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Rewards for Rehabilitation

Michelle Fitzgerald MSc., BSc.(Physio), MISCPHSCP Lead, Irish Hip Fracture Governance Committee

Irish Hip Fracture Meeting 2019Royal College of Surgeons Ireland

12th November 2019

Michelle Fitzgerald HSCP Lead Irish Hip Fracture Database

Overview

1. The IHFD Rehab Story 2013-20182. Recent evidence updates3. Spreading the IHFD Rehab Story4. The IHFD Rehab Plan 2019-2021 and beyond

THE IHFD REHABILITATION STORY: 2013 - 2018

Early Mobility is Important

Post-Op Long-Term

Mobility

Survival

+

Function

(Boonen et al. 2004, Dubljanin-Raspopovic et al. 2013, Hirose et al. 2010)

To get better:

Know what we are doing

Add function specific data-fields to the IHFD

Functional progress

Rehabilitation service provision

Effect of hospital approaches

Databases

Direct Communication

International Guidelines

Michelle FitzgeraldSenior Physiotherapist & HSCP Lead forIrish Hip Fracture Database

Edel CallananPhysiotherapy Manager & HSCP Lead forNational Clinical Programme for Traumaand Orthopaedics

Prof Catherine Blake &

Dr. Caitriona CunninghamSchool of Public Health, Physiotherapyand Sports Science, University CollegeDublin

Irish Hip Fracture Physiotherapy Working Group

Care Standard Guideline Synopsis

Physio assessment First postoperative day

Frequency of mobilisation Daily (7days)

Rehabilitation Early, MDT

Discharge planning Early, MDT, individualised

Type of physiotherapy Multidimensional

(ANZHFR 2014, NICE 2011, Waddell 2011, SIGN 2009, BOA 2007)

CAS & NMS

Feasible clinical indicators

for early rehabilitation planning

Baseline

• New Mobility Score (0-9)

1st post-op Day

• Physio assessment (Yes/No)

• Mobilisation (Yes physio/Yes other/No)

• Cumulated Ambulation Score (0-6)

Discharge

• Cumulated Ambulation Score (0-6)

IHFD Rehabilitation Data-fields

Guideline adherence

Service provision

No extra work

Ideal outcome measures

Irish data

National IHFD Reports: Rehabilitation Data

2016

NMS: 2383 cases

CAS: 649 cases

2017

NMS: 2979 cases

CAS: 1202 cases

2018

NMS: 3506 cases

CAS: 1677 cases

Pre-fracture mobility – New Mobility Score

(National Office of Clinical Audit (2019), Irish Hip Fracture Database National Report 2018)

Physiotherapy Assessment Day One Postop

(National Office of Clinical Audit (2019), Irish Hip Fracture Database National Report 2018)

2017 IHFD Facilities Audit• Physiotherapy service resourcing • Weekend service provision (<50%)• Other factors

Early Mobilisation

(National Office of Clinical Audit (2019), Irish Hip Fracture Database National Report 2018)

Mobilised by physio

Mobilised by other

Not mobilised

(National Office of Clinical Audit (2019), Irish Hip Fracture Database National Report 2018)

Postoperative Function - CAS

(National Office of Clinical Audit (2019), Irish Hip Fracture Database National Report 2018)

Day of discharge

Day after surgery

Independent• Bed Mobility • STS• Mobility

Unable• Bed Mobility • STS• Mobility

HIP FRACTURE REHAB:RECENT EVIDENCE UPDATE

UK CSP Hip Sprint Audit (2 months, 580 physios)

Does it matter how many CAS points you lose?

Courtesy of Morten T Kristensen

Clinical Practice Guideline: Physical Therapy Management of Older

Adults with Hip FracturePublication Expected Winter 2019/Spring 2020

Rehabilitation Outcome Measures

• Early (day one) mobilisation

• High frequency (daily) inpatient physiotherapy

• Structured exercise

• Mild/mod dementia

• Health related quality of life

• Fear of falling

• Physical impairment

• Activity Limitations (Self/proxy reported & Performance based)

MustShould Could

Across continuum of care

SPREADING THE IHFD REHAB STORY

From Broken Bone to Walking Home – A National Hip Fracture Physiotherapy Quality Improvement Project

National HSCP Office Innovation and Best Practice Awards: Semi-finalists

Physical Therapy Outcomes Registry Meeting 2019

• Moving towards a structure that makes providers accountable for patient outcomes and costs

• Need to understand and promote the value physical therapists bring to health system

How did the IHFD do it?

IHFD standardised measures - feasibility

How the IHFD disseminated the information

Collaboration: Clinician, Manager & Academics

Hip, Hop and Happening !!

