Leading Better Value Care
Local vignette – Mid North Coast LHD

Osteoarthritis Chronic Care Program

Condition specific clinic and telehealth – a clinician's perspective

By Andrea Cartwright

29 Apr 2021 Reading time approximately

What is important to know about your service?

The Osteoarthritis Chronic Care Program (OACCP) is at Port Macquarie Base Hospital. This is a large regional teaching hospital in a coastal area that is popular for retirement.

What organisational model do you use?

A multidisciplinary clinic and team-based 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 multidisciplinary team includes a registered nurse (with orthopaedic and pain management experience and expertise), a physiotherapist, dietician and administration support.

Patients are referred to the clinic via the elective joint replacement surgical waitlist or by their general practitioner or specialist.

An initial multidisciplinary assessment leads to the development of a plan to improve the patient’s overall health and fitness for surgery.

The initial assessment is with the physiotherapist and nurse. Patients then have face-to-face and/or telephone reviews on a three-monthly basis until surgery or able to self-manage their osteoarthritis. All new patients receive a follow-up phone call two weeks after their appointment to help with patient engagement. Patients can be monitored more closely either by phone or in-person consultations if required.

Patients can access hydrotherapy and dietitian services at the hospital.

Team-based care reinforces positive messages to patients and supports more comprehensive planning and preparation for surgery.

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

How does it make a difference?

Often as a consequence of healthcare, patients report experiencing improvement in their other comorbidities, such as diabetes, obesity and hypertension, as well as their osteoarthritis. In the 2018-2019 financial year, 15% of the waitlisted patients we saw in the clinic were removed from the list and did not proceed to surgery due to significant reductions in pain, improvement in function and the ability to self-manage their condition.

What tips do you have for others?

  • Have sufficient staffing resources including administration support.
  • Get the right mix of team members to deliver the best possible care.
  • Get buy-in and support from surgeons and keep open lines of communication.

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