TEAMS - towards integration of services Rhian Lewis Ysbyty Gwynedd Bangor

Chaos

TEAMS T argeted E arly A ccess to M usculoskeletal S ervices Reorganisation of services Problems encountered Improvements achieved

Reorganisation of services

Problems encountered

Improvements achieved

Order

Bangor

North Wales

Challenges Difficulty in coping with referral demand Long waiting lists No acute back pain service Patients on multiple waiting lists Limited co-ordination of services Inappropriate referrals in orthopaedics – low surgical conversion rates

Difficulty in coping with referral demand

Long waiting lists

No acute back pain service

Patients on multiple waiting lists

Limited co-ordination of services

Inappropriate referrals in orthopaedics – low surgical conversion rates

Wider environment WAG programme: Innovations in Care in orthopaedics Project group on accessibility of musculoskeletal services

WAG programme: Innovations in Care in orthopaedics

Project group on accessibility of musculoskeletal services

TEAMS working party GP representing local health group Senior manager Orthopaedic surgeon Pain management consultant P hysiotherapist R heumatologist

GP representing local health group

Senior manager

Orthopaedic surgeon

Pain management consultant

P hysiotherapist

R heumatologist

Aims of TEAMS Improved access to services Reduced waiting times Timely surgery

Improved access to services

Reduced waiting times

Timely surgery

Key features Common access point Triage into appropriate specialty Development of care pathways ESP-led Back Pain Service Community-based musculoskeletal clinics Fibromyalgia clinic

Common access point

Triage into appropriate specialty

Development of care pathways

ESP-led Back Pain Service

Community-based musculoskeletal clinics

Fibromyalgia clinic

Integration of services GP referral Triage Surgical advice Chronic back OA/soft tissue Arthritis/CTD Acute back Physio assessment Pain management Rheumat- ology Orthopaedic service

Difficulties to overcome Change is threatening Rheumatologists ?Take-over bid? Ortho objected to pooled referrals Delegation of responsibility Supporting new nurses time-consuming

Change is threatening

Rheumatologists ?Take-over bid?

Ortho objected to pooled referrals

Delegation of responsibility

Supporting new nurses time-consuming

Acute back pain New service: ESP (physio) triage Reduce acute backs seen in ortho Screen Red flags (fast-track to ortho) Onward referral of Yellow flags to pain clinic Weekly meeting of ESP with pain clinic MDT

New service: ESP (physio) triage

Reduce acute backs seen in ortho

Screen Red flags (fast-track to ortho)

Onward referral of Yellow flags to pain clinic

Weekly meeting of ESP with pain clinic MDT

Acute back pain pathway Orthopaedics GP Referral Teams Co-ordinator RED Flags ESP screening / telephone Re-assessment Pain Team/Epidural Physio Treatment Resolving D/C Further physio

Telephone reviews TENS and drug reviews by specialist nurses Greater emphasis on education, exercise and self-management Flare-up protocols Weekly MDT meeting Chronic pain - changes

Telephone reviews

TENS and drug reviews by specialist nurses

Greater emphasis on education, exercise and self-management

Flare-up protocols

Weekly MDT meeting

Pain clinic - staff increases 3.5 Consultant sessions 0.5 Specialist nurse 0.5 Psychologist 0.5 Physiotherapist

3.5 Consultant sessions

0.5 Specialist nurse

0.5 Psychologist

0.5 Physiotherapist

Chronic pain - results Increased throughput – 400 -> 700/year Waiting list of 2-3 months (down from 12 months) Acute referrals from ESP seen within 1 week

Increased throughput – 400 -> 700/year

Waiting list of 2-3 months (down from 12 months)

Acute referrals from ESP seen within 1 week

Rheumatology - changes inflammatory triage GP referral non-inflammatory rheumatology musculoskeletal

New programme - GPwSI 5 GP's with an interest in MSM Work closely with ESP Physio Triaged by rheumatology consultant Overseen by clinical lead Treatment of uncomplicated musculoskeletal problems

5 GP's with an interest in MSM

Work closely with ESP Physio

Triaged by rheumatology consultant

Overseen by clinical lead

Treatment of uncomplicated musculoskeletal problems

Musculoskeletal clinics One clinic weekly in each geographical area Bangor, Llandudno, Holyhead, Pwllheli, Dolgellau 125 patients a month Monthly combined education programme

One clinic weekly in each geographical area

Bangor, Llandudno, Holyhead, Pwllheli, Dolgellau

125 patients a month

Monthly combined education programme

Rheumatology - results Reduced waiting times Greater responsiveness to patients More use of nurse-led, multidisciplinary review clinics Telephone helpline

Reduced waiting times

Greater responsiveness to patients

More use of nurse-led, multidisciplinary review clinics

Telephone helpline

Orthopaedics - changes LBP seen by ESP Musculoskeletal to GPwSI and ESP Reduction in out-patient waiting times Surgical conversion increased to 60%

LBP seen by ESP

Musculoskeletal to GPwSI and ESP

Reduction in out-patient waiting times

Surgical conversion increased to 60%

Educational meetings Physio GPwSI Ortho trainees A and E staff GPs

Physio

GPwSI

Ortho trainees

A and E staff

GPs

Results in first year (2002) Total monthly referrals 400 --> 900 Orthopaedic share 250 --> 200 Increase in pain, MSM, physio Abolished duplicate referrals Surgical conversion rate improved

Total monthly referrals 400 --> 900

Orthopaedic share 250 --> 200

Increase in pain, MSM, physio

Abolished duplicate referrals

Surgical conversion rate improved

Waiting time reductions (weeks) 2001-2002 T and O 52 --> 13 36 --> 9 52 --> 7 Pain Rheumatology

T and O

52 --> 13

Current position 2007 Improvements maintained Referrals 890/month Waiting times maintained

Improvements maintained

Referrals 890/month

Waiting times maintained

Pain clinic perspective Back pain service in place ESP and Pain clinicians Increase in: semi-acute backs MRI scans tertiary referrals

Back pain service in place

ESP and Pain clinicians

Increase in:

semi-acute backs

MRI scans

tertiary referrals

What did we learn? Integration improves services Community clinics effective for uncomplicated musculoskeletal problems Nurse-led clinics can reduce W/L Acute back pain service valued by GPs Helpline valued by patients

Integration improves services

Community clinics effective for uncomplicated musculoskeletal problems

Nurse-led clinics can reduce W/L

Acute back pain service valued by GPs

Helpline valued by patients

TEAMS - the answer? One-stop shop for patients Joined up services for practitioners

One-stop shop for patients

Joined up services for practitioners