Leading Better Value Care
Local vignette – South Eastern Sydney LHD

Osteoarthritis Chronic Care Program

Multidisciplinary clinic and coordinated care – a clinician's perspective

By Erica Morgan

28 Apr 2021 Reading time approximately

What is important to know about your service?

The Sutherland Hospital and Community Health Service is located in the Sutherland Shire of Sydney. The 370 bed hospital provides orthopaedic, general surgical, medical, maternity and paediatric, stroke, respiratory, critical care services, cardiac, oncology, aged care, rehabilitation and mental health services. Approximately 240 new patients per year attend the Osteoarthritis Chronic Care Program (OACCP) clinic at Sutherland Hospital from both the Sutherland and St George local government areas.

What organisational model do you use?

A multidisciplinary clinic and coordinated care.

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?

The clinic at Sutherland Hospital is based on the OACCP model of care, developed by the Agency for Clinical Innovation (ACI), and is available to all people with hip and knee osteoarthritis who are on the waiting list for hip or knee replacement surgery. People may also attend with a referral from their general practitioner, specialist or allied health professional.

Patients are referred to other services or health professionals as required to support healthy eating and a physically active lifestyle. This includes using ‘Get Healthy NSW’ and ‘Stepping On’ along with community exercise groups and hydrotherapy. Patients are also encouraged to attend a hospital-based exercise group which runs twice a week.

Patients are reviewed every three months until they either undergo surgery or are managing their symptoms independently. Patient-reported measures are collected at all appointments to ensure the assessments and treatments are tailored to what outcomes are important to the patient. Telehealth appointments are also available for those people who prefer not to come to the hospital.

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?

Patients are able to see all clinicians in the one place at the one time. Both staff and patients report satisfaction with patient flow as there are three patients booked in at a time, with three clinicians available. This promotes patient satisfaction by reducing waiting times.

What tips do you have for others?

  • Engage and educate orthopaedic surgeons and general practitioners about the program.
  • Two clinics per week starting at different times works well as it gives those patients who live further away an opportunity for a later appointment.
  • Record accurate key performance indicator data regularly.

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