Intercity Rounds Division of Rheumatology

Intercity Rounds Division of Rheumatology October 24, 2006 Development and Early Evaluation of an Interdisciplinary Post-graduate Academic and Clinical Education Program in Arthritis Care for Experienced Physical and Occupational Therapists Rachel Shupak MD Katie Lundon PhD Jodi McIlroy PhD Rheumatology Intercity Rounds October 24, 2006 Learning Objectives: 1. 2. 3. To understand the rationale for the development of the ACPAC program To understand the process of development and the underlying principles of the ACPAC program To understand the principles underlying the assessment of outcome in health education as it relates to the ACPAC program Arthritis Statistics        One in six Canadians have arthritis 3 of every 5 arthritis sufferer is under 65 2 in 100,000 die from arthritis related disease Largest single cause of disability in Canada Lost productivity cost: $3.5 billion Direct cost in hospital and Dr visits: $903.8 million 6 million people, aged >15 will be diagnosed with arthritis by 2026 Bone and Joint Decade 2001-2010 Alliance for the Canadian Arthritis Program (ACAP) The National Standards on Arthritis Prevention and Care  Every Canadian must be aware of arthritis. All relevant health professionals must be able to perform a valid, standardized, age appropriate musculoskeletal screening assessment. Every Canadian with arthritis must have timely and equal access to appropriate medications.   Alliance for the Canadian Arthritis Program (ACAP) The National Standards on Arthritis Prevention and Care Inflammatory arthritis must be identified and treated appropriately within 4 weeks of seeing health care professional Health care professional must recognize OA as a significant health issue and treat it according to current guidelines Every Canadian with arthritis requiring surgery must wait no longer than 6 months from time of decision to have surgery    Arthritis Care Disparity in supply and demand has and will continue to lead to difficulties in    access to care early diagnosis effective interventions What are the unmet needs of patients with arthritis? Background Information Under serviced area in Northern Ontario     Full time rheumatologists Part time rheumatologist Visiting rheumatologists 4 1 7  Higher Wait Time (1) for consultation to see a Rheumatologist Wait Time for a Rheumatologist Arthritis Society Statistics Region Average Wait Time for non-urgent patients (wks) Average Wait Time for New Likely Inflammatory Patients (wks) Algoma-Cochrane Manitoulin-Sudbury Northern Shores 22.6 19.3 10.7 19.3 Northern Western Ontario 56.0 32.6 19.0 16.3 2.3 Average Time for Northern Ontario Toronto 5.9 Hip and Knee replacement:Wait Times Arthritis Society Statistics Service Hospitals Reporting Providing Service Completed procedures Median (Days) Average (Days) 90% completed Joint Replacement HIP 52 of 60 1,938 106 150 341 KNEE 56 of 60 3,213 150 203 431 Treating the unmet needs of all patients with arthritis will require a crossing of traditional professional boundaries Background Information:  Team Care    Physicians: rheumatologists, orthopedic surgeons Other Health Professionals: PT, OT, RN, dietician, SW Evidence for pain, function, overall health  Extended Care Roles   RN (UK) PT/OT (UK)   no standardized training/evaluation Improve access, reduce waiting times Shared responsibility in select patient population  PT/OT (HSC)  Models of Care HSC Physical Therapist Practitioner Model       1 year+ academic, clinical education program Team approach Shared clinical responsibilities; decrease physician burden Education role Equivalent overall patient satisfaction Other Patient outcomes not documented Evidence for Effective Management by Extended Scope Practitioners (ESP-UK)  Langridge & Moran 1984 Rheum Clinic  Pts better informed about Rx 40-60% of pts referred to Ortho can be managed by experienced physio 85% of pts referred to ortho clinic can be managed independently by physio  Byles & Lang 1989 Ortho Clinic   Hockin & Bannister 1994 Ortho Clinic     Hourigan & Weatherly 1994 Ortho Clinic Weale & Bannister 1995 Ortho