Clinically supported by
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
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