1. www.pspbc.ca MSK Train the Trainer 1 Arthritis and Low Back Pain Wireless: Westin-Meeting Code: bcma2013 Westin Wall Centre April 4-5, 2013

2. Welcome and Introductions Dr. Diane Lacaille

3. 3  Our patients: Megan and Mary Beth  Teaching faculty › Arthritis: Diane Lacaille, Lori Tucker, › Low back pain: Julia Alleyne, Brenda Lau › Family practice: Bruce Hobson › Patient self-management: Connie Davis › Workshop and panelist faculty  Moderator: Diane Lacaille, Garey Mazowita Faculty Introductions

4. 4  USB Keys  Handouts  Internet: Wireless: Westin-Meeting Code: bcma2013  Cell Phones, Bathrooms  Breaks  Credits  Parking  Mikes  Evaluation  Physician Reimbursement Form Housekeeping

5. 5  What hat are you wearing?  How does it fit?! Ice Breaker

6. 6  Multiple choice questions  Student response system technology  Audience answers  Data filed  Pre-post day comparison Clicker Time

7. 7 1. Family Physician 2. Specialist Physician 3. Medical Office Assistant 4. Rehabilitation Professional 5. PSP Coordinator/Manager 6. Administrator 7. Clinical Faculty 8. Patient What hat are you wearing?

8. 8 1. Vancouver Coastal Health Authority 2. Vancouver Island Health Authority 3. Northern Health Authority 4. Interior Health Authority 5. Fraser Health Authority Which area do you work in?

9. 9 1. Rehab & exercise, weight management, pain management, patient self-management 2. Exercise, pain management, imaging and investigations, patient self-management 3. Rehabilitation, disability management, pain management, patient self-management 4. Weight management, pain management, patient education, early surgical referral What are the four pillars of osteoarthritis treatment? Choose one

10. 10 1. Morning stiffness greater than 30 minutes 2. Bony enlargement 3. Synovial thickening 4. Joint involvement of hands and feet 5. Pain increased with rest or immobility Which key clinical features are NOT suggestive of Inflammatory Arthritis?

11. 11 1. Acute joint swelling to rule out septic arthritis 2. Acute joint swelling to detect presence of crystals 3. To differentiate inflammatory from non-inflammatory causes of joint swelling 4. To relieve pressure of moderate joint hemarthrosis 5. To improve joint mobility and function 6. 1,2 and 3 7. 1,2 and 4 In which of the following situations would joint aspiration be clinically useful?

12. 12 1. Early initiation of prednisone medication 2. Prioritizing depression as a common co-morbidity 3. Early initiation of non-biological disease modifying anti- rheumatic drugs (dmard”s) to reduce joint damage 4. Referral to a rheumatologist prior to medication initiation What is best practice for the management of Rheumatoid Arthritis?

13. Program Orientation Dr. Diane Lacaille

14. 14  Patient’s journey  Gap analysis  Evidence-informed practice guidelines  Juvenile idiopathic arthritis  Clinical tools  Application to practice with video  Shared care panel  Practice implementation Rheumatoid Arthritis and Osteoarthritis

15. 15  To discuss a comprehensive approach to improve FP care and supports for patients living with RA, OA and LBP demonstrated by: › A reduction in pain › An increase (or reduced decline) in patient functioning › Informed and activated patients managing their condition to the best of their abilities › Specialist support and consultation, when needed, is available in a timely manner  To review selected tools and provide an overview of how to access additional tools / information through either electronic or hard copy toolkits  To have a plan for the action period Why are we here?

16. 16  MSK Project Charter: Scope of Work, Deliverables, Inclusions & Exclusions)  Needs / Gaps / Barriers to Care informed by:  Incidence /prevalence of disease in BC  Arthritis Service Framework (2008)  Small survey of FPs  Input from experts / working groups  Review of relevant literature  Experience of other jurisdictions  Framed around evidence-based best practices:  GPAC Guidelines (BC) for OA and RA  Alberta, New Zealand, UK Guidelines for LBP Foundation of Work

17. 17  Paper-based vs. EMR office set ups  Alignment with currently used or planned tools  Office time constraints / workflow  Pattern recognition vs. algorithmic care  Recognition that management may precede diagnosis  Access to specialists and rehab experts  Awareness of education and community resources  Role of physician in dialogue / discussion of PSM  Time implications / alignment with physician fee schedule Physician Issues / Considerations

18. 18  Practical & simple point of care tools / checklists  Screening tools for early identification of inflammatory arthritis  Red and yellow flags and criteria for expedited referral  Supports for dealing with complex and chronic pain  Tools for responding to psychosocial needs of patients  Tools for Joint Action Planning  Awareness of programs, services, resources available Areas of Focus - In the FP Office

19. 19  Access to specialists for quick advice (RACE telephone service)  Criteria for appropriate referrals / consults  Meaningful consult letters that support the FP in ongoing care for patients  Building the network of relationships at local / community level  Awareness of Provincial, regional and local programs and resources for patients and care givers Areas of Focus – For Specialist / Community Support

20. 20  Management of co-morbidities and related issues  Readiness for self-management responsibilities  Alignment with currently used or planned PSM tools  Keeping tools comprehensive yet useable  Tools in a format that address issues of health literacy, ethnic diversity  Desire for hard-copy, printed materials to take away from visit  Awareness of and access to education programs and community resources  Use of patient health record Patient Issues / Considerations

