teams - towards integration of services
DESCRIPTION
This lecture was given by Dr Rhian Lewis, Consultant in Pain Management from Bangor, North Wales, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. Her lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care". www.wspg.org.ukTRANSCRIPT
TEAMS - towards integration of services
Rhian LewisYsbyty Gwynedd
Bangor
Chaos
TEAMSTargeted Early Access to Musculoskeletal Services
• Reorganisation of services
• Problems encountered
• Improvements achieved
Order
Bangor
North Wales
Challenges
• Difficulty in coping with referral demand • Long waiting lists• No acute back pain service• Patients on multiple waiting lists• Limited co-ordination of services• Inappropriate referrals in orthopaedics –
low surgical conversion rates
Wider environment
• WAG programme: Innovations in Care in orthopaedics
• Project group on accessibility of musculoskeletal services
TEAMS working party• GP representing local health group• Senior manager• Orthopaedic surgeon• Pain management consultant• Physiotherapist• Rheumatologist
Aims of TEAMS
• Improved access to services
•Reduced waiting times
•Timely surgery
Key features
• Common access point
• Triage into appropriate specialty
• Development of care pathways
• ESP-led Back Pain Service
• Community-based musculoskeletal clinics
• Fibromyalgia clinic
Integration of services
GP referral
Triage
Surgical advice
Chronic back
OA/soft tissue
Arthritis/CTD
Acute back
Physio assessment
Pain management
Rheumat- ology
Orthopaedic service
Difficulties to overcome
• Change is threatening
• Rheumatologists ?Take-over bid?
• Ortho objected to pooled referrals
• Delegation of responsibility
• Supporting new nurses time-consuming
Acute back pain
• New service: ESP (physio) triage• Reduce acute backs seen in ortho• Screen Red flags (fast-track to ortho) • Onward referral of Yellow flags to pain
clinic
• Weekly meeting of ESP with pain clinic MDT
Acute back pain pathwayGP Referral
Teams Co-ordinator RED Flags
ESP screening / telephoneRe-assessment
Pain Team/Epidural
Physio Treatment
ResolvingD/C
Further physio
Orthopaedics
• Telephone reviews• TENS and drug reviews by specialist
nurses• Greater emphasis on education,
exercise and self-management• Flare-up protocols• Weekly MDT meeting
Chronic pain - changes
Pain clinic - staff increases
• 3.5 Consultant sessions
• 0.5 Specialist nurse
• 0.5 Psychologist
• 0.5 Physiotherapist
Chronic pain - results
• Increased throughput – 400 -> 700/year• Waiting list of 2-3 months (down from
12 months)
• Acute referrals from ESP seen within 1 week
Rheumatology - changes
triage
GP referral
inflammatory non-inflammatory
rheumatology musculoskeletal
New programme - GPwSI
• 5 GP's with an interest in MSM• Work closely with ESP Physio• Triaged by rheumatology consultant• Overseen by clinical lead• Treatment of uncomplicated
musculoskeletal problems
Musculoskeletal clinics
• One clinic weekly in each geographical area
• Bangor, Llandudno, Holyhead, Pwllheli, Dolgellau
• 125 patients a month
• Monthly combined education programme
Rheumatology - results
• Reduced waiting times
• Greater responsiveness to patients
•More use of nurse-led, multidisciplinary review clinics
• Telephone helpline
Orthopaedics - changes
• LBP seen by ESP• Musculoskeletal to GPwSI and ESP• Reduction in out-patient waiting times
• Surgical conversion increased to 60%
Educational meetings
• Physio
• GPwSI
• Ortho trainees
• A and E staff
• GPs
Results in first year (2002)
• Total monthly referrals 400 --> 900 • Orthopaedic share 250 --> 200• Increase in pain, MSM, physio• Abolished duplicate referrals• Surgical conversion rate improved
Waiting time reductions (weeks) 2001-2002
T and O 52 --> 13
36 --> 9
52 --> 7Pain
Rheumatology
Current position 2007
• Improvements maintained• Referrals 890/month • Waiting times maintained
Pain clinic perspective
• Back pain service in place
• ESP and Pain clinicians
• Increase in:
– semi-acute backs
–MRI scans
– tertiary referrals
What did we learn?
• Integration improves services• Community clinics effective for
uncomplicated musculoskeletal problems• Nurse-led clinics can reduce W/L• Acute back pain service valued by GPs• Helpline valued by patients
TEAMS - the answer?
• One-stop shop for patients• Joined up services for practitioners