Clinic Hattan & Smeatham 1999 Spine Clinic  72-76% of pts referred to spine clinic, managed by physio Decreased pain and improved functional disability of pts managed by ESP  Daker & White 1999  Roles of ESP (UK)   Triage referrals Assessment & management which may include:      Advice and discharge Referral for physiotherapy or other professionals alone Investigate with blood tests, x-rays Referral for medical opinion Report writing    Patient consent required Recognition of competencies and limitations Continuing Education ACPAC ADVANCED CLINICIAN PRACTITIONER IN ARTHRITIS CARE “ACPAC” Program St. Michael’s Hospital/HSC ACPAC Program was developed in response to:  Recognized need for interdisciplinary approach to manage more efficiently and improve access to care for patients with OA and RA ACREU report to Ministry of Health April 2005  Progressive decline in # of arthritis care specialists  Academic / reduced clinical loads  Falling enrollment in Rheumatology training programs Hanly JG, J. Rheum 28(9):1944-51, 2001 Sept. Advanced Clinician Practitioner in Arthritis Care (ACPAC) Program Dr Rachel Shupak SMH Program Director, Adult Training, SMH Dr Rayfel Schneider HSC Program Director, Pediatric Training, HSC Katie Lundon PhD Jodi McIlroy PhD Director, Evaluation Program Coordinator, SMH ACPAC Program St. Michael’s Hospital/HSC  Advanced Clinician Practitioner in Arthritis Care program is a two year pilot study, of one year, post-graduate academic and clinical training program for experienced musculoskeletal physiotherapists and occupational therapists. The trainees develop knowledge and clinical skills required for triaging, assessing, diagnosing and managing selective MSK and arthritic disorders. ACPAC Program Objectives: 1. To provide a post-entry to practice curriculum of basic science, clinical science and management as it pertains to arthritis care 2. To facilitate the application of best practices through an extensive clinical experience 3. To develop independent practitioners in selected areas of arthritis care in an extended scope of practice ACPAC Program Objectives: 4. To develop triage skills for patients with OA, RA and other select arthritic/MSK disorders 5. To improve access to arthritis care in outreach areas 6. To develop a new model of care by optimizing health care resources and utilizing highly trained health professionals ACPAC Program: Step 1 Establish Competencies 1.develop and set competencies 2.establish mechanism achieve competencies 3.establish evaluation methods  measure whether competencies have been achieved ACPAC Program: Step 2 Curriculum Development  Faculty Engagement Format: “episodic” (ten – one week per month- sessions)   Module Content Module Content  5 modules     Basic Science and Theory Underlying MSK Practice (52 hrs) Foundations of Clinical Practice (54 hrs) Therapeutic Management (60 hrs) Art and Science of Clinical Practice (Clinics)-(160 + hrs)   General: Adult Rheumatology/Pediatric Rheumatology (80+ hrs) Specialty (2-4 choices, 80 hrs+) -Orthopedic ( knee, shoulder and elbow,foot and ankle, U/E, sports, spine) -Plastics, Hand Clinic -Dermatomyositis/Juvenile DM clinic/haemophilia/ ankylosing spondylitis ACPAC Program: Step 3 Candidate Selection Criteria 1. Minimum 5 years broad experience post-completion of an accredited, entryto-practice program in either Physical Therapy or Occupational Therapy 2. At least 2 years experience in a clinical specialist (Musculoskeletal) area 3. Written agreement to complete the one-year, modular based ACPAC program 4. A mature individual with exceptional interpersonal and communication skills 5. Completion of the post-graduate level course "Total Assessment of Inflammatory Polyarthritis” offered by The Arthritis Society, Ontario Division. 