Samantha Goodwin - Gold Coast Health - Embracing Disinvestment: A Multidisciplinary Approach to TCP...

Samantha Goodwin Senior Physiotherapist Transi4on Care Program

Embracing Disinvestment: Mul4disciplinary Knee Clinic

Disinvestment …..the withdrawing of investment Merriam-‐Webster online dic4onary

! Economic evalua4on of service delivery

! Be;er value for money

! Removal of services

Embracing Disinvestment

! Be the drivers, not vic4ms of change

! Make what we do well….even be;er

! Start some things…..but stop others

! Work smarter…..not harder

! http://www.youtube.com/watch?v=N8JYBT0Ahe8

Gold Coast TCP

! 96 packages: 82 community, 14 residen4al ! 2013 Mean Occupancy Rate: 93%

! “quicker and sicker” discharge [1][2] ! Case Mix: 40% orthopeadics (8 TKR)

! District pressures/integrated care

Evalua4on of a Physiotherapy Service Delivered to Post-‐Acute

Community Rehabilita4on Pa4ents through a Transi4on Care Program

Samantha Goodwin1, Abel Myoung Kim2, Rebecca Lackie1, Emma Ayres1, Dr Michael Steele3and Dr Nancy Low Choy2

1Department of Physiotherapy, Transition Care Program, Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia 2Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia

3Faculty of Business, Bond University, Gold Coast, Queensland, Australia Acknowledgement to all Physiotherapists of the Gold Coast Hospital and Health Services District TCP

Approval for the study was provided by Gold Coast Human Research Ethics CommiBee

And Bond University Ethics CommiBee

Australian Physiotherapy Associa4on

“Inmo4on” March 2014 p45 [3]

How much service do we provide?

! Total PT service 11.2 mins/day

! 7 direct contact OOS @ 51.2 mins per visit ! Significantly more individualized services (74%) than classes (26%)

(p<0.001)

! More home treatments (66%) than centre-‐based (34%) (p<0.001) Is more necessarily be;er? -‐ a review of mobility/balance outcomes

! We have clinically posi4ve outcomes….but could we get the same with less 4me….?… Can we work smarter not harder

! Aim to increase use of Centre and Group based treatment – expecta4ons, barriers, need more groups, add MDT?

Knee Arthroplasty

! Effec4ve means to relieve

symptoms of arthri4s…rehabilita4on (nursing & therapy) necessary adjunct to surgery to return func4on[4] ! 42 000 TKR in 2012 [5] ! 70% 65 + years [5] ! Room for improvement -‐ 20% not happy in UK[6]

Senior Physiotherapist

Clinical Nurse Consultant

Senior Pharmacist

Rehabilita4on Specialist

Allied Health Assistant

Mul4disciplinary Knee Clinic

Team Approach " Client Centred Care " Pain Management " Medica4on Review " Wound Care " Oedema Management " Massage/Manual Therapy " Exercises " Gait and Stairs Retraining " Help with Transport

What the Research says about Group v Home Therapy

! As effec4ve as individual treatments for stroke pa4ents [7], ortho-‐geriatric clients [8] and frail older adults [9]

! More independence in walking and greater pa4ent sa4sfac4on [7] and beSer balance, func4onal tests and QOL gained [9]

! Significant reduc4on in rate of falls [10] ! Joint Replacement – same outcomes (WOMAC, SF-‐36, ROM, TUG,

6 metre walk test), most efficient with less physiotherapist’s 4me per pa4ent for centre based (direct 27 v 38 mins; indirect 10 v 26 mins) [11]

What the Research says about MDT approach to Knee Arthroplasty

! One systema4c review of cochrane database…[12]

“silver level evidence that following hip or knee joint replacement, early mulHdisciplinary rehabilitaHon can improve outcomes at the level of acHvity and parHcipaHon. The opHmal intensity, frequency and effects of rehabilitaHon over a longer period and associated social costs need further study. ”

12 month Review of MDT Knee Clinic

! Demographic descrip4on of clients a;ending Knee Clinic

! Snapshot examina4on of MDT services for 2 comparable TKR clients: home v knee clinic

! Validated client sa4sfac4on survey

Demographics of our Knee Clinic Clients Age years (range) 74 (61-86)

Gender: Male (%)

Female (%)

12 (32%)

26 (68%)

Length of Stay (days) 52

Number of Visits 5

Number of clients using classes (% total)

38/40 (95%)

