1. Timely Access To Health Care February 9, 2007
System redesign for improving the continuum of care for the osteoarthritis population
Timely Access To Health Care
February 9, 2007

2. Agenda I The Arthroplasty Plan II UBC/CSI Initiative III OASIS
IV Provincial Musculoskeletal Council
We have been asked to speak to you on two initiatives taking place with Vancouver Coastal Health Authority and also on a provincial initiative in BC.
I will be speaking to you regarding Hip & Knee Reconstruction Project that took place within Richmond Health Services (part of VCH).
Dr. Ken Hughes will be speaking about the OASIS program, and
Valerie MacDonald will be speaking about the provincial collaborative work being done around arthroplasty.
Since we each only have five minutes to speak to our topics, we will be keeping it fairly high level. There is a question/answer period and we will all be available after if you would like additional details.

3. The Arthroplasty Plan (Richmond Hip & Knee Reconstruction Project)
Purpose
Implement and evaluate a high quality/volume low cost hip and knee reconstruction model
Objectives
Maximize utilization of resources:
Reduce average waiting time to 4-6 months
Reduce ALOS to 4 days for hips 3 days for knees
Improve OR efficiency by 20-25%
Evaluate patient outcomes
Integrate with regional and provincial initiatives
TAP Model (Toolkit)
Wait time for hip and knee replacement range from 8.9 to 20.6 months
Population demographics projected increase in arthroplasty cases over next 10 years
Indications the patient is to have surgery within 6 months have better clinical outcomes
To implement and evaluate a high quality, high volume, low cost Hip and Knee Reconstruction model for “best practice” hip and knee replacement in a community hospital setting.

4. Components of TAP Model
650 cases/year
process for running concurrent ORs
Prioritization scoring tools
Waitlist Management
Clinical Pathways
Standardization of prostheses
Evaluation (Project Database)
650 cases/year based on 92 dedicated OR days (2 concurrent OR’s) and 8 dedicated inpatient beds
Hip & Knee Replacement Surgical Assessment Tool for BC tool (based on Western Canada Wait List tool)
Waitlist management for all hip and knee patients
VCAT – Clinical Pathways for Hip and Knee Replacement (at Richmond the pathway crosses the entire continuum of care for the surgical encounter – from decision for surgery to post-op rehab complete)
VCH (RSEC) Equipment, Prosthesis and Supply Standardization
Optimize resource utilization throughout the perioperative phase – across continuum of care (used multidisciplinary team for redesign and implementation)
Evaluation (including development of a project database) – assessing:
Patient outcomes – using WOMAC, Oxford and SF12 patient evaluation tools (pre and post surgery). Also using the Hip and Knee Replacement Surgical Assessment Tool for BC.
Financial impact – efficiencies and cost per case (pre and post project initiatives implemented)
Patient satisfaction – holding focus groups for patients in March and again in the fall
Provider satisfaction – meet with providers to assess what worked, what didn’t, how to improve next time

5. Completed Surgery Case Numbers
Project Accomplishments included:
Increase in annual cases of 136% - from a base of 275 cases to 650 cases – (actually completed over 650 cases last fiscal year)

6. Waitlist Numbers for All Cases
Decreased overall waitlist by 30%

7. Waitlist Numbers for Cases > 24 Weeks
Decrease our waitlist for patients waiting greater than 24 weeks by 63%

8. Wait (Lead) Time for Hip & Knee Joint Replacement Surgery
Wait (Lead) time decreased by 75% (decision for surgery to surgery)