6. Evidence of strengths in advanced problem solving and management of complex clinical cases in the arthritis/musculoskeletal field 7. Member in good standing of respective college at a provincial level, and eligibility for membership in the related national professional association ACPAC Program: Step 3 Candidate Selection Criteria  1. Supporting Documentation  Curriculum vitae  Letter of intent Letter of support from institution addressing conceptual role change 2 references, identifying clinical, academic strengths    2. Interview Process ACPAC Program Role of the Institution   Institutional support     Signed agreements including liability coverage for clinical work Release time with pay from their clinical practice for one week/month x 10 months Backfill organized locally New job descriptions for the re-integration of practitioners into their respective institutions Continuing Education fee:pilot project - nominal $950.00 ACPAC PROGRAM FACULTY Institution      # 34 10 2 3 3 3 2 1 58     St. Michael’s Hospital Hospital for Sick Children Mount Sinai Hospital UHN Sunnybrook Southlake District Hospital (TAP) Arthritis Society Department of Surgery, U of T TOTAL ACPAC Program Institution Role   Institutional support     Signed agreements including liability coverage for clinical work Release time with pay from their clinical practice for one week/month x 10 months Backfill organized locally New job descriptions for the re-integration of practitioners into their respective institutions Continuing Education fee:pilot project - nominal $950.00 ACPAC Program FACULTY Physicians Adult Rheumatologists Pediatric Rheumatologists Pediatric Endocrinologists Orthopedic surgeons Physiatrist Plastic surgeons Psychiatrist General internists Radiologists Pathologist Anaesthetist Other Health Professionals 8 6 1 10 1 2 1 5 5 2 2 PhD physiotherapists/occupational therapists (basic science, clin epidemiology) PT/OT Practitioners Dieticians Pharmacists Social Workers Information Specialist Nurses 3 3 2 2 2 1 2 ACPAC Program Curriculum Delivery         Lectures Seminars Radiology/Imaging Rounds Case write-ups/MD Referral Letters Problem based learning/Clinical Case Vignettes Laboratory Group/Student led presentations Clinics (160 hours+) ACPAC Program: Step 4 EXTENSIVE EVALUATION: TRAINEE knowledge • • • • Theory: MCQ exam (130 questions) Clinical Case write up/MD letters (n=5) Self Directed Learning: Portfolios/Structured Personal Learning Projects Clinical Vignettes (n=7) skills • • Practical Skills exam (5 stations) Midpoint Clinical Evaluation attitude • CANMEDS: 360 ACPAC Program: Step 4 EXTENSIVE EVALUATION: Program • Pre-Post Theory and Practical Skills Evaluation Self-Report Competency/Practice Surveys: baseline, midpoint, end, 18 months, 24 months • • Outcome: Impact of Program (patient satisfaction, practice codes, wait list, institution, impact on other health professions) ACPAC Program: Credentials  Upon successful completion of the training program, the trainee will be awarded a Certificate of Completion as an Advanced Clinician Practitioner in Arthritis Care from the Department of Continuing Education, Faculty of Medicine, University of Toronto ACPAC PROGRAM Where are we going? 1. 2006-2007 cohort (n=5) 2. Evaluation +++Impact of the Program-Year I 3. Certificate  ? Masters Program 4. Foster network of Physical and Occupational Therapy Practitioners Assessing Outcomes in Health Education – Dixon’s Four Levels Level Perceptions /Opinions Competency Clinical Practice Health Care Outcomes Description Reaction to the educational experience -- satisfaction and relevance Change in the skills, knowledge or attitudes of the learner as a result of the experience Extent to which change in professional behaviours in actual clinical work occurred as a result of the experience Impact on patient status as a results of the experience Dixon, J. (1978). Evaluation criteria in studies of continuing education in the health professions: A critical review and a suggested strategy. Evaluation in the Health Professions, 1(2), 47-65. ACPAC Participants Found the Program Satisfying and Relevant  100% (5/5) stated that the course:    Was relevant to their practice Met stated objectives Will alter their practice performance:    Expanded my knowledge across a broader range of diagnoses w.r.t. assessment Improved clinical skill level in all areas Allowed me to better understand clinical presentations and potential complications of