MSK Rapid Access Clinics

Engagement with Key Associations

February 23, 2018

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Agenda

• Welcome

• The vision for MSK Rapid Access Clinics

• The core elements of the RAC’s first two pathways

• Hip and Knee Arthritis

• Low Back Pain

• The benefits for patients and providers

• Implementation

• Association engagement

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Who is on the call today

• Ontario Orthopedic Association -

OOA

• Ontario College of Family Physicians

- OCFP

• Ontario Medical Association - OMA

• Ont Hospital Association - OHA

• Ontario Physiotherapy Association -

OPA

• Ontario Chiropractic Association -

OCA

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• Ontario Society of Occupational

Therapists - OSOT

• Nurse Practitioner's Association of

Ontario - NPAO

• Provincial Neurosurgery Ontario -

PNO

• Association of Family Health Teams

of Ontario - AFTHO

• Association of Ontario Health

Centres - AOHC

• Registered Nurses Association of

Ontario - RNAO

The need to address access to care for patients with

MSK conditions is growing

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Utilization• 3.1M Ontarians made 8M outpatient visits

associated with MSK in 13/14 (5.6M were primary care visits, 560K ED visits)

• At least 37% of MRIs in the province are ordered for MSK conditions

Surgical utilization• MSK surgeries account for 15% and

represent the lowest % completed within target, of surgical procedures in ON

• Volumes steadily increasing since 12/13: hip replacement: 5.1%/year, knee replacement: 3.3%/year

Opioid dependency• Timely access to appropriate MSK services

reduces the incidence of unnecessary opioid prescriptions. Any opioid prescription carries with it a risk of opioid dependence.

Clinical appropriateness• Evidence for sustained reductions in

inappropriate utilization (e.g. low back pain pilot in three sites saw $500K/year in costs avoided in reduced imaging)

• Aging population will continue to require procedures that are clinically appropriate (e.g. hip/knee replacement)

Evidence for Action:Prevalence• 1 in 3 adults affected by musculoskeletal

(MSK) diseases (e.g. arthritis, repetitive strain injuries), which will only grow as the population ages

The Vision for MSK Care Primary care providers will know what to refer and where, to appropriately support their patient’s care pathway. Shared care

models make them active participants in their patient’s care across the continuum.

Specialists receive more appropriate referrals which allow for more predictable practice and

improved wait list management.

Ontario’s health system will become more sustainable, with improved access to

appropriate and high quality care.

All Ontarians have timely access to high quality, integrated

MSK Care through:

• Proven models of care

• A team approach, Shared care

• Improved value

• Patient choice

• Selective referral to surgeons

• Integration through community resources and linkages

• E-tracking/referral management

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• The first pathways to be implemented are:

• Hip and knee arthritis pathway for patients presenting

with moderate to severe osteoarthritis; and,

• Low back pain pathway for patients presenting with less

than 12 months of back pain.

• Over time, proven pathways for managing other MSK conditions will be

integrated into the RACs.

What do RACs provide?

• When a primary care provider is contemplating an opioid prescription, an imaging referral or specialist

referral, they can refer their patient to a RAC.

• At a RAC, patients will see a specially trained interprofessional MSK provider who will work with them

to determine the appropriate care pathway.

• Patients that do not need surgery will be given an evidence-based self-management* plan and

directed to local services if needed.

Where will RACs be located?

• All around a LHIN! RAC providers will work with patients in community and hospital settings.

• Assessor practice locations are being determined locally under the principle of minimizing patient

travel while ensuring safety and efficacy of care.

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Implementation of RACs follows an evidence-based approach

Appropriate opioid prescribing for MSK conditions is a critical element of improving MSK care… The ministry has tasked Health Quality Ontario (HQO) to, in collaboration with system partners such as the regulatory colleges and health professional associations, implement an integrated continuing education and professional development (CPD) model focused on appropriate pain management and opioid prescribing

60% of people referred to the hip & knee

pathway need surgery.7% of people referred to

the low back management pathway

need surgery.

