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

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.

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.

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

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)

Waitlist Numbers for All Cases Decreased overall waitlist by 30%

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

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

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 65-70 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

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

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

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

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.

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

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

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.

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

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

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

Thank you.