MDT Knee Clinic v Home Service Knee Clinic Home Only

Age (years) 73 77

Length of Stay (days) 41 40

Post Op Day at Admission 5 6

Distance from Centre (km) 5.0 3.5

Visits to Clinic 5 0

Physiotherapist Occasions of Service (OOS) Contact (hours) Direct Indirect

8 5.8 2.6

10 9.5

7.3 **

Nursing OOS Contact (hours) Direct Indirect

3 2

4.3**

8 4.5 5.2

Pharmacist OOS Contact (hours) Direct Indirect

1 0.3 0.3

0 0 0

Allied Health Assistant OOS Contact (hours) Direct Indirect

6 3.8 1.3

2 1.7 1.1

All Contact Time (hours) Direct Indirect Total

11.9 8.5 20.4

15.7 13.6 29.3

** case management included

Direct – face to face Indirect – travel, chart notes/review

Economic Cost Comparison Knee Clinic v Home

Knee Clinic Home Client

Professional Contact ($50/hr) $ 765 $1325

AHA Contact ($26/hr) $ 133 $ 73

Transport $ 130 $ 0

TOTAL $1028 $1398

Excluded costs are PCW for domestic/shopping, hired equipment. Transport is based on taxi fare estimates from website

Knee Clinic Client Sa4sfac4on Survey ! 38 Clients reviewed admitted from February 2013 -

January2014

! 36 validated client surveys posted out to clients with reply paid envelope supplied. (1 client had 2nd knee admission in the 12 months, 1 deceased)

! 32 respondents (89% response rate)

How would you rate the quality of service you received?

Excellent 97% (31)

Good 3% (1)

Fair 0%

Poor 0%

Did you get the kind of service you wanted?

Yes, definitely 91% (29)

Yes, generally 9% (3)

No, not really 0%

No, definitely not 0%

To what extent has our service met your needs?

Almost all of my needs have been met 84% (27)

Most of my needs have been met 16% (5)

Only a few of my needs have been met 0%

None of my needs have been met 0%

If a friend were in need of similar help, would you recommend our service

to him or her?


Yes, I think so 0%

No, I don’t think so 0%


How sa4sfied are you with the amount of help you received?

Very sa4sfied 94% (30)

Mostly sa4sfied 6% (2)

Indifferent or mildly sa4sfied 0%

Quite sa4sfied 0%

Have the services you received helped you to deal more effec4vely with your problems?

Yes, they helped a great deal 94% (30)

Yes, they helped somewhat 6% (2)

No, they really didn’t help 0%

No, they seemed to make things worse 0%

In an overall, general sense, how sa4sfied are you with the service you received?

Very sa4sfied 94% (30)

Mostly sa4sfied 6% (2)

Indifferent or mildly sa4sfied 0%

Quite sa4sfied 0%

If you were to seek help again, would you come back to our service?


Yes, I think so 3% (1)

No, I don’t think so 0%


What our clients had to say “the experts built confidence and infused self confidence…sessions

were enjoyable..”

“the consideraHon, aPtude and personal effort everyone showed

was excepHonally helpful in my Hme of need”

“cannot improve on PERFECTION – stay just the

way you are”

“could not have managed without them”

“will be back in touch soon for the other knee”

“ wish it could go for longer…missed you all aVer 6 weeks”

“tea and biscuits instead of water…ha ha”

“follow up phone call a few weeks aVer”

What could we improve?

Case Study – Saving Knees to Saving Lives MD Knee Clinic in ac4on

! 65 year old lady admi;ed to TCP 27 days post elec4ve (L) TKR.

! Slow to progress in rehab… premorbid mobility past 3 years in a wheelchair.

! Co-‐morbidi4es – HTN, neurofibramotosis tumor (9kg), 4/12 prior THR with DVT/PE for pathological #NOF

! Socially isolated– lives alone, HACC services (transport, domes4c/laundry, shopping)

MRS H

Case Study – Saving Knees to Saving Lives MD Knee Clinic in ac4on cont…..2

Ini4al joint review at home by OT/CN due to safety risk. Referred to MD Knee Clinic

Func4on at admission

! Hygiene – seated, independent ! Mobility – 4 ww indoors, Wheelchair outdoors

! Stairs – X 1 assist to carry wheelchair. Limited assistance


First Visit-‐ Client noted to be SOBAR in wai4ng room – put down to walk from car…decondi4oned had come with 4ww not wheelchair. ! Physiotherapist – client reported feeling more SOB than usual, but just needed sleep. 9/10 groin pain. Nil cough. Commenced exercise:minisquat x 2, very SOBOE….on ausculta4on chest clear.

