Transforming Musculoskeletal (MSK) Care in Ontario: A Comprehensive MSK Access to Care Program

London Middlesex Primary Care AllianceMarch 28, 2018

2

Objectives• Provide an overview of the Provincial MSK Strategy

• Context for action/case for change• Why MSK populations first?• Patient Pathway: hip and knee OA and low back pain patients• Standardized provincial program elements• Local planning and implementation flexibility• South West LHIN project initiation update• Next steps/key planning milestones

• Primary Care survey results & feedback received to date

• Discussion

3

Patient Story – Impact of Waiting for Ortho Surgery

Patient Healthcare Forum Patient Story/

4

Overview of the MSK Strategy

5

Case For Change: Hip and Knee Replacements Wait Times

• Patients in the South West LHIN waited between 245 days and 757 days for their hip replacement consultation and surgery in Q3

• Patients in the South West LHIN waited between 224 and 817 days for their knee replacement consultation and surgery in Q3

6

Case For Change: Lower Spine Surgical Consultation Wait Times

178 189 183 171 169196

160

616 621

560 569538

558592

FY 2016/17 Q1 FY 2016/17 Q2 FY 2016/17 Q3 FY 2016/17 Q4 FY 2017/18 Q1 FY 2017/18 Q2 FY 2017/18 Q3

LHSC Spine Surgery Consultation (Wait 1) Wait Time (days)

Mean 90P

• Low back pain patients in the South West LHIN waited an average of 160 days, and 9 of 10 patients waited as long as 592 days for spine surgery consultation in Q3 2017/18.

• Generally, less than10% of patients referred for spine surgery consultation are surgical candidates. This results in patients waiting months “in the wrong queue”.

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Case For Change: Why are hip and knee wait times so long?

Funding

Patient Demographics

Referral Patterns

Reporting/Waitlist Management

Prevention/Self-Management

Long Wait Times(Total Hip and

Knee)

Backlog of Open Cases is consistent and Allocations don’t address the population waiting

Inflated Demand Versus True Raw Demand Due to multiple referrals for single patients

Out of LHIN patients in contrast to LHIN patients going elsewhere

Clinical Appropriateness of patients on open case wait lists

Process Changes ( e.g. Intentional Movement of patients From wait 1 to wait 2 lists

Backlog of Open Cases is consistent and Allocations don’t address the population waiting

Filing Cabinet of Patients Not Documented In WTIS or Novaris ( Surgeon’s Cushion)

? Imbalance of Supply and Demand

? QBP Funding Does Not Match Demand for Service

Funding Incents reinvestment to a Maximum amount Hospitals Prioritize OR time/

global budget to other case types b/c allocations are set

Primary Care Preference for Certain Surgeons

Patients Shop Different Lists

No Central Intake in current State enables historical reference patterns

OA Prevalence in the South West – Are our Patients

Really different?

Clinical Appropraitenes of patients on open wait lists

Ortho Surgeons per capita inThe South West

Community Resources unknown to providers

Lack of standardized conservative Management

Prevention Strategies

? Data Quality and Gaming

Variation between providers impacts reported wait times

Long Wait Lists Encourage Early ReferralsPatients choose to wait

longer for a certain surgeon

We know our referral patterns and reporting/waitlist management practices directly contribute to long wait times. Through the implementation of the MSK program we will

endeavor to understand if our funding meets our local population demands

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What actions are required to improve Ortho wait times?

9

10

11

12

13

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South West LHIN Project Initiation Update• Local project governance structure has been developed (Steering Committee, Clinical Advisory

Board and Working Group) with all tables launched in December 2017

• Executive Sponsors of the initiative are Cathy Vandersluis, VP of Surgery at London Health Sciences Centre and Sue McCutcheon, Director of Regional Programs at The South West LHIN.

• Project Core Team members laisse with provincial colleagues on a regular basis to inform and receive updates on standardized tools and resources to be used across the province

• Engagement strategies with Primary Care, Community Support Services, Allied Health Professionals, and Surgical Teams are taking place to influence and inform the local direction

Technology:

• Novari e-request has been confirmed as the Central Intake software for this and future coordinated access models in the South West LHIN

• Provincial work is underway to expand the use of eReferral from Primary Care to facilitate referrals for patients to specialist and community resources. MSK has been identified as a priority pathway for early eReferral implementation.

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Next Steps/Key Planning Milestones

• Job postings for Advanced Practice Leaders to champion the assessment component of the pathway will be posted by March 31st. A staggered recruitment approach will be used for Assessors and Central Intake Administration.

• Determination of the location of the “Assessment Centres” across all sub-regions in the South West LHIN

• Further engagement with Primary Care and Allied Health to inform final referral forms • Support for building new forms into EMRs will be enabled by Partnering for Quality

• Implementation and central intake “go-live” in Q2, 2018/19

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Primary Care Survey – Results received to date (n=32)

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Location of Respondents

3.13% 3.13%

56.25%

28.13%

9.38%

Grey BruceHuron PerthLondon-MiddlesexOxfordElgin

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Physiotherapy

0.00%

10.00%

20.00%

30.00%

40.00%

80-100% 60-80% 40-60% less than 40%

What % of your patients with hip or knee OA do you refer for

physiotherapy?