21. 21  FP survey  Cross-section of stakeholders on steering committee and working groups  Webinars and telephone consults  FP trial / test of OA, RA, LBP “point of care” tools  Focus groups Physician & Patient Engagement in Content Development

22. 22  Shared Care Committee (SCC)  General Practice Services Committee (GPSC)  Specialist Services Committee (SSC)  The Ministry of Health (Primary Care Division)  The Arthritis Society  Mary Pack  OASIS Program  Patient Voices Network  Individual Physicians, Clinical Specialists, Patients Acknowledgements

23. 23 Charter

24. Patient Journey Ms. Meghan Smaha

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29. Gap Analysis: Why is MSK a tough nut to crack? Dr. Garey Mazowita

30. 30 To be able to describe the common barriers that physicians, patients and the health care system are challenged by with MSK conditions (RA, OA, JIA, LBP) Objective

31. 31  Dealing with complex and chronic LBP  Delayed RA diagnosis  No “expectant” self-management strategies/resources for OA  Patient expectations for MRI & referrals  Psychosocial patient needs  Lack of patient educational resources  Lack of tools in guideline recommendations  Defining work-related restrictions  Rational use of therapeutic options including opioids Primary Care Provider Barriers

32. 32  Understanding of investigative and referral rationale  Funding for physiotherapy  Lack of Self-management strategies  Medication focus  Work-related concerns  Minimal or missing “functional” focus  Mixed provider/media messages  Access to medical appointments  “Can’t do anything about arthritis” attitude Patient Barriers

33. 33  Poor communication between providers  Lack of coordinated patient education material  Lack of validated Web resources  Non-standardized care pathways  Who is the “right” specialist?  Access to specialists  Access to Allied Health System Barriers

34. 34 Don't know  Specific guidelines  Exercise prescription  Specific rehabilitation  Differential diagnosis  Ordering of imaging  Work restrictions Common Practice Knowledge Know  Red flags  Medications  No bed rest  Referral to physiotherapy  Association of depression

35. 35  Build on the foundation of GPAC Guideline  Tools supporting early identification of RA & screens for red flags  Provide guidance about appropriate prevention, assessment & intervention strategies for RA  Ability to initiate strategy for medical stabilization +/- referral criteria to Rheumatology  Engage patients in goal-setting and support patients in self-care responsibilities Module Goals for RA

36. 36  Screen for RA to mitigate delays in treatment  Key Features of Inflammation suggesting RA  Laboratory Investigations  Differential Diagnosis and key conditions to rule out before starting +/- referring for DMARDs  RA-related examination, management, follow-up and patient self- management considerations  Tools for assessing disease activity and treatment targets  Criteria for referral to a Rheumatologist  Guidelines for management of co-morbidities  Multi-disciplinary care for RA; allied health access and utility RA Content

37. 37  Utility / value of clinical tools and checklists at point of care  Decision support tools for patients regarding medication options and lifestyle management  Screening for patient depression and self-management issues  Points for discussion with patients  Organization of provincial rheumatology services for expedited access  Promotion of best practices RA Content

38. 38  Improve the early recognition of juvenile arthritis  Provide clinicians with tools to assist in the diagnosis of MSK complaints in children  Suggest pathways for referral of children with MSK complaints when needed, and increase awareness among GPs of accessibility of care for children and teens with arthritis in BC Goals for the JIA MSK Module

39. 39  Build on the foundation of GPAC Guideline and Tools  Address gaps/barriers to care from Arthritis Service Framework (2008)  Include criteria for making an accurate diagnosis with functional assessment  Optimize pain and function through education, rehab, medication and referrals (as required)  Emphasize physician-supported pro-active patient self management, not passive acceptance Module Goals for OA

40. 40  Office efficiency / workflow alignment  Relevant examination skills  Pattern recognition and algorithmic care  Address patient expectations re joint deterioration and joint replacement  Deal with psychosocial needs of patient  Make coordinated patient education materials & awareness of resources available OA Content

41. 41  Electronic toolkit & education materials – to add value & enhance working relationships  Provincial alignment/fit  Evidence-based best practices  Early common pathway - red flags first  Management can precede diagnosis  Patient ownership & PSM  Address occupational issues OA Content

42. 42  Patient questionnaires  Electronic tools that fit with office work flow  Consistency in approach between provider assessment and treatment  Coordinated system for access to specialists and rehab expertise  Alignment with physician fee schedule OA Content

43. 43  Patient engagement: a therapeutic relationship  Strategies for both acute and chronic  Dealing with burden of suffering  Dealing with patient expectations  Best practice management  Involving other health care practitioners  Resources Module Goals for LBP

44. 44  Identifying specific etiology  Dual management – cause + pain  Dealing with expectations for investigations and referrals  Identifying psychosocial needs of patients  Address co-morbidities of mood, sleep, function, adverse drug effects  Accessing coordinated patient educational resources  Negotiating work related restrictions  Role of medication (including opioid management)  Identification of responsibility for ongoing care LBP Content

45. 45  Initial screening for pain and pain-related disability or limited function  Built-in reminders to reassess pain, function, adverse effects over time with embedded pain management guidelines  RACE telephone hotline and mentor-mentee networks to support GP linkage to pain specialists LBP Content

46. 46 Action Planning  Define self-management, self-management support, and self-efficacy  Describe what is known about assessing confidence and the effect on patient behavior and health Patient Self Management Patient Passport  Effective patient tool  Applicable in multiple conditions as it is based in the value of health and lifestyle  Patient passport tool for individuals managing long-term chronic conditions like RA and OA

47. 47 Right Care Right Time Right Way