Leading Better Value Care
Local vignette – Illawarra Shoalhaven LHD

Osteoarthritis Chronic Care Program

Integrated inreach model with a multidisciplinary approach – a clinician's perspective

By Emily Mayze

27 Apr 2021 Reading time approximately

What is important to know about your service?

The Osteoarthritis Chronic Care Program (OACCP) operates Monday to Friday, 8:00am–4:30pm at Wollongong Hospital. Wollongong Hospital has about 600 elective hip and knee replacements in a year. The emergency department sees 70,000 presentations each year.

What organisational model do you use?

The OACCP is an integrated inreach model with a multidisciplinary approach.

Whole-of-person assessment
leads to
Coordination of conservative care
leads to
Regular review
leads to
Shared decision-making about surgery

What is special about the way care is delivered that is valuable for others to know?

Patients with osteoarthritis of the hip or knee are eligible to participate in the OACCP. The program is designed to reduce pain and increase functional capacity and quality of life.

The multidisciplinary team (MDT) includes: a physiotherapist, dietitian, occupational therapist and a social worker. The interventions available through the program include: comprehensive assessment, education, land-based exercise classes and prescription of home exercises.

Patients on the surgical waitlist for hip and knee replacement (category C) can access the program or orthopaedic consultants can make a direct referral.

A comprehensive assessment is completed within 42 days of the patient being referred to the OACCP using a multidisciplinary approach.

The patient is assessed by a multidisciplinary team on the same day and this usually takes two hours. Behaviour change conversations are used to assist patients in creating realistic goals and action plans to support self-management.

Referrals are made to community services, such as Get Healthy and My Aged Care. Patients can access a subsidised three month gym membership.

A companion document describes options for organisational models in the management of osteoarthritis. One option is a multidisciplinary clinic and coordinated care – this vignette describes the model from a local perspective.

How does it make a difference?

Often we have patients who appear to be managing well on face value. Having the entire team present for the initial assessment allows patients to be assessed from various angles. On multiple occasions we have been able to identify mental health, dietary and musculoskeletal conditions that may have otherwise been missed.

What tips do you have for others?

  • Discuss previous knowledge and patient expectations prior to diving into the assessment.
  • Support patients to get up and move throughout the assessment. It prevents them from getting stiff and sitting too long.

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