Value Based Musculoskeletal Services Leading Whole System Change Senga Cree, National Lead NHS Scotland MSK Programme

Carolina Wallenius, GE Healthcare Sweden

Kevin Evans, GE Healthcare Partners

A small nation, with lots of islands and snow

• We didn’t set out to “do Value Based Care”. We just wanted better outcomes, for more people, without spending more money.

• We learned a lot. We had to bring many people with us. We had to be strong.

Better Care Experience

Better Outcomes Better Use of

Resources

Simple aims – but what do our customers think ?

“I want advice, quickly” “I don’t want to wait, if I need treatment”

Why start with Musculoskeletal conditions ?

Prevalence

700,000 New Patients every year

~9 million MSK consultations

Cost

~1 million working days lost

2nd largest group on disability

payments (22%)

Variation

Patient information,

access, investigations, interventions

Paper based systems

No data

No analysis

Key changes to improve experience and outcome

Days Months Months

Key changes to improve experience and outcome

Key changes to improve experience and outcome

Weeks Minutes Seconds Months

Key changes to improve experience and outcome

Electronic referral, tracking and appointment

Data for improvement

Robust IT Leadership and Quality Methods

Standards

Change Package

Education Tool

Preparing for Value Based Care

Policy/Structures

-concrete attributes

Processes

- sequence of events

Relationships

–patterns, Behaviours

High Impact Changes

Self referral and telephone

triage

Supported Self Care

MSK Hubs

Efficient use of limited resource

Productive Patient Flow

Virtual Fracture Clinics

Data to guide Improvement

Culture Shift

IT Infrastructure Workforce

Distributed Leadership

Self Referral & Telephone Triage

NHS 24 Musculoskeletal Advice and Triage Service (MATS) 100% self referral to MSK

services in Scotland 70% population self referral to

MSK accessed through MATS

NHS24 Spread and Scale

Self referral & Telephone Triage

Better

Care

• Single point of contact, consistent advice, appropriate onward risk stratified referral

• All patients get advice and self care info on the day they call

Better

Outcomes

• 13% patients triaged as low risk and can self-manage

• Fewer return appointments for those accessing via self referral

Better

Cost

• Allied Health Professional costs saving of £623,000 [SEK 8 million] annually

• Family doctor cost avoidance of £489,405 [SEK 6m] annually

Supported Self Care

Exercise Videos…with Exercise Reminder !

Supported Self Care

Better

Care

• Consistency of evidenced based information at every contact

• Interaction as important as intervention

• Information in printed and video form available via post, email or app.

Better

Outcomes

• De-medicalisation of MSK conditions

• 7% reduction in re-referral rates through improved self management

Better

Cost

• £184,000 AHP savings for every 1% increase in self management

• Each 10% true self referral realises £1million in saved family doctor appointments.

0

5

10

15

20

25

Pe

rce

nt

Physiotherapy New Patient Did-Not-Attend

Efficiency - MSK Hubs

Efficiency - MSK Referral Hubs

Better

Care

• Referrals losses and delays eliminated

• Single point of contact in Health Boards for patient appointments, queries or cancellations

Better

Outcomes

• Easy cancellation, appointment reminder, patent focused booking = easier access for patient and biggest contribution to reduced waiting times –reducing chronicity and improving clinical outcomes.

Better

Cost

• Better management of capacity has released equivalent of 40 full time Allied Health Professionals, worth £0.9million [SEK 12 million]

Surgery

Orthopaedic Consultation

Community Allied Health Professions

Self Management

Productive Patient Flow

500

1000

1500

2000

2500

apr-12 jul-12 okt-12 jan-13 apr-13

# Ortho Outpatients Waiting

Patient to Right Info or Right Person, First Time

Productive Patient Flow

Better

Care

• Patient to the right person first time- clear efficient pathways

• Mental health and employability status and case management integral to pathways

• MSK Solutions Tool-and Minimum Standards Documents – consistent care, consistent outcomes http://msksolutions.lifemc.co.uk/register/

Better

Outcomes

• New Patient conversion to surgery rates improved from 25% to 50% (best performers 70%)

• Mental Health -19.4% patients identified as moderate to extreme anxiety - 69% reported decrease in scores