Local

Data

Irish data

Functional

OutcomePhysio service

provision

Leading hip

fracture care

THE IHFD REHAB PLAN:2019-2021 AND BEYOND …..

IHFD Best Practice Tariff

Meet all 8 (9) standards = €1000 extra per case

Physiotherapy Best Practice Tariff

Day One

Physio Assessment

Day One

Function (CAS)

Reason for unsuccessful mobilisation

• Two Stage Pilot underwayo Tallaght University Hospital o St Vincent’s University Hospital o Connolly Hospital, Blanchardstown

• National Survey Nov-Dec 2019o IHFD rehab measureso Process around data collection/inputo Future vision

National HSCP Office

New Trauma and Elective Orthopaedic Advisory Group

• Clinical Programme for Trauma and Orthopaedics • Increasing HSCP input into design, planning,

implementation and evaluation of projects• Provide support, networking and education • Representation – HSCP discipline, care setting, geography• A new coordinated HSCP opportunity to drive change

richard.smith@hse.ie//mfitzgerald@peamount.ie

How will we get the Rewards for Rehab ?

• Continue acute IHFD data collection

o Data quality

o Best Practice Tariff

o Local governance committee

o Increase resourcing

o Support of HSCP Office

How will we get the Rewards for Rehab ?

• Continue acute IHFD data collectiono Data quality o Best Practice Tariffo Local governance committeeo Increase resourcing o Support of HSCP Office

• Plan post-acute IHFD data collectiono IHFD & NOCA commitment to progressing data collectiono Create a network of rehabilitation hospitals and otherso Team-work & considered, coordinated approach to developing

rehabilitation & discharge pathway initiatives nationally

How will we get the Rewards for Rehab ?

• Continue acute IHFD data collectiono Data quality o Best Practice Tariffo Local governance committeeo Increase resourcing o Support of HSCP Office

• Plan post-acute IHFD data collectiono IHFD & NOCA commitment to progressing data collectiono Create a network of rehabilitation hospitals and otherso Team-work & considered, coordinated approach to developing

rehabilitation & discharge pathway initiatives nationally

Policy Makers

CliniciansPatients

Collect

Measure

Improve

Small Changes:

Big Effect

Rewards for Rehab

Better Care …. Better Outcomes

Acknowledgements

• Physiotherapy Working Group– Edel Callanan– Dr Caitriona Cunningham – Prof Catherine Blake

• Every member of the Irish Hip Fracture Governance Committee especially: – Louise Brent – Mr. Conor Hurson– Dr. Emer Ahern – Catherine Farrell – Mr Paddy Kenny – Dr Mary Walsh

• Physiotherapy teams and managers in the Irish trauma orthopaedic hospitals

• National HSCP Office, especially Alison Enright

• Irish Society of Chartered Physiotherapists

Key References

• British Orthopaedic Association (2007) ‘The Care of Patients with Fragility Fractures’. London, United Kingdom

• Fitzgerald, M. Blake, C. Askin, D. Quinlan, JQ. Coughlan, T. and Cunningham, C. (2018) ‘Mobility one week after a hip fracture- can it be predicted?’. International Journal of Trauma and Orthopaedic Nursing. May, 29:3-9. doi:10.1016/j.ijotn.2017.11.001. Epub 2017 Dec 2.

• Foss, N. B. Kristensen, M. T. and Kehlet, H. (2006) 'Prediction of postoperative morbidity, mortality and rehabilitation in hipfracture patients: the cumulated ambulation score'. Clinical Rehabilitation, 20(8): 701-708.

• Kristensen M T. and Kehlet H. (2010) ‘Most patients regain prefracture basic mobility after hip fracture surgery in a fast-trackprogramme’. Dan Med J. 2012 Jun;59(6):A4447.

• National Institute for Health and Clinical Excellence (2011) ‘The management of hip fractures in adults’ [CG124]. London.

• National Office of Clinical Audit, (2017) Irish Hip Fracture Database National Report 2016. Dublin: National Office of ClinicalAudit.

• National Office of Clinical Audit, (2018) Irish Hip Fracture Database National Report 2017. Dublin: National Office of ClinicalAudit.

• National Office of Clinical Audit, (2019) Irish Hip Fracture Database National Report 2018. Dublin: National Office of ClinicalAudit.

• Royal College of Physicians. National Hip Fracture Database Annual Report 2018. London: RCP, 2018.

Thank you for listening

mfitzgerald@peamount.ieedel.callanan@hse.iecaitriona.g.cunningham@ucd.iec.blake@ucd.ielouisebrent@noca.ie