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

80-100% 60-80% 40-60% less than 40%

What % of your patients cannot afford physiotherapy?

59.38%40.63%

Does your community have easily accessible physiotherapy facilities

(location, cost…)?

YesNo

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Knee Osteoarthritis Injections

100.00%

0.00%

Do you recommend injections –cortisone and/or HA injections to your

patients with knee OA?

Yes

No

9.38%

18.75%

34.38% 37.50%

0.00%0.00%

10.00%

20.00%

30.00%

40.00%

80-100% 60-80% 40-60% less than 40% I do notrecommend

injections

What % of your patients with knee OA receive injections – cortisone

and/or HA?

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Hip Osteoarthritis Injections

58.06%41.94%

Do you recommend injections -cortisone and/or HA injections to your patients with hip OA?

Yes

No 9.68% 6.45%12.90%

51.61%

19.35%

0.00%10.00%20.00%30.00%40.00%50.00%60.00%

80-100% 60-80% 40-60% less than 40% I do notrecommend

injections

What % of your patients with hip OA receive injections - cortisone and/or

HA?

21

Community Programs

54.84%45.16%

Does your community have free or affordable community exercise programs (through community

centres, gyms, arthritis society….)?

YesNo

012345678

YMCA

VON

Arthrit

is socie

ty

Memoria

l Boys

and Girls

Club

SMART e

xerci

se progra

m

Tai C

hi for A

rthrit

is

Senior's

Centre

Centre fo

r Acti

vity a

nd Aging

Healthlin

e

Community Exercise Programs Available

67.74%32.26%

Do you refer to or provide your patients with self-management

programs/tools (through the Arthritis Society, the …

Yes

No

0123456789

Chronic painself

managementgroup

Arthritissociety

FowlerKennedy

Bioped Sole Science SW LHIN selfmanagement

Self Management Tools and Programs

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Discussion

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What We’ve Heard So Far From Our Primary Care Partners (PCP)

• Clear messaging is needed regarding the volume, extent and locations of assessments performed by the interprofessional team.

• Develop and communicate roles and responsibilities for PCP, Assessors and Surgeons.

• Consider algorithm about when to provide cortisone vs. knee replacement.

• “Desire for this program to provide education to PCPs and other providers (i.e. Chiropractors, Inter-professional teams, Community Programs)” [about the referral process and inclusion criteria?]

• Negate conflicting medical measures being recommended to PCPs ( i.e. Opioids).

• “Today, PCPs are having to send multiple x-rays/MRIs due to 6+ month waitlists.”

• Current referral process is cumbersome for PCPs, i.e. PC is currently the gatekeeper for requesting and communicating appointments to patients.

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What We’ve Heard So Far From Our Primary Care Partners (Continued)• “Wait times for people who need replacements are too long” & a plan is needed to address

the backlog of surgeries.

• “I have many newcomer clients for whom having an interpreter funded for their [assessment] sessions is important.”

• “Wait times may be reduced by unnecessary referrals.”

• “Cost of bracing, orthotics, physiotherapy is a major barrier for our CHC clients and many others I expect”.

• “Make [publish] a list of family physicians doing injections to help with wait times.”

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Discussion

• What early advice/feedback would you offer the MSK Team to achieve success in implementation?

• How would you like to be communicated with, using what mechanism’s?

• How do you support your non-surgical patients today?

• What education/supports would be beneficial to you in PC?

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Appendix A – Additional MSK Program Information

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LHINs with CIACs have seen a greater improvement in their wait time for hip and knee replacement surgery (Wait 2)…

• A comparison between LHINs with CIACs and without CIACs demonstrates significantly lower wait times in LHINs with CIACs. CIACs have also contributed to a greater percentage of change in wait time since 2007/08, decreasing by 27%.

• CIACs with high participation rates (volumes of patients going through the CIAC vs other process) are providing patients with faster access to consultation (Wait 1) and surgery (Wait 2), while CIACs with low participation rates have less of an impact on wait times.

• Wait times in the Champlain LHIN (where the CIAC model is mandatory for primary care physicians making hip and knee referrals), wait times have shown significant improvement and are among the best of CIAC sites.

90th percentile wait time 07/08 15/16 Change (days) % Change

LHINs with CIACs 253 185 -68 - 27%

LHINs with no CIAC 263 229 - 34 - 13%

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• LHINs with CIACs have seen a greater improvement in their wait time for hip and knee replacement surgery and patients going through CIACs experience shorter waits

• In the Champlain LHIN, where the CIAC model is mandatory for primary care physicians making hip and knee referrals, wait times are better than in LHINs where CIACs are not mandatory.

