Spotlight on patient-reported measures

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Promoting patient centered care for people with osteoarthritis

Northern NSW Local Health District

16 Jul 2024 Reading time approximately

The Clarence Valley Knee and Hip Arthritis Service (KAHAS) operates in Northern NSW Local Health District (NNSWLHD) as a modified version of the Agency for Clinical Innovation’s Osteoarthritis Chronic Care Program Model of Care.

The service operates across three sites at Grafton Hospital, and Maclean and Yamba Community Health centres. KAHAS offers physiotherapist-led osteoarthritis assessment and management with multidisciplinary support.

KAHAS accepts all referrals for osteoarthritis knee and hip management, not just patients on the joint replacement surgery waitlist. The service supports patients to optimise osteoarthritis management, general health and wellbeing through evidence-based, conservative practices including exercise and weight management. This includes targeted osteoarthritis group exercise programs and an outreach clinic for Aboriginal patients.

KAHAS has  been using patient-reported measures (PRMs) as part of routine clinical care since 2017, and moved from paper-based to electronic collection via the Health Outcomes and Patient Experience (HOPE) platform in March 2021. The opportunity to transition to electronic collection and reporting offers patients a digital workflow to complete their PRMs, and enhances reporting capabilities for patient-centred outcomes. The service uses three measures – the PROMIS29 , a generic quality of life patient-reported outcome measure (PROM), as well as the Oxford Hip Score and Oxford Knee Score. The team also uses a patient-reported experience measure (PREM), the Outpatient Patient Reported Experience Measure.

Patient-reported measures workflow

  • Patients are registered and PRMs are assigned within eMR to patients at point of care.

  • PRMs are completed at initial assessment either electronically using a QR code or on paper (preferred by some patients due to their IT skills). Paper surveys are transcribed into the HOPE portal.

  • Results are discussed with patient as part of their assessment, and patients may also review their results in HOPE.

  • Results help guide recommendations for best intervention, including options for surgery or conservative management. If surgery is indicated, results also guide surgical prioritisation needs.

  • PRMs outcomes help to guide agreed goals in the patient's care plan.

  • Results are documented in clinical notes and correspondence to GP, surgeon or other health professional as indicated.

  • PRMs repeated at conclusion of the KAHAS program or at follow-up assessment as needed. Patient goals and interventions are revised as indicated by PRM outcomes, and follow-up correspondence includes outcomes and recommendations for management.

Consumer story

Steve*, a 62 year old male, completed PROMs (PROMIS-29 and Oxford Knee Score) on his initial assessment appointment at KAHAS. The completed PROM results indicated osteoarthritis was severely impacting Steve’s quality of life, most notably in the domains of pain and physical function. There was a high indication for surgical intervention. The clinician was able to share and discuss these results with Steve.

Steve found the review of the PROM results enabled him to reflect on the current effect of knee osteoarthritis on his function and mobility. He also used the PROM results for goal setting and planning with his clinician. At the next KAHAS appointment, Steve had shown significant improvement, with results moving to the mild to moderate range. Steve reported it was really helpful to see the change in results which gave him further motivation to stick with the lifestyle changes that had been adopted.

*Name has been changed for patient privacy.

Benefits of patient-reported measures

Benefits for the patient

  • Supports patient and surgeon decision making with conservative management of OA.
  • Supports patient and surgeon decision making about surgery acceleration or deferral with change of PROMs over time.
  • Easy to show patient results and changes to their condition and wellbeing, using graphs in HOPE.
  • Opens discussions around patient wellbeing and any additional clinical or social support needs or referrals, e.g occupational therapy, Get Healthy program.

Benefits for the service

  • PRMs in HOPE calculates and aggregates results in real time, supporting clinician assessment and analysis of results
  • Easy access to individual and service-level reports and data, to provide information on service outcomes.
  • PROMIS-29 provides additional reporting power, allowing profiling of patient’s non-physical domains of concern, e.g. high rates of anxiety in cohort.
  • Telehealth compatible, as PRMs can be shared online with out-of-area patients to complete prior to appointment.