9. Summary of TAP Project Objectives met Operationalized TAP model
Decreased wait list size and wait times
Achieved 28% OR efficiency
ALOS 4.1 Days for Hips
ALOS 3.1 Days for Knees
Operationalized TAP model
Collaborative effort
Shared knowledge
We have achieved 25% efficiency in the OR by concurrent tasking and standardization (Total average time for total joint cases was 2:38 (hip was = 2:48 and knee was = 2:28). We have decreased case time to 1:50 – a decrease of 44 minutes, or just over 28%
71% of all total HIP patients (not just primary joints) have stayed on the pathway in 2005/06 (Note: 80%  5 days LOS)
If we include patients who have not reached the HIP pathway target date, our overall LOS is still very close to our target at 4.3 days
We consider a patient off the pathway if they do not meet the target LOS, however, they continue to follow care plan so that all our patients receive consistent care.
Approximately 50% of all total KNEE patients (except unit knees) have stayed on the pathway in 2005/06 (Note: 74% are still less than 4 day LOS, with overall LOS being 4.2 days)
If we include patients who have not reached the pathway target date, our overall LOS is 4.2 days.
Aligned and integrated with several orthopedic initiatives: SPR, prioritization tool, VCAT pathway, etc.
Produced TAP Model Toolkit – transfer knowledge of our experience, what we learned during the project and how we implemented changes – have distributed approximately copies throughout the province and several copies nationally.
"Coordinating a multidisciplinary approach to process improvement is key. Every area that has potential impact on the patient's journey throughout the arthroplasty encounter, from decision to have surgery to completion of post-op rehabilitation, was involved at some point in redesigning the model. This included support staff that never actually came in contact with the patient to clinicians with hands on involvement.“
We were warmly welcomed to come and share in others learning – Rothman’s Institute in Philadelphia and Calgary Health to see their work with the Bone and Joint Project. We acknowledged all these individuals in our toolkit.
We met the established objectives
Model has been operationalized
Including sharing what we learned

10. II UBCH - CSI INITIATIVE
Program announced February 2006
Goals:
decrease wait time for arthroplasty surgery by providing focused funding
provide a model to explore and implement peri-operative efficiencies
allow information transfer of successful approaches to all Health Authorities
1,600 additional arthroplasty cases per year

11. UBCH CSI INITIATIVE Results Cases completed 1,147
Surgeon Participation 25/100
Perioperative efficiencies
Patient Satisfaction 4.7/5
Information Transfer

12. OASIS - Gaps in Care Fragmentation of current services
– limited coordination between care providers
Lack of coordinated capacity
to respond to increasing demand for services
Waitlist and wait time pressures
consults and surgeries
Gaps in care for non-operative patients
Lack of knowledge
regarding available resources and supports
Arthritis second most costly disease category in Canada
Musculoskeletal diseases including arthritis are second most costly disease category in Canada, second only to cardiovascular disease and ahead of cancer.
Estimated 3 Million Canadians with symptomatic OA
Arthritis in Canada (2003), reported the estimated prevalence of symptomatic OA cumulatively over all joints as 10% of Canadian adults or about 3 million people.
40-50% patients suffer intermittent pain, with 10% suffering extreme pain
Krueger (2004) suggests that 40-50% of OA patients are said to suffer intermittent pain and disability compared with those experiencing ongoing, daily pain requiring more active treatment. Only about 10% of patients suffer extreme pain with increasing incapacitation.
Increasing prevalence of OA associated with aging
With the increasing prevalence of OA associated with aging, the incidence of arthritis is expected to explode within the next decade

13. OASIS - Goals Limit the development and progression of OA
Slow onset of complications that can cause severe disability
Reduce avoidable declines in health
Reduce variations in care
Reduce variations in care by outlining the services that all people should expect to receive across the continuum of disease, based on the evidence for optimal care.

14. OASIS Program (OSTEOARTHRITIS SERVICE INTEGRATION SYSTEM)
Services
Multi-disciplinary assessment of treatment & education needs
Personalized action plans
Listing of resources available in public and private sectors
Tools for self-management
Coaching & group education
Coordination of referrals (optional)
Target Populations
Patients in early and advanced stages of osteoarthritis of the hip and knee:
- Non-operative cases
- Surgical candidates
- Individuals seeking information on options
Source of Referrals
primary care physicians
orthopedic surgeons
rheumatologists
Benefits
Enhanced Relationship with Primary Care Physicians
Improved access to services
Skills in self-management
Improved quality of life and health outcomes
Collaborative Partnerships
Improved use of system resources & expertise
Linkages with other Chronic Disease Initiatives
Benefits of OASIS
Equitable access to services based on need rather than entry into referral queue
Access to first available surgeon
Up to date inventory of public and private sector services
Standardized referral forms and assessment tool
Personalized action plan for all clients
Alignment with other CDM initiatives

