Enhancing clinical and economic outcomes
Physiotherapy Screening
& MD Management
in Orthopaedics and Neurosurgery
David Smith, Maree Raymer
David_Smith@health.qld.gov.au 0407 767 632
SOPD Innovation Workshop
Wednesday 27th November 2013
Significance of MSK conditions
31% of Australians
Disability & productivity loss
Expenditure ($ Billions)
7
$4.1 billion
6
5
4
3
2
1
0
Cardiovascular
Disease
Oral Health
Mental Disorders
4th largest contributor to direct health costs (2004/2005)
Musculoskeletal
Traditional Pathway (Ortho or N/Surg)
Triage
(Cat 1,2,3)
GP
Referral
SOPD
Wait List
(Ortho or N/S)
Initial
SOPD
Consult
10-25%
High demand – needs poorly met
~60% not seen in time
Poor QoL & deterioration while wait
Most patients don’t need surgery
Inefficiency
Non-operative
Management
eg. PT, ongoing
R/V
Elective Surg.
Wait List
(Cat 1,2,3)
Discharge
to GP
Physio. Screening & MD management
Triage
(Cat 1,2,3)
GP
Referral
SOPD
Wait List
Initial
SOPD
Consult
Non-operative
Management
eg. PT, ongoing
R/V
Elective Surg.
W.List
(Cat 1,2,3)
Deliver
Physiotherapy
Screening
Clinic
MD
Non–surgical
Management
Redirect
Discharge
to GP
N/OPSC & MDS Outcomes
Services established State wide
- 13 facilities Orthopaedics, 4
N/Surgery
12%
Activity (FY13) : 5 532 new
Management :
(4837 R/V)
72% Referred to
Non surgical Mx
Wait list
Waitlist
Reductions :
65%
Managed, &
Removed
27 – 54%
Discharge Patterns
Urgency
ISQ
23%
65%
12%
Urgency
Upgraded
Managed &
removed
SOPD wait
list
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
Consultant Feedback
100
90
80
70
60
2006(n = 357; 4 sites)
50
2008 (n= 59; 3 sites)
40
2010 (n=332; 12 sites)
30
20
10
0
Information
provided
Comprehensive
management
Outcome of
management
% Satisfied/ Very Satisfied
100
90
80
70
60
2006 (n = 19)
50
2008 (n = 15; 4 sites)
40
2010 (n=42; 12 sites)
30
20
10
0
Review by
MskPT
Quality of
diagnoses
Overall patient
management
GP Feedback
% Satisfied/Very Satisfied
% Satisfied/very Satisfied
Patient feedback
100
90
80
70
60
50
40
30
20
10
0
2006 (n = 87; 3 sites)
2008( n=14; 3 sites)
2010; n=113; 12 sites)
Information
provided
Overall
management
Overall outcome
OPSC as
component of
Orthopaedic
Service
Service Model
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 completed
OPSC & 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 Learned
The 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’d
Innovation 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’d
Measures, 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.
Opportunities
Challenges
Demand > N/OPSC capacity =
scope for expansion at existing
sites to better match patient need
Not 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
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
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
Other 1st contact models: ED,
Urology/Gynae etc
National Categorisation Guidelines
David_Smith@health.qld.gov.au 0407 767 632