90th percentile wait time 07/08 15/16 Change (days) % Change

LHINs with CIACs 253 185 -68 - 27%

LHINs with no CIAC 263 229 - 34 - 13%

50

100

150

200

250

300

0%10%20%30%40%50%60%70%80%90%

100%

HamiltonNiagara

HaldimandBrant

Central West Toronto Central Central Champlain North SimcoeMuskoka

North East North West

90th

Perc

entil

e W

ait 1

(Day

s)

Volu

me

Prop

ortio

n C

IAC

/Oth

er

Source: Wait Time Information System, Access to Care at Cancer Care Ontario

Comparison of CIAC vs Other Models Wait 1 Volume and Days –Hip and Knee Replacement Surgery - Q3 2016/17

CIAC Wait 1 Volume Other Models Wait 1 Volume CIAC Wait 1 Days Other Models Wait 1 Days

CIAC Success To-date

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ISAEC Pilot Care Pathway

ü Central referralintake and patient

bookings“1-800-#”

Primary Care Provider (granted referring privileges

after LBP training) LBP Patient

üDI Referral, etc. (when indicated)

Community Programs, Physiotherapists, Chiropractors, Psych Counseling,Occupational Therapists, Registered Massage Therapists, Acupuncturists.

Spine Surgeons, Rheumatologists, Pain Specialists,Physiatrists

MRI, etc.

Diagnostic Services

ü (Updated)Consult Note and Patient TreatmentPlan and other resources

ü (Updated) Tailored Treatment Plan and resourcesfor ongoing self-management

Specialists

Community Providers

üRecommendations for ancillary

support (when indicated)

ü ISAEC follow-ups for patients assessed to be Complex

üStreamlinedaccess tonetworkedspine specialistsand diagnosticservices* (when indicated)

Specially trained Advanced Practice Physiotherapists

and Chiropractors

* Spine Surgeon and Imaging arranged by ISAEC.

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ISAEC Pilot* Successes to Date:• Since November 2012, ISAEC has consistently demonstrated positive results in terms of

delivering accessible, evidenced-based, patient-centred LBP services. Key achievements include:

• Provided services to over 6,000 patients, including referral to APCs in under two weeks;

• High rates of patient and provider acceptance as evidenced through high satisfaction rates (patient at 99% and provider at 96%);

• Improved patient outcomes with reduction in chronicity six months following ISAEC treatment;

• Significant built-in knowledge transfer to participating PCPs, who reported a two-fold increase in their confidence in treating/ managing LBP.

• Greater than 96% of patients referred for ISAEC surgical consultation by their ISAEC APC were surgically appropriate, and less than 7% of ISAEC patients have gone on to imaging or specialist intervention.

* ISAEC pilot sites are in Toronto, Hamilton and Thunder Bay

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Appendix B – Additional Survey Responses (N=32)

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Knee Osteoarthritis Injections

3

10

5

18

6

12

02468

101214161820

Other family

medicine…

Sport a

nd exercise m

edicine…

Rheumatologist

Orthopedic S

urgeonOther

Physiatr

ist

Wee

ks

Average wait times

56.25%

43.75%

0.00%

Do you inject your knee OA patients, or refer them out?

Inject myself

Refer out

I do not recommendinjections

16.13%

22.58%

6.45%

45.16%

9.68%

If you refer out, who do your refer to?

Other family medicinecolleaguesSport and exercise medicinephysicianRheumatologist

Orthopedic Surgeon

Other

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Hip Osteoarthritis Injections

6

22

6

30

0

5

10

15

20

25

30

35

Sport and exercisemedicinephysician

OrthopedicSurgeon

Other Radiology

Wee

ks

Average wait times

8.70%

69.57%

21.74%

Do you inject your hip OA patients, or refer them out?

Inject myself

Refer out

I do not recommendinjections

3.70%

14.81%

3.70%

37.04%

29.63%

11.11%

% of Respondents that refer to specialists

Other family medicine colleagues

Sport and exercise medicinephysicianRheumatologist

Orthopedic Surgeon

Other

I do not recommend injections

34

Hip Osteoarthritis Injections

6

22

6

30

0

5

10

15

20

25

30

35

Sport and exercisemedicinephysician

OrthopedicSurgeon

Other Radiology

Wee

ks

Average wait times

10.00%

70.00%

20.00%

Do you inject your hip OA patients, or refer them out?

Inject myself

Refer out

I do not recommendinjections

7.69%

12.82%2.56%

35.90%

30.77%

10.26%

If you refer out, who do your refer to, and what is the wait time? (select all

that apply)Other family medicinecolleaguesSport and exercise medicinephysicianRheumatologist

Orthopedic Surgeon

Other

I do not recommend injections

35

Bracing Stores

74.19%25.81%

Does your community have specialized bracing stores (eg.

Shoppers Home Health, Athletic World….)?

YesNo

0

1

2

3

4

5

6

7

Lifemark ShoppersHomeHealth

WreckRoom

Right Fit FowlerKennedy

Bioped Med e Ox PhysioClinics

Foot byFoot

Bracing Stores