patients’ disease profiles ACPAC Participants Increased Knowledge and Practical Skills 90 80 70 60 50 40 30 20 10 0 p = 0.001 p = 0.005 pre post Error bars = 95% CI written practical ACPAC Participants Increased Knowledge and Practical Skills 5 4 3 2 1 Case 1 Case 2 Case 3 Case 4 Case 5 1 2 3 4 5 0.5 1 2 3 4 5 pre-prog end-prog mid-prog 1.5 2.5 3.5 4.5 0 Ad ul tD at a G Ad at ul h tT ec h Sk Ad ill ul s tD ia gn Ad os ul is tR x M Pe gm ds t Da ta G Pe at ds h Te ch Sk Pe ill ds s Di ag no Pe sis ds Rx M gm Co t lla bo ra tio Se n lf Re fl e Se ct lf io As n se ss m en t ACPAC Participants Self-Assessment of Knowledge and Skills Improved ACPAC Participants Increased Frequency of Some Clinical Tasks  Self-report of frequency of tasks  General, e.g., interpretation of plain film xrays, of serology, etc. Within-condition        History and physical Interpretation of findings incl. lab and imaging Initial treatment and management Follow-up and monitoring of treatment Monitor meds and complications Patient education ACPAC Participants Increased Frequency of Some Clinical Tasks daily weekly monthly hx_px interpret init_rx fu_monitor meds_comps pt_ed rarely never id Po st Pr e M Future Outcomes for ACPAC Program   Extent to which participants’ clinical practices change to include enhanced role Direct or indirect method(s) to evaluate implementation of new learning in practice Facilitators and Barriers to    Implementation of new learning Enhanced Scope of Practice Future Outcomes for ACPAC Program Impact on patients     Quality of Care Quality of Life Improved Access to Appropriate Care Model for Continuing Education Expert panel (Knowledge Translation/Guidelines Program Link) Level 6 Level 5 Level 4 Master’s Program University Certificate Course of Completion (Opinion Leader) Preceptorship Level 3 Level 2 Skills Training Traditional Course (Knowledge) Level 1 Model for Continuing Education Level 1 Level 2 Level 3 Knowledge: One day review course Annual Arthritis Day (SMH) Skills Training: Arthritis Society Course, Ottawa, Ontario Preceptorship: Ankylosing Spondylitis Clinic, SMH Level 4 Level 5 Opinion leader training: ACPAC: Certificate Continuing Education, U of T Professional Masters: Education/Public Health To be developed Level 6 Evidence Base: Leader / International Reputation Arthritis Care Model Traditional Vs New Paradigm Family Physician = Gatekeeper of care  Current practice    Referral to Rheum, Ortho, PT, OT, SW, dietician Current needs not being met Further decline specialist physicians, community resources Exception Multidisciplinary care, education  Southlake Regional TAP/HSC   Arthritis Care Model Traditional Vs New Paradigm  New Paradigm       Referral to Comprehensive Arthritis program Define roles of the team members (may overlap) Triage Interdisciplinary, seamless care with cross referrals as needed so that the right client sees the right specialist(s) and/or care giver(s) at the right time. Improved patient education Outreach to under serviced areas A New Model of Care Primary Care Traditional New Model Rheumatology Orthopedics Physio/OT Arthritis Care Program Triage Data Entry Electronic chart Trauma Internal derangement Inflammatory Osteoarthritis RHEUM/ORTHO PT/OT EDUCATION PT/OT/DIETICIAN EDUCATION RHEUM/ORTHO ORTHO CAST TECNICIAN PT/OT ACPAC Program Obstacles  Regulated Health Professional Act   Professional Colleges are slow to recognize and implement change Medical directives are hospital dependent   Diagnose & Order investigations Order x-rays, U/S, CT, MRI  Position currently non transferrable Education Salary  Cost    Reimbursement Issues SUMMARY    ACPAC program provides a means to ensure that non physician providers of care have the knowledge and skill required to assess, diagnose and triage arthritis patients in a multidisciplinary setting. Advanced or extended scope practitioners may in select circumstance, independently manage patients in accordance with College regulations and/or delegated hospital acts The role of the advanced practitioner is flexible and will vary according to the needs of the academic or the community institutions