Standard components ensuring timely access to

high quality, integrated MSK care

• Education for primary care providers on MSK clinical pathways

• Referral criteria defined and referral tools provided for primary care providers

Patient and PCP use guidelines to determine appropriate next steps

• Primary care providers have one point of contact

• Defined information requirements (completeness criteria), +/- imaging requirements

• Triage that follows standard criteria

• Defined time to referral acknowledgment and assessment scheduling

Central point of contact for referral intake

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• Advanced practice providers assess patients within 4 weeks of referral• Comprehensive with standard assessment tools and diagnostic investigations and outcome measurement • Criteria-based triage• Patients provided with individualized recommendations and optimization

Interprofessional assessment

• Appropriate patients proceed to surgical consultation• All surgeons accept and book procedures for patients that have gone through central intake• Informed patient choice (next available surgeon or patient’s choice of surgeon)

Surgical consultation

• Common metrics defined to facilitate performance monitoring and program improvement

Data collection and performance monitoring

Standard components ensuring timely access to

high quality, integrated MSK care

These components all contribute to enhanced communication with improved timeliness, consistency & completeness of content for PCP, patient, surgeon/specialist

Benefits to Patients and Primary Care Team

CENTRAL INTAKE

• Streamlined approach with standards for wait

times

• Reduced wait times with option of referral to

next available surgeon

• Urgent referrals identified, with prompt actions

• Referral and wait time tracked

• Supports and improves communication with

referring physician/primary care team regarding

patient’s care trajectory

ASSESSMENT AND MANAGEMENT

• Increase PCP capacity to manage MSK conditions

• Comprehensive assessment

• Decisions based on standardized outcome measures

• Individualized recommendations, including evidence

based self management plan

• Choice of surgeon

• Education on treatment options

• Time for questions

• Re-entry options

• If surgical: jump-start on health issues

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Benefits to surgeons

• See patients that are appropriate to sub-specialty interests

• Receive full history and physical examination, with outcome measurement

• Receive information as to patient’s readiness for surgery

• Focused assessment with work up completed

• More time for answering patient’s questions

• Avoids surgical delays/cancellations with health issues identified earlier

• Team approach maximizes the surgeon’s time

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The implementation of MSK intake, assessment and

management models is a collective responsibility

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MOHLTC and MSKExecutive Committee

ARTICProject Implementation

TeamsLHINs

• Establishes broad strategic vision

• Defines standard components as outlined in LHIN mandate letters

• Establishes performance targets

• Overall project management, including change management methodology

• Ensures fidelity to provincial plan

• Implementation support

• Develop clinical pathway, including common elements and resources

• Clinical model leadership

• Develop a Community of Practice

• Implementation support and expertise

• Lead local implementation, including common elements and local customization

• Collaborate with Project Implementation Teams

Adopting Research To Improve Care (ARTIC)

• Originally developed by the Council of Academic Hospitals of Ontario

(CAHO)

• Now co-led in partnership with Health Quality Ontario

• Helps spread proven interventions quickly and effectively, bringing evidence-

based care to more people in Ontario

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1. Guidance and facilitation

o From the ARTIC program and project leads, including central coordination, implementation

planning and expertise, and supporting communities of practice across a project’s spread sites

2. Executive champions and governance

o Where senior leaders across project sites are mutually accountable for the successful

implementation of the intervention, with oversight and support from the ARTIC program

3. Education and training materials

o About the intervention, to provide knowledge and understanding about how the project works

to improve care

4. Evaluation

o Of outcomes against project objectives and across ARTIC core evaluation metrics,

incorporating learnings at both the project and ARTIC program level.

Grounded in implementation science, ARTIC’s proven model is based on the

following enablers:

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Overall Timeline

2017/18

• LHINs with existing CIAC: All hip and knee patients referred via centralized intake, assessment, and management

• LHINs without CIAC: centralized intake, assessment, and management is established

• LHINs that have indicated readiness: All ISAEC patients referred via centralized intake, assessment, and management

2018/19

All hip and knee patients referred via centralized intake, assessment and management

All ISAEC patients referred via centralized intake, assessment, and management

Centralized intake, assessment, and management model supports broader MSK conditions (shoulder)

2019/20

• Expanded hip and knee conservative management program

• Evaluation analysis

• Adding other MSK pathways

Progress to date includes:

• The provincial funding announcement and letters to LHINs made in December

• ARTIC has shared with LHINs a high-level implementation plan to provide guidance

and direction to address the streams of work.