! CNC – SaO2 90%...previous obs 98% on RA, client suggested mild chest pain to nurse. Irregular pulse, very high HR, looked unwell. ! Pharmacist – reviewed meds, no an4coagula4on therapy unusual given history of PE/DVT

! Rehabilita4on Consultant –given history, supported team’s suspicion of PE…referred client direct to A&E via QAS…

! Client refused, preferring “to sleep it off” and would see GP next day…..

! Knee Clinic Team discussed barriers : 4ww, previous experience A&E wai4ng, transport home

! Team met united with client with facilitators

……………………………………………………….

! Inves4ga4ons showed massive PE


Moving forward….Embracing Disinvestment

! Be the drivers, not vic4ms of change eg preoperaHve predictor tool [2]

! Make what we do well….even beSer eg evaluate local service

! Start some things…..but stop others eg telerehabilitaHon [3] ! Work smarter…..not harder eg co-‐locate clients

Thank You

References [1] Kosecoff J, Kahn K, Rogers W et al.(1990) Prospec4ve payment system and impairment at discharge. Journal of American Medical AssociaHon 264:1980–83.

[2] Oldmeadow L, McBurney H, Robertson V (2001) Hospital stay and discharge outcomes ayer knee arthroplasty. Journal of Quality in Clinical PracHce 21:56-‐60

[3] Goodwin S (2014) Evalua4on of a physiotherapy service delivered to post acute community rehabilita4on clients through a Transi4on Care Program. Australian Physiotherapy AssociaHon InMoHon. Mar 45 [4] Russell TG, Bu;rum P, Woo;on R, Jull GA (2011) Internet-‐Based Outpa4ent Telerehabilita4on for Pa4ents Following Total Knee Arthroplasty: A Randomized Controlled Trial Journal of Bone and Joint Surgery Jan 19;93(2):113-‐120

[5] Australian Orthopaedic Associa4on Na4onal Joint Replacement Registry 2013 Annual Report h;ps://aoanjrr.dmac.adelaide.edu.au ….accessed 27 April 2014

[6] Simpson AH, Hamilton DF, Beard DJ, Barker KL, Wilton T, Hutchison JD, Tuck C, Stoddard A, Macfarlane GJ, Murray GD (2014) Targeted rehabilita4on to improve outcome ayer total knee replacement (TRIO): study protocol for a randomised controlled trial. Trials Feb 1;15:44. doi: 10.1186/1745-‐6215-‐15-‐44.

[7] English CK, Hillier SL, S4ller KR, Warden-‐Flood A (2007) Circuit class therapy versus individual physiotherapy sessions during inpa4ent stroke rehabilita4on: a controlled trial. Archives of Physical Medicine and RehabilitaHon. Aug;88(8):955-‐963

[8] Carmeli E, Sheklow S & Coleman R (2006) A compara4ve study of organized class-‐based exercise programs versus individual home-‐based exercise programs for elderly pa4ents following hip surgery. Disability and RehabilitaHon. 28(16):997-‐1005A

[9] Eko VWM, Naylor JM, Harris IA, Yeo AET, Crosbie J (2011) Is centre-‐based rehabilita4on superior to home-‐based rehabilita4on ayer knee replacement? A single-‐blind, randomised controlled trial. ArthriHs and RheumaHsm Conference, Annual ScienHfic MeeHng Chicago, IL, USA. Publica4on John Wiley and Sons Inc 63(12) (pp4043)

[10] Comans T, Brauer S, Haines T (2010). Randomized trial of domiciliary versus center-‐based rehabilita4on: which is more effec4ve in reducing falls and improving quality of life in older fallers. The Journal of Gerontology Series A: Biological Sciences and Medical Sciences June;65(6):672-‐679. [11]Coulter CL, Weber JM, Scarvell JM (2009) Group Physiotherapy Provides Similar Outcomes for Par4cipants Ayer Joint Replacement Surgery as 1-‐to-‐1 Physiotherapy: A Sequen4al Cohort Study. Archives of Physical Medicine and RehabilitaHon. Oct 90(10):1727-‐1733

[12] Khan F, Ng L, Gonzalez S, Hale T, Turner-‐Stokes L. (2008) Mul4disciplinary rehabilita4on programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database SystemaHc Review Apr 16;(2):CD004957

Samantha Goodwin - Gold Coast Health - Embracing Disinvestment: A Multidisciplinary Approach to TCP...

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