Docstoc

Orthopaedic Demand Management

Document Sample
Orthopaedic Demand Management Powered By Docstoc
					  A Whole Systems Approach
to Orthopaedics in Gwent, or…
  3 years of hitting my head on a brick
                   wall
      Where we were at end of
         December 2002
• Out patient
  – Waiting Lists - 13,357 pts, max wait 48 months
• In patients
  – Waiting Lists - 3,151 pts max wait 48 months
  – 142 Pts waiting over 18 months
      Edwards Report (Jan 03)
 O/Pt waiting times > of 3 years was no service at
  all
 Joint replacement rates in Wales were
  significantly below those in England
                Edwards Report -
                Recommendations
•   Outpatient demand management - LHBs
•   Tighter WL control -Trust
•   Efficiency improvements in secondary care - Trust
•   Investment in secondary care - WAG
•   “Do it better” – but how! – all of us
          What happened?
• Let’s form some committees, then..
• More of the same
• Planning of the St Woolos development
         Progress to April 04

 Extra WLI Consultant Clinics
 WLI Operating


OP & IP WL - None waiting over 18 months
           What happened?
• More of the same, but also..
• New Extended Scope Physiotherapy
  Practitioners clinics
• New Nurse Practitioner clinics
• Surgical Care Practitioner clinics
• Tighter list management
Outpatients - Is this sustainable?
• 30% surgery conversion rate = 70% non
  surgical
• Is the Consultant Orthopaedic OPD the
  right service for them?
         Effect on Inpatient list
• O/P to I/P conversion rate average 30% but
  increasing due to ESP clinics

•  out patient activity =  numbers on I/P W/L
  – I/P W/L Dec 03 = 4,124 (3000 in Dec 02)
  – waiting time 17 months


• Now of course – 12 months, but SOS at a cost.
          Is this sustainable?
• O/P & IP  activity and better management
  = shorter waiting times but tail of list has
  disappeared
350

300

250

200

150

100

 50

  0
      2   5   8 11 14 17 20 23 26 29 32 35 38 41 44 47
350

300

250

200

150

100

50

 0
      2   5   8   11   14   17   20   23   26   29   32   35   38   41   44   47
          The Proposal
 A better way of treating patients
Whole Systems Approach -
  – Integrated primary care based Multi
    Professional Treatment and Triage Team
  – Increased secondary care capacity through…
  – Improved EPAC
  – better theatre usage.
  – Higher throughput per bed – Assisted discharge
                                                                                                11,500
                                                                                                                 1
                                                                                                 Patient
                                                                                               presents at
                                                                                                   GP
                                Discharge to GP                     2
                                   Investigations         9,500
                                         Podiatry
                                       Orthotics         1st Stage                             4                                       3
                                        Dietetics       Paper Triage     2,300
                            Occupational Therapy          (physio)
                          Primary Care Pharmacy                          375       Mainstream                             Back Pain            Rheumatology
                                                             Multi -
                                         Dentist          Professional              Physio                                 Pathway
                                  Ophthalmology             Triage &
                                     Optometrist        Treatment Team
                                  Rheumatology
                           Orthopaedic Physician                                                                         Exisiting
                                      Pain Clinic                                  Discharge to                           Service
                                       Physician                                       GP                               (Caerphilly)
                                 Social Services
                                Voluntary Sector

                                                                    2,850


                                                           Consultant
                                               2,000      Paper Triage


                                                          Orthopaedic
                                                          Out- Patient         5
                                                          Appointment


Rheumatology or                                        Other Musculo                                      ACL Repair
other Secondary     Orthopaedic         Shoulder         - skeletal          Arthroplasty                  patients                            Hand Surgery
                                                                                                                                  Spinal                         Foot Surgery
care practitioner                       Surgery
                     Physician                            patients             Patients                    (WMC)                 Surgery


                       Specialist        Specialist                         EPAC and pre-                Pre admission           Specialist        Specialist        Specialist
                      Practitioner      Practitioner   Pre-admission         admission             6       and pre op           Practitioner      Practitioner      Practitioner
                     involvement       involvement                             clinic                     physio clinic        involvement       involvement       involvement
                                                           clinic


                                                                            Admission for                 Admission /
                                                        Admission for        arthroplasty                DC for surgery
                                                                                                   7
                                                          surgery              surgery



                                                                                                          1st Post op
                                                                            Rehabilitation         8        FU with
                                                                              at home                      consultant



                                                                                                           All other
                                                          Outpatient          Outpatient                  FUAs with
                                                        rehabilitation      rehabilitation               physio team


                                                                            Long term follow            Consultant
                                                         Follow up if        up / monitoring           FUA if needed
                                                          required          via EPAC / nurse
                                                                              practitioners
                    MPT3


•   Primary care based
•   Local provision of clinics
•   Scaleable to meet demand
•   Triage and TREATMENT
•   Discharge early, minimal follow up
           The suggested team
•   Up to 5 clinicians and one admin support
•   Should include a GP and a physio
•   Also nurses, podiatrists, ?OT.
•   Teams pulled from a pool depending on
    demand, availability and expertise
                Training
• Initial generic musculoskeletal training in
  secondary care Outpatients
• Ongoing CPD with rotation through OPD at
  least monthly
         Expected Outcome
• 11,500 estimated total ortho referrals for
  2004/05
• 2,000 direct to secondary care
• 2,300 paper triaged to Physio
• Remaining 7,200 assessed by MPT3
• Of those, 2,850 referrals on to Orthopaedic
  secondary care.
                                                               Patient
                             2,000                           presents at
                                                                 GP
      Discharge to GP
         Investigations      9,500
               Podiatry
             Orthotics      1st Stage
              Dietetics    Paper Triage     2,300
  Occupational Therapy       (physio)
Primary Care Pharmacy                       375     Mainstream              Back Pain     Rheumatology
                                Multi -
               Dentist       Professional            Physio                  Pathway
        Ophthalmology          Triage &
           Optometrist     Treatment Team
        Rheumatology
 Orthopaedic Physician                                                      Exisiting
            Pain Clinic                             Discharge to             Service
             Physician                                  GP                 (Caerphilly)
       Social Services
      Voluntary Sector