• Regular communication via webinars, newsletters and communiques with LHIN

implementation teams and clinical leadership

• Development and dissemination of tools, resources, and guidance documents

• Individual LHIN meetings, phone calls and follow up to support local planning

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Shaping your role(s) is part of today’s discussion. Consider the following:

• Share relevant content with your members for information

• Be available to engage and share messaging at relevant junctures

• Share concerns being raised by your members with the core team

Inquiries can be directed to ARTIC@hqontario.ca

Role of Associations

Next steps

• What are the best ways to keep connected with this group?

• Do you have questions about the model or timelines for implementation?

• Other questions…

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Appendices

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Provincial Leads

Dr. Jeff Gollish, Provincial Clinical Lead, Hip and Knee, Orthopaedic Surgeon, Holland

Orthopaedic and Arthritic Centre

• Dr. Gollish has a subspecialty interest in total joint replacement (hips and knees),

both primary and revision. Dr. Gollish has championed the role of the Advanced

Practice Physiotherapist and team-based model of care among his colleagues and

decision-makers across Canada. He has a keen interest in improving care

processes for the hip and knee arthroplasty population, including the development

and implementation of standardized care pathways and protocols. An accessible

leader, he has motivated and inspired Holland Centre multidisciplinary teams toward

innovative patient care solutions.

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Provincial Leads

Dr. Raja Rampersaud, Provincial Clinical Lead, ISAEC, Orthopaedic Spine Surgeon at

Toronto Western Hospital, University Health Network

• Dr. Rampersaud is a world renowned spine surgeon who is a recognized leader and

innovator in minimally invasive spinal surgery. His clinical research focuses on

health services, quality of care, including comparative/cost-effectiveness analyses

for orthopaedic disorders such as low back pain and osteoarthritis. He is an

advocate for interprofessional models of care for spine and musculoskeletal

disorders. In addition to his leadership alongside the Ministry of Health and Long-

Term Care on the Ontario Low Back Pain Strategy, he serves as the Advocacy Chair

for the Canadian Spine Society and the National Director-Spine for Bone and Joint

Canada.

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Provincial Leads

Susan Robarts, Clinical Implementation Lead, Advanced Practice Physiotherapist,

Holland Orthopaedic & Arthritic Centre, Sunnybrook Health Sciences Centre

• Susan Robarts is an advanced practice physiotherapist in hip and knee arthritis,

arthroplasty and spine specialty clinics at Sunnybrook and is the clinical supervisor

for the advanced practice team. She researches clinical decision-making and

effectiveness of new roles and has assisted with spreading the team-based model of

care nationally and internationally. She is trained in and has implemented Lean for

healthcare processes. Susan has been a physiotherapist in remote northern

communities along the coast of James Bay and researched the needs of people

with disabilities. The experience continues to inform her efforts to improve access to

care through innovation and team-based models of care.

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In 2017-18, LHINs have indicated commitment to the following

implementation objectives…

LHINLow Back Management

(ISAEC)Hip & Knee

South East Implement Begin implementation

Hamilton Niagara Haldimand Brant Spread Pilot Make mandatory

Mississauga Halton Implement Begin implementation

South West Implement Begin implementation

Toronto Central Spread Pilot Make mandatory

Waterloo Wellington Implement Make mandatory

Central West Implement Make mandatory

North Simcoe Muskoka Implement Make mandatory

Erie St. Clair Implement Begin implementation

Central Defer to FY18-19 Make mandatory

Central East Implement Begin implementation

North East Implement Make mandatory

North West Spread Pilot Make mandatory

Champlain Implement Already mandatory

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Advanced Practice Roles in

MSK Models of Care

Designed to Improve

Access

Research in Canada

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• Aiken, Healthc Q. 2008

• Aiken and McColl, J Interprof Care. 2008

• Robarts, Healthc Q. 2008

• MacKay, J Eval Clin Pract. 2009

• Kennedy, Physiother Can. 2010

• Sarro, JAN. 2010

• MacKay, Osteoarthritis and Cartilage. 2012

• MacKay and Davis, BMC Res Notes. 2012

• Desmeules, BMC Musculoskelet Disord. 2012

(A Systematic Review)

• Razmjou, Physiother Can. 2013

• Desmeules, Physiother Can. 2013

• Robarts, Can J Surg. 2017

• Decary, BMC Musculoskelet Disord. 2017

• www.ISAEC.org