Many patients were being referred by their GP to physiotherapy for treatment and management of osteoarthritis of the knee. The current model of care and management of these patients was reviewed.
The NICE guidance for care and management of osteoarthritis (CG177) were reviewed and a plan was made to bring all patients for first contact into an education group. Patients deemed suitable for this group must have a clinical diagnosis of osteoarthritis, be over 45 years old and with radiographic confirmation of osteoarthritis. Exclusion criteria were also agreed. A presentation was formulated for the education session. A screening tool was developed to ensure 'red flags' were identified at initial contact and those patients managed appropriately. Outcome measures were decided upon (PROM's & PREM's). A follow up review appointment was offered to all patients 3 months after initial contact. The impact was that patients with OA knee were seen quicker.
The outcomes measured identified a reduction in pain and improvement in function at 3 month review. A high percentage if patients felt confident to self manage their pain and this was maintained at 3 month review. Most patients would recommend the service to friends and family and were very satisfied with their care.
Aims and objectives
To provide best care to patients with OA knee referred to Physiotherapy by their GP.
Identify patients appropriate for the group. Triage them effectively. Screen them for red flags at contact. Provide them with best practice and information. Offer them a review if required to action patient-centered care.
The goals of the project were to address; long waiting list for physiotherapy; provide efficient and effective management of patients with osteoarthritis of the knee and ensure the implementation of best practice management. To improve patient experiences of the physiotherapy department (measured with the friends and family test FFT). To provide evidence of the effectiveness of physiotherapy input for patients with osteoarthritis of the knee.
Reasons for implementing your project
We needed to think differently about how patients accessed the physiotherapy service. We needed to try to reduce waiting times for a physiotherapy appointment. We wanted to be efficient with physiotherapy contacts. We wanted to provide consistency in management across the department. We wanted to offer best / recommended practice to all patients with osteoarthritis of the knee. We wanted patients to have a good experiences of the Physiotherapy Department.
How did you implement the project
The challenges and ideas for change were discussed and brain stormed in a small working group. The group included those physiotherapists currently working in the lower limb pathway and included the lower limb APP and consultant physiotherapist. Inclusion and exclusion criteria for the group were identified. A powerpoint presentation was formulated for the initial and review sessions to be used as a basic guide for the structure of the session. The content of the presentation was based on NICE guidance and formulated through team discussion. Outcome measures were agreed and included; VAS, timed sit to stand, MSK-HQ and the friends and family test.
A screening tool was developed to identify 'red flags' and those patients who required 1:1 review and further assessment and management.
The challenges included obtaining adequate administrative support to book patients into the sessions and subsequent reviews.
Arc booklets were given to patients who attended the session alongside information about local community exercise groups and online education resources.
More patients were seen quicker. The quality of care provided for patients with OA knee was standardised across the service and was of a high quality. Data collected after the first 5 months showed 77% of patients were discharged happy to self manage after first initial contact. 10% required a 1:1 appointment for further review. This review was with a physiotherapist who would asses the patient and if required could refer to the APP for further assessment and management. DNA rate was less than 1%. Friends and family data collection showed all patients were likely or extremely likely to recommend the service.
Examples of comments received:
"Importance of preventative Healthcare–so very important". "A lot of information Very well explained."
"I was given practical information in an easily understood format".
"Your expert approach to osteoarthritis".
Data collected at the review sessions for the first 50 patients has shown that 54% scored higher on the their 'sit to stand' functional test. 84% of those who attended for review remained confident to self manage their condition. Those who did not feel confident were offered a review appointment and were therefore managed appropriately.
Key learning points
To implement a new system of working you need good administrative support. If we were to implement change in the future I think it would help to get the whole team on board (including admin) so everyone felt invested in the change and motivated to support its success.
We still struggle with how the patients complete the screening tool and are working at ways of improving this which including highlighting important words and vocal emphasis when giving an explanation. There remains the desire of most patients to want to talk to a therapist about their own individual problem 1:1. We have not been able to change this but for those patients who are not happy to attend a group they are offered an opt out at attendance and a 1:1 appt is arranged.
Overall we have learnt how successful change can be and how it can benefit both patients and physiotherapists. If you have a good idea, get everyone on board and be enthusiastic and sell it to those involved. Listen to feedback and be open to change ongoing.