1. The Holland Centre – PROVINCIAL CENTRE OF EXCELLENCE On behalf of the Holland Centre Interprofessional Team – February 6 th, 2013

2. Referral Surgical Consult Preadmission Clinic Sent to Individual Surgeons (Batched) No system for tracking referrals or wait times 12-15% not fit for surgery Surgery delayed or cancelled 40% dont want/need surgery Long waits No time for questions Limited education on treatment options

3. 50% wait > 220 days for surgery Length of stay? Destination? Surgeons unable to keep up with volumes Long clinic waits Limited patient education No room for new patients Surgery Post Operative Follow up

4. Overview Major Restructuring of Outpatient Services New Benchmarks, New Processes Key Elements: Non-physician based model of care Centralized electronic referral management Emphasis on patient choice and empowerment Selective referral to surgeons driven by defined criteria Team approach to post op follow-up: increased capacity Community partnerships to support active healthy living Early Ongoing Evaluation; Research Strategy

5. Physiotherapist Orthopaedic Surgeon Research Studies : Attain high diagnostic accuracy; Comparable to surgeons; Performed better than other HCPs Shared Orthopaedic Foundation Independent & Overlapping Roles Childs 2005, 2007; Moore 2005; Gardiner 2002; Aiken 2008; Razmjou 2013

6. 4. ID priority problems and goals to improve model of care Goals: maximize human resources, improve efficiency 4. ID priority problems and goals to improve model of care Goals: maximize human resources, improve efficiency System-wide Reconfiguration with APP Role Surgeon collaboration is key! System-wide Reconfiguration with APP Role Surgeon collaboration is key! 1. Determine need for new model of care High demand, system burden 1. Determine need for new model of care High demand, system burden 2. Define patient population and current model Traditional surgeon roles 2. Define patient population and current model Traditional surgeon roles 3. Identify stakeholders and recruit team Administration, surgeons, patients, physiotherapists 3. Identify stakeholders and recruit team Administration, surgeons, patients, physiotherapists 5. Define new model of care; obtain stakeholder consensus Developed Advanced Practice Physiotherapist (APP) role 5. Define new model of care; obtain stakeholder consensus Developed Advanced Practice Physiotherapist (APP) role 6. Plan implementation strategies Identify barriers and facilitators; Medical Directives extend scope 6. Plan implementation strategies Identify barriers and facilitators; Medical Directives extend scope 9. Long term monitoring Evolve and expand role to match needs 9. Long term monitoring Evolve and expand role to match needs 8. Evaluate APP role and new model of care Structure- Process-Outcome 8. Evaluate APP role and new model of care Structure- Process-Outcome 7. Initiate APP role implementation plan PLAN-DO-STUDY-ACT cycles 7. Initiate APP role implementation plan PLAN-DO-STUDY-ACT cycles Robarts et al. Healthcare Quarterly 2008

7. APP provides initial assessment and treatment plan APP triages all referrals in 2 days APP performs all routine follow up and tele support IDs need for new joints/revisions APP provides earlier post op intervention Assessment and Optimization Surgery Central Intake Physician Referral Long-term Follow up Non surgical path: Treatment and re-entry options. Tele support

8. 230 visits/month 12,000 visits (2007) 250 referrals per month e-Tracking; Wait 1 reporting 400 patients/month High patient satisfaction. ACCESS Patients better prepared. Cancellations 3-4 days LOS 85 to 90% go home Assessment and Optimization Surgical Consult / Surgery Central Intake Physician Referral Long-term Follow up Non surgical path: 30% defer consult; community partnerships

9. INTAKE ASSESSMENT Comprehensive Individualized recommendations Choice of surgeon Treatment options Time for questions Re-entry options Jump-start on health issues Decisions based on standardized outcome measures POST OP FOLLOW UP ** Kennedy, et al. Physiotherapy Can 2010 HIGHLY SATISFIED** Prompt Telephone Support Improved access to clinics Education/Time for questions Enhanced monitoring Optimization of function

10. CBCs White Coat, Black Art with Dr. Brian Goldman: Unnecessary Surgery Show – aired November 3 rd 2012 : Holland Centre Wins Prestigious National 3M Award: http://sunnybrook.ca/content/?page=Focus_MSK_Prog_HKAP_Home http://www.cbc.ca/whitecoat/episode/2012/11/03/unnecess ary-surgery-out-from-under-the-knife / http://www.youtube.com/watch?v=qU krYz-xXEY