Benefits for the organisation

  • The aggregated collection of patient outcome data allows real reporting on service effectiveness against validated reporting tools for the clinical cohort.
  • This also assists service managers, directors and executive teams to have confidence in service investment, and/or guide decisions for ongoing service management.
  • The data assists Quality Managers preparation for accreditation with Standard 2 and Standard 5 with support from the NNSWLHD PRM program team and existing governance.
  • The consistent use of PRMs allows patient’s current function to be communicated to orthopaedic specialist and GPs, and provides evidence to assist with shared decision making on the appropriate management of the patient's osteoarthritis.
  • The majority of patients are seen by the KAHAS teams prior to orthopaedic consult and subsequently placed on the waitlist for joint replacement surgery. Engaging patients early in their OA journey improves the opportunity to self-manage their OA development and improve symptoms affecting function and wellbeing. This can potentially reduce the number of patients requiring surgical intervention in the district.

Helpful tips for other services

Learn from other clinicians’ experiences. PRMs leads can provide information and connect you with similar services already using PRMs, to provide support with workflow and confidence using PRMs in clinical practice.

Involve the patient. Using PRMs will likely be new for your patients too. Take time to explain their purpose and how they support clinical care. Explain the nature of the questions about social and mental wellbeing so they are prepared. Provide reassurance about confidentiality and the ability to opt out.

Stay with it. Any new process in clinical practice can be challenging, particularly at the start. Repetition and application in early stages helps builds better efficiency and experiences for the clinician and patient.

Clinical engagement approach

PRM leads took a collaborative approach at all stages. They worked closely with KAHAS service staff and managers to understand the service, and identified best opportunities and methodologies for using PRMs within established clinical norms and routines.

Support from the PRMs leads included:

  • Creating agreed workflows for PRMs with management approval.
  • Organising training based on service needs and preferences.
  • Using the HOPE training platform to build user confidence prior to go-live, including iPad use in both clinician and patient mode.
  • Developing reference guides that reflected the service workflow and surveys used.
  • Making the PROMIS-29 and Oxford Hip and Knee scores available in HOPE to improve interpretation of results, assist with patient engagement and highlight possible referral pathways for areas of concern.
  • Demonstrating the power of collected, validated and standardised data electronically in real time, to streamline reporting, benchmarking and enhance service quality and safety.
  • Supporting onsite at go-live for immediate assistance and troubleshooting, including supporting patients in navigating unfamiliar technology and surveys.
  • Providing an activity report and preliminary results to staff and management two weeks post go-live, as well as sharing a confidential feedback survey on the training and materials provided.
  • Providing advanced training sessions after one month, to consolidate skills and practically apply HOPE reporting function with own patient and aggregated service data.

Organisational structure

Governance

PRMs Leads and PRMs Program Manager develop biannual briefings and reports for the NNSWLHD Executive Leadership Team. This includes reporting on PRMs activity, service outcomes and patient stories. It also includes challenges and risks affecting the performance and rollout of the program.

At a district level, the NNSWLHD Healthcare Quality Committee receive a report and presentation three times per year. The district PRMs program provides regular reporting and feedback to the Consumer Advisory Committee.

Regular meetings between the PRMs Executive Sponsor and PRMs Program Manager include PRMs updates and requests for action as required. Weekly one-to-one meetings are held between PRMs Leads and PRM Program Manager, with formal PRMs team meetings held fortnightly.

Multiple approaches are taken to raise awareness and engagement with PRMs within the district, including the following:

  • Standardised emails are developed for manager and staff for PRM orientation and engagement in line with NNSWLHD Implementation Timeline Document.
  • Education packages are established to support PRMs orientation and practice for managers, consumers and clinicians.
  • PRMs workflows are developed for all participating services in consultation with management and service staff.
  • Broader awareness of PRMs program is raised through established media and generic IT work platforms.
  • Intranet hosts a local staff repository for resources and information on PRMs, including information for users and non-users.
  • PRMs staff receive a ‘PRM Tips and Tricks’ email with information to improve PRMs and HOPE user and patient experience.
  • Numerous PRMs educational articles and updates are published on LHD internal channels and newsletters.

Acknowledgements

  • Jane Linton, KAHAS Coordinator and Physiotherapist, NNSWLHD
  • Rebecca Davey, Manager, Value Based Health Care, NNSWLHD
  • Peter Kelly, Patient Reported Measures Program Lead, Clarence Valley, NNSWLHD
  • Matthew Hanley, Patient Reported Measures Program Lead, Richmond, NNSWLHD
  • Luke Schultz, Patient Reported Measures Program Lead, Richmond, NNSWLHD
  • Brenton Sahlqvist, Physiotherapy Manager Clarence Valley, NNSWLHD
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