Management
eg. PT, ongoing R/V
Elective Surg.Wait List
(Cat 1,2,3)
High demand – needs poorly met
~60% not seen in time
Poor QoL & deterioration while wait
Most patients don’t need surgery
Inefficiency
10-25%
Physio. Screening & MD management
GP Referral
SOPDWait List
Initial SOPD
Consult
Triage(Cat 1,2,3)
Discharge to GP
Non-operative Management
eg. PT, ongoing R/V
Elective Surg.W.List
(Cat 1,2,3)
Physiotherapy Screening
Clinic
MDNon–surgical Management
Select Deliver
Redirect
Activity (FY13) : 5 532 new (4837 R/V)
Management : 72% Referred to
Non surgical Mx
Waitlist
Reductions : 27 – 54%
65%
Managed, & Removed
Wait list
12%
N/OPSC & MDS Outcomes
Services established State wide - 13 facilities Orthopaedics, 4 N/Surgery
Discharge Patterns
Safety Net
Urgency ISQ
Urgency Upgraded
Managed & removed SOPD wait list
Rem
ain
SO
PD
w
aitli
st
12%
65%23%
Red Flags
Significant pathologies identified (> 40 in a sample between 2008 & 2012)
• Neoplasms• spinal, soft tissue, pelvic • lung, thyroid
• Fractures – hip and pelvis• Auto immune conditions and Inflammatory conditions
incl. MS• Cerebral Vascular anomalies• Sub-arachnoid cysts• Cord Compression req. emergency decompression.• Parkinson’s Disease
Stakeholder satisfaction
GP Feedback
0
1020
3040
50
6070
8090
100
Informationprovided
Overallmanagement
Overall outcome OPSC ascomponent ofOrthopaedic
Service
% S
atis
fied/
Ver
y S
atis
fied
2006 (n = 87; 3 sites)
2008( n=14; 3 sites)
2010; n=113; 12 sites)
Consultant Feedback
0
10
20
30
40
50
60
70
80
90
100
Quality of diagnoses
Overall patientmanagement
Service Model
% S
atis
fied
/ Ver
y S
atis
fied
2006 (n = 19)
2008 (n = 15; 4 sites)
2010 (n=42; 12 sites)
Patient feedback
0
10
20
30
40
50
60
70
80
90
100
Informationprovided
Comprehensivemanagement
Outcome ofmanagement
Review byMskPT
% S
atis
fied
/ver
y S
atis
fied
2006(n = 357; 4 sites)
2008 (n= 59; 3 sites)
2010 (n=332; 12 sites)
Research Projects to maximise effectiveness
Project 1 : Optimising patient selection
: develop a prediction model to identify early those patients likely to be successful or unsuccessful with non surgical management
Project 2 : Cost effectiveness analysis
: fully informed cost effectiveness analysis and identification of the optimal mix of services between traditional and physiotherapy led service model
Progress : economic analysis
Pilot study completedOPSC & MDS model likely to be highly cost effective
Results tempered by uncertainty in some parameters
Prospective study required to apply this economic model in a fully informed prospective analysis
Prospective multi - site study underway√ Grant funding awarded (AusHSI)√ Central and site specific ethics approvals in place√ Patient Recruitment underway with > 400 patients enrolled
Summary to date N/OPSC & MDS = expert physiotherapy assessment (advanced role) and comprehensive MD management for selected Cat 2 & 3 patients
Well established in 13 facilities in Orthopaedics and 4 Neurosurgery – delivering > 5 500 new SOPD app’ts p.a.
Overall very well received by surgeons, GP’s and patients
Patient outcomes and health system benefits clearly demonstrated
→ more timely, efficient and cost effective services which maximise value of the workforce
Lessons LearnedThe patient and planning• Placing patient experience & patient choices at centre of
planning, both for flow and treatment options.• Tangible patient benefits have to be demonstrated.• Abiding by guiding principles helps check direction &
integrity when changes may be demanded.
Support• Sustained Executive buy-in essential : actions > words.• Ongoing Executive support required to overcome
barriers and resistance to change.• Continual advocacy and networking for success.• Executive doesn’t stop at HHS but also Systems
Manager.
Lessons Learned cont’dInnovation and problem solving • Willingness to work backwards from a problem to a
solution with a blank page vs more of the same.• Understanding the problem from its root cause more
important than focussing on the secondary effects or barriers.
• Taking a good idea and making better is innovation.
Workforce• Enabling staff to work towards full potential is extremely
motivating; helps to maximise value of both physiotherapy and medical workforce.
• Ongoing workforce development required for sustainability and expansion.
• Higher level roles/responsibilities demand advanced/ higher level skills.
Lessons Learned cont’dMeasures, data & relevance• Reporting measures that are meaningful across a range of
domains resonate with different stakeholders eg. patient outcomes, stakeholder impacts, organisational and cost impacts.
• Data collection built in.• Understand different stakeholders have different motivating
factors for success.• KPI’s aligned with funding and priorities.
Continuous improvement & change management• Building in an ethos of continual improvement and flexible
responsiveness to changing environment is essential.• Resourcing for improvement and research is critical.• Must be able to adapt to changing political environment, (both
small p and big P) – opportunities and challenges.• If something no longer works – accept it, make it work or make
any necessary change.
OpportunitiesDemand > N/OPSC capacity = scope for expansion at existing sites to better match patient need
Sites that currently don’t have this model could adopt & benefit
Cost efficiency potential
Broader MSK service reform -
Adopt similar approach to Chronic pain, Rheumatology
Other 1st contact models: ED, Urology/Gynae etc
ChallengesNot working to full scope –– enable and progress to extended scope incl. access to imaging, pathology and prescribing
How to best work/integrate with ML’s
Inconsistent application of triaging and integration of N/OPSC with medically led clinics in SOPD
Changing perceptions re: timing and role of referral to SOPD
VMO factor
Regional/Rural service access
Workforce supply and skills development
National Categorisation Guidelines
[email protected] 0407 767 632