                                       2,850


                              Consultant
                   2,000     Paper Triage


                             Orthopaedic
                             Out- Patient
                             Appointment
Estimated Effect on Orthopaedic
          Outpatients
• Reduction in Outpatient Clinics required
• Conversion rate will increase from 30% to
  estimated 65%
• Potential for change in job plans from
  clinics to operating
Still awake?
   Estimated Need for Surgery
• Need for THR/TKR 1,100 pa (800) now
• A further 629 non joint replacement
  treatments,
• Total increased treatment demand of 929
      Extended Preadmission
• EPAC at 3 months prior to surgery, closely
  tied in to anaesthetic review
• Pre-assessment 2 weeks prior to surgery

• Plan – move EPAC to 1 month after listing,
  and standard EPAC is via phone
        Innovative theatre use
• 3 session working
• SCP or staff grade lists to fill vacancies
• High efficiency lists
              Standard list




8   9   10      11   12    1      2   3   4   5




             Surgeons are cheap
    2 Theatre, 2 SCP / Reg, 1 Cons




8     9   10   11   12   1   2   3   4   5
    1 Theatre, 2 anaesthetists, 1 ½
     teams, 1 Cons & Reg / SCP




              HESTA list
8    9   10   11   12   1   2   3   4   5
And now, to bed(s)
          Assisted discharge
• With efficient pre-assessment and social
  care, 75% of joint replacement patients
  could be discharged on day 4
• 17 beds released (of 50)
• Hospital based outreach service
    Recurrent Costs of the Whole
         System Approach
•   MPTT Team - £401k
•   Mainstream Physio - £303k
•   Treatments - £2.3m
•   Assisted discharge - £303k
        What your bunce buys?
•   Total recurring cost - £3.388m
•   7,200 Outpatients
•   2,675 Physiotherapy Treatments
•   929 Treatments
•   6,190 bed days saved

• “Cheap as Chips!!!”
What next?
What next? - really



    • Do a trial
       TOMATO - Trauma and Orthopaedic
Multiprofessional Triage and Treatment Organisation

              Robin Rice, Jan Smith,
                Leanne Watkins
               TOMATO
• TOMATO phase 1 ran for 29 weeks,
  including all orthopaedic referrals to NHH
  from 1 LHB.
Paper Triage (w29) n = 888, 67% TOMATO (593)
                                                       TOMATO
300
                                                       Physio
                                                       Cons
250


200


150


100


50


 0
                               t
       m




                                                                                      t
                                                                   er
                  k


                         w




                                                        g
                                                 ee
                                           ip
                                       d




                                                                                r
                                o




                                                                                     ris
                 ec




                                                                             de
                                                      Le
                                    an
                      bo


                             Fo
      Ar




                                           H




                                                                 th
                                                Kn




                                                                                    W
                                                                            l
             N




                                                                O
                                    H
                      El




                                                                         ou
             d




                                                                        Sh
           an
       ck
      Ba
           Outcomes so far
• 614 Appointments offered
• Average wait of 50 days (s.d. 30 days)
                     Clinic Outcome
350
300
250
200
150
100
       3%      6%                                                     8%
 50
  0
      C.N.A.   DNA   Discharge   Discharge   TOMATO   Investigate Refer on to Refer on to
                        to GP    to Physio     FU       and FU      Ortho       Other
                                                                               services
                        Investigations requested

35

30

25

20
                                                        Pre OPD
                                                        At OPD
15

10

5

0
     Bloods   Isotope          MRI         NCS     XR
       68 FU appts as 17.5.05
• 21 Discharged, 16 discharged to physio, 24
  to ortho, 4 to other, 3 to rheumatolgy
    1st Month Results at 1 Year
• 106 patients

• No patient satisfaction survey performed
         Triage to physio - 2
• Both discharged and have not been
  re-referred
        Triage to consultant - 49
• Awaiting 3 sets of notes
• 10 placed on waiting lists (32%)
• 10 were valid consultant referrals
• 7 could have been seen and investigated by
  TOMATO
• 1 tertiary referral
• 18 have not yet been seen
          Triage to TOMATO - 55
• 21 seen & referred on to consultants (T & O)
  –   5 put on lists (29%)
  –   2 conservative treatment
  –   1 Pain clinic
  –   4 awaiting consultant review
  –   1 re-referral by GP with same problem
  –   8 awaiting notes
• Seen, treated and discharged by TOMATO, and
  not re referred - 34 (32% of total, 61% of triaged)
              Conclusion
• Proven to work in many other health
  systems
• LET’S DO IT!



              Ah, but….
Money (or, more realistically,
     lack of money)
How have I done?
                MPT3


• In Caerphilly LHB Nov 04
• Newport LHB March 05
• Torfaen LHB any time now


• But Monmouth & BG –   No
            Theatre efficiency
• Trial of HESTA list 28/6/05
         Assisted discharge
• Trial run on HESTA cohort 28/6/05
    Costs of the Whole System
             Approach
• MPTT Team - Rec - £401k, Non-Rec - £78k
• Mainstream Physio - Rec £303k, Non-Rec - £17k
• Treatments - EPAC / Pre-admission - Rec - £92k,
  Non-Rec - £11k
• Treatments - Rec - £2.3m, Non-Rec - £88k
• Assisted discharge - Rec - £303k, Non-Rec £52k

				
DOCUMENT INFO