15. OASIS Patient Journey ASSESSMENT INFORMATION Core EDUCATION & Services
OASIS multidisciplinary team assesses client needs:
Weight management
Pain management
Nutrition
Mobility / exercise
Home support
Aids to daily living
Social services
Need for surgery
Client presents to Physician with hip or knee pain
Physician completes and submits referral documentation to OASIS
Client contacted and scheduled for assessment appointment
Physician assesses clients for OA and appropriateness for referral to OASIS
ASSESSMENT
Client triaged into appropriate care stream
Candidate for surgery in next 6 mos.
Client requiring medical management and other non-surgical support
Core
Services
Clients in early stages of disease requiring “Information Only” are referred to OASIS website and inventory of services
INFORMATION
EDUCATION &
NAVIGATION
All Clients scheduled for Group Education Sessions delivered by OASIS teams or Education Partners
Focus on self-management tools
Preparation and communication of personalized action plans
Discussed with client
Copy to referring physician
Copy to surgeon (surgical candidates)
Clients requiring medical management and/or “readiness for surgery” referred on by OASIS or Physician for physio, home support, weight mgmt., etc.
Clients booked for 6 mos. follow-up appointment
Surgical candidates referred on to Surgeon for surgery consultation
Client participates in OASIS classes for optimization for surgery

16. OASIS - Multiple Stakeholders
Clients and caregivers
Primary Care Physicians (PCPs)
Allied Health Professionals
Orthopedic Surgeons
Rheumatologists
Community Organizations
Education Partners
You will recall that integration and coordination of care is a key theme in the OASIS program.
We want to provide a full continuum of care for our clients/patients, which can be achieved by integration of the services.
In VCH that integration falls across our three service networks – primary health care, one acute and community care.
Today we have Dr. Garey Mazowita, our Family Practice Lead on the OASIS team, to take to you about Primary Care Participation.

17. OASIS - Engagement Strategies
Participation in planning for system re-design & implementation processes
Focus groups – testing ideas
Leadership of Depts. of Orthopedics, Family Practice & Rheumatology
Multiple vehicles for communications and engagement
Beta-testing tools and processes
Evaluate impacts on physician practice and gaps in care
Soft launch and incremental up-take
Communications & feedback loops

18. Provincial Musculoskeletal Council
Initial Focus
Facilitating use and engagement of UBCH / CSI throughout all health authorities
Sharing of information regarding TAP and OASIS models
Confirming the need for building Health Authority capacity to deal with projected demands for musculoskeletal care
Formed in February 2006 to allow a forum for discussion and recommendations regarding the health care needs of the musculoskeletal patient
Membership includes clinical and administrative representatives from each HA, Ministry of Health (acute and chronic disease representatives), primary care and a representative from the B.C. Arthritis Society

19. Provincial Musculoskeletal Council
PMC Subcommittees
Prostheses Standardization
Rehabilitation subcommittee
Provincial collaborative
Future Roles
Expand discussion into other areas of concern (e.g. foot and ankle, spine, fractured hip)
Ensure a coordinated provincial approach
Share lessons learned with other jurisdictions
PMC Subcommittees
Prostheses Standardization: clinical recommendations regarding use of alternate bearing surfaces
Rehabilitation subcommittee: update needs, track performance measures, opportunities for system re-design
Provincial collaborative: direct the work of arthroplasty pathways
Future Roles
Expand discussion into other areas of concern including foot and ankle, spine, fractured hip et al.
Ensure a coordinated provincial approach for the care needs of the musculoskeletal population.
Share lessons learned/opportunities with other jurisdictions

20. Thank you.