Evolving New Practices in Hip & Knee Arthroplasty: It Takes A Team! CCHSE National Healthcare Leadership Conference June 11-12, 2007 Toronto

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Ashlyn White
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1 Evolving New Practices in Hip & Knee Arthroplasty: It Takes A Team! CCHSE National Healthcare Leadership Conference June 11-12, 2007 Toronto

2 Focus of Presentation Toronto Central LHIN is developing a new model of care for hip & knee arthroplasty Implementation 2007/08 Focus of model is to reduce access time in a more clinically efficient and effective manner through multidisciplinary teams Model of care is being implemented at Sunnybrook Holland Orthopedic & Arthritic Centre

in a more clinically efficient and effective manner through multidisciplinary teams

3 Sunnybrook Health Sciences Centre Holland Orthopaedic & Arthritic Centre 2,400 Hip/Knee Replacements Annually ALOS 4.6 days, 65% discharged home 35% inpatient rehab, ALOS 5.6 days 4 Operating Rooms 70 Beds (48 acute and 22 short-term rehab) 2 Special Care beds 75% of patients from outside Toronto Central LHIN

6 days, 65% discharged home 35% inpatient rehab, ALOS 5.

4 TC LHIN Hip & Knee Replacement Program Referring Physician Central Intake Assessment Centre Surgeon Consult Surgery Post-Op Discharge Follow-Up

5 Principles for Model of Care Patient Centred Interdisciplinary Partnerships Evidence-Based Quality & Efficiency Integrated Continuum

6 Framework for New Model of Care Process & Role Redesign Collaboration/Consensus/Communication Assigning Champions Human Resource Strategy Information Systems/Technology Physical Facilities Evaluation

7 Hip & Knee Arthroplasty New Roles Advanced Practice Physiotherapists Anaesthesia Assistants (RN s & RT s) Nurse Practitioner, Acute Pain Service Nurse Practitioner, Postop Medical Management RN First Assistants Critical Care Rapid Response Team

Practitioner, Acute Pain Service Nurse Practitioner, Postop

8 Central Intake & Assessment Advanced Practice Physiotherapist Registered Nurse (If Surgical Candidate) Role: Intake Centre Triage Referrals (2 Days) Assessment Centre (Appointment within 2 Weeks) Impact: Comprehensive Physical Assessment Education & Treatment Plan High level Nursing Assessment if Surgical Candidate Timely Access based on Urgency Patient Choice 20% of patients choose 1 st available appointment versus specific surgeon Patient Satisfaction is high 30% of Patients deemed to be non-surgical candidates or decide to defer surgery and pursue other options - reduced time by Orthopaedic Surgeons in seeing non-surgical candidates.

Timely Access based on Urgency Patient Choice 20% of patients choose 1 st available appointment versus specific surgeon Patient Satisfaction is high 30% of

9 Surgery RN First Assistant Anaesthesia Assistant (RN s & RT s) Role: RN FA - technical assistance at surgery and support the perioperative care process. Replace GP Assistants Anaesthesia Assistants (RN s & RT s) work collaboratively with Anaesthetists to improve efficiency and quality of care. Impact: 85% of patients receiving regional anaesthesia Reduced anaesthesia-related complications 15% reduction in OR time Reduced length of stay Improved patient experience. RNFA approx. 50% cost of GP Assistants

Replace GP Assistants Anaesthesia Assistants (RN s & RT s) work collaboratively with Anaesthetists to improve efficiency and

10 Post-op Management Nurse Practitioner Role: Nurse Practitioner timely postoperative assessment and treatment for medical problems. Critical Care Rapid Response Team available Mon to Friday during working hours to respond to urgent patient management concerns. Impact: Improved quality of care & safety. Improved communication & consistency in care and outcomes. Reduced need to transfer to higher level service ie. Critical care. Critical Care Rapid Response Team

Critical Care Rapid Response Team available Mon to Friday during working hours to respond to urgent patient

11 Pain Management Acute Pain Service Anaesthetist Role: Anaesthetist & Nurse Practitioner work collaboratively to supervise postoperative pain management. Multimodal pain management Standard order sets Education/certification of care team members. Impact: Rapid recovery, with fewer complications. Reduced length of stay. Improved patient satisfaction Nurse Practitioner

Multimodal pain management Standard order sets Education/certification of care team members.

12 Follow-Up After Discharge Role: Advanced Practice Physiotherapists manage routine follow-up visits after discharge from Hospital Advanced Practice Physiotherapists Impact: 80% of patients managed by APP versus Orthopaedic Surgeon Systems savings Salary of APP vs Fee for Service of Orthopaedic Surgeons Allows surgeons to invest time in surgery

Impact: 80% of patients managed by APP versus Orthopaedic Surgeon Systems savings

13 Implementation Challenges No formal role recognition through Colleges ie. Advanced Practice Physiotherapists, Extended Class Nurses Acute Care Limited/No formal training programs ie. Advanced Practice Physiotherapists, RN First Assistants, Anaesthesia Assistants Legislative barriers Limited recognition of extended class roles Limited funding primarily through demonstration projects. Limited policy framework role profiles, medical directives, etc. Uncertain liability issues

Advanced Practice Physiotherapists, RN First Assistants, Anaesthesia Assistants Legislative barriers Limited

14 Early Evaluation Improved Access, Shorter Wait Times Shorter Hospital Stays Reduced time spent by Specialist MD s in routine care (ie. Surgeons, Anaesthetists) High Patient Satisfaction System Savings vs Costs

15 The Future Long term evaluation of model Specialists vs Generalists Clarity of Roles Integration vs Overlap Alignment with Interprofessional Care Models Sustainability: Positive for recruitment & retention Dependent on qualified professionals Requires education/training resources Dependent on funding of the model

Sustainability: Positive for recruitment & retention Dependent on qualified

16 Thank you! Questions?

Patient Optimization Improves Outcomes, Lowers Cost of Care >

Patient Optimization Improves Outcomes, Lowers Cost of Care > Consistent preoperative processes ensure better care for orthopedic patients The demand for primary total joint arthroplasty is projected to