• Reduction in Orthopaedic (12 weeks) and AHP (4 weeks) waits

Better

Cost

• Orthopaedic to AHP shift , cost avoidance of £1,660,000 [SEK 21million]

• Fewer unnecessary MRI , cost avoidance of £506,000 [SEK 6 million]

Fracture Clinics Redesign

Jenkins PJ, Nugent MP, Gilmour A, Ireland A, Murray O, Rymaszewski L and Anthony I (April 2014) The Glasgow Fracture Pathway: a virtual clinic

Fracture Clinics Redesign

Better

Care

• Patients only attend fracture clinic if they need to be seen face to face:55% follow up work now done by telephone by Nurse Practitioners to patient’s home.

• Earlier mobilisation

Better

Outcomes

• Surgeon time released for faster, safer ED response

• 55% fewer fracture patients presenting at ED return fracture clinics

Better

Cost

• Work just about to be published 38% reduction in fracture clinic costs

Data to guide Improvement

Web-PROMS: anchor us in the patient’s experience

National MSK and Orthopaedic dashboard, supported by national standard data set: helps us to scale and spread, as well as find new opportunities to improve.

We knew our clinical intervention was helping helping ?

• 400+ patients measured before and after our intervention

• On all measures, physical health was improved

• On all measures, mental health was improved So we seem to be on the right track – can we do it better ?

Fr3PROMS-Whole System View

Patients interact through Apps, www, dedicated devices

Patients perform different roles depending on their requirement, including sharing their data

sVIEW users have access via secure API to all project data and bespoke views such as dashboards by Health

Board.

Clinicians use the c-VIEW portal to invite, review patients as well as schedule follow up surveys and

exporting of local data.

More dashboard views

Data to Drive Improvement

Better

Care

• Transparency through publication Physiotherapy, Orthotic, Podiatry and OT waiting times in addition to ortho waits

• Introduction of patient held PROMS-MSK HQ

Better

Outcomes

• 51% all patients now waiting under 4 weeks- before, we didn’t know!

• Progress to 90% in next 9 months

• PROM EQ5D and body part measure shows 89% patients improve

Better

Cost

• We can identify value add

• Only evidence-based improvement now!

Data set complete in purple areas: >90% of population

Where it helped to have help

Developing leadership skills and confidence

Getting the national targets agreed

Managing projects to tight deadlines

Understanding and standardising our processes

Developing the dashboard

Working out the governance

What’s next… • New filters to telephone triage • Technology- Web Access

algorithms • Arthroplasty Rehabilitation

Guidelines • Patient peer coaching for

chronic pain • Transfer the learnings of MSK to

other national programmes • Population health: “AILIP”, less

health focused, more community based, strongly embraced by our regional leaders.

senga.cree@nhs.net

Tak sa mycket!

MSK and Orthopaedic Quality Hub http://www.qihub.scot.nhs.uk/quality-and-efficiency/msk-and-orthopaedics-quality-drive.aspx AHP Minimum Standards 2015 http://www.gov.scot/Publications/2014/04/6453 AHP’s as Agents of Change http://www.gov.scot/resource/0039/00395491.pdf Driving Improvements in our Healthcare 2014-2020 http://www.healthcareimprovementscotland.org/previous_resources/policy_and_strategy/our_strategy_2014-2020.aspx Jenkins PJ, Nugent MP, Gilmour A, Ireland A, Murray O, Rymaszewski L and Anthony I (April 2014) The Glasgow Fracture Pathway: a virtual clinic Vardy J, Jenkins PJ, Clark K, Chekroud M, Begbie K, Anthony I, Rymaszewski LA and Ireland AJ (June 2014) Effect of a redesigned fracture management pathway and 'virtual' fracture clinic on ED performance Anthony IC, Brooksbank K, Gilmour A, Jenkins PJ, Nugent MP and Rymaszewski LA (December 2014) Functional outcome and satisfaction with a “self-care” protocol for the management of mallet finger injuries: a case-series Anthony IC, Edge MJ, Gamble D, Gilmour A, Jenkins PJ, Nugent M and Rymaszewski LA (February 2015) Satisfaction and functional outcome with “self-care” for the management of fifth metacarpal fractures