The Osteoarthritis Chronic Care Program (OACCP) provides evidence-based conservative management for people with hip and knee osteoarthritis, including those who may receive joint replacement surgery in the future.
Nepean Blue Mountains Local Health District (NBMLHD) implemented the program to manage Category 3 (non-urgent) patients, usually requiring surgery within 365 days. These patients often have comorbidities, and while waiting for surgery, can deteriorate significantly. This can:
- increase the risk of surgeries being cancelled
- be costly for the service and patients
- affect the patient’s length of stay
- lead to poorer surgery outcomes for patients
- decrease the likelihood that patients will be in a good condition for major surgery.
The program aims to improve these outcomes by focusing on pre-surgery conditioning and management of comorbidities.
The OACCP captures feedback from patients via patient-reported measures (PRMs) surveys. This includes patient-reported outcome measures (PROMs) that help to inform consultations and care planning, response to treatment regimens and when patients require referrals to the multidisciplinary team and other services. Patient-reported experience measures (PREMs) help to identify any areas for further review and improvement, and aid in the evaluation of service delivery.
Patient-reported measures workflow
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Patients are invited to take part in PRMs during their first contact with the service.
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Patients are registered in the Health Outcomes and Patient Experience (HOPE) platform and assigned surveys (PROMIS-29 and Oxford Hip/Knee Score) to complete electronically (if able).
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If unable to complete electronically, patients are supported to complete surveys during their first clinical assessment.
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The OACCP physiotherapist discusses the survey results during clinical consultation and care planning is conducted in collaboration with the patient.
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Results are shared with surgeons and GPs via letters.
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PRMs are repeated quarterly until program discharge.
Consumer story
Janice*, a 72-year-old female, led an active lifestyle and had been waiting 114 days for a left hip replacement. On Janice’s initial PROMIS-29 survey, the results showed she had decreased physical and social function, increased anxiety and depression, mood swings, increased fatigue and moderately high pain interference.
Janice reported to her physiotherapist that she was experiencing hip pain, but denied clinical depression and anxiety, and expressed that she didn’t want her husband to see her distress. Following discussion of the survey results, Janice agreed to a social work referral for emotional support and her physiotherapist provided her with a fatigue management resource.
*Name has been changed for patient privacy.
PRMs are helpful for clinicians because they allow us to measure how much a particular issue affects a patient’s well-being or function, and then remeasure this later to see if treatment has been effective.
Benefits of patient-reported measures
Benefits for the patient
- Patient-reported outcome measures (PROMs) provide a fair approach to patients, especially when recommending escalation to surgery.
- Patients receive consistent care that considers what matters most to them.
- PROMs confirm subjective and objective assessment results and are usually consistent with a patient’s perceptions of their own progress.
- PRMs help guide difficult conversations, especially around mental health. The clinician can refer to depression or anxiety scores and ask if the patient would like to discuss them.
Benefits for the service
- The PRMs lead has developed data analytic tools (Power BI and Microsoft Excel) to evaluate the service in terms of symptom changes, function, mobility and quality of life. The HOPE platform is able to provide data for services to develop a business case to enhance OACCP to provide non-surgical management for appropriate patients.
- PRMs facilitate data analysis for continuous improvements. Patient-reported experience measures (PREMs) data showed that 12% of patients were not sure if they had a treatment plan for their condition. The team is working on ways to improve this aspect of care provision.
- PRMs is an excellent tool for assessing the value of treatment, particularly during the provision of virtual care, when the clinician is unable to perform physical tests that would usually take place in a face-to-face setting.
Benefits for the organisation
- Within NBMLHD, PRMs foster a culture of patient-centred care, collaboration, and shared responsibility in achieving the best outcomes and experiences for patients.
- The PRMs Program Lead, in partnership with the local service, develops a quarterly report and distributes it to the service team and service sponsor for review and action. The lead also communicates these reports via established local channels, including working groups, committees and operational meetings.
- By reviewing PRMs data, the PRMs lead identifies ways to improve service delivery and clinical care. Service teams work collaboratively on quality and service improvement projects to address consumer needs and improve efficiencies.
- For opportunities that require broader collaboration, the local service team will engage local stakeholders and other service teams to drive positive change and improve outcomes and experiences for patients.
Helpful tips for other services
Admin support staff play a significant role in helping patients use PRMs effectively.
Allow for extra time in clinical consults to discuss completed PROMs and the management options available.
Plan for more than one mode of delivery to optimise patient participation e.g., email and face-to-face.
Clinical engagement approach
The PRMs Program Lead and sponsors at NBMLHD engage with staff across the organisation to identify clinical services that would benefit from using PRMs and the HOPE platform. They build relationships through consultation and awareness-raising across the LHD . The district promotes PRMs and HOPE via newsletters, meetings, working groups, SharePoint updates and regular email communication.
NBMLHD takes a methodical approach to the implementation of PRMs and HOPE locally. The district PRMs lead provides the following support.
- Information sessions about PRMs to encourage clinician and service uptake.
- Workflow mapping, reinforcing the need for PRMs collection at point of care, to support shared decision making with patients.
- Virtual and in-person training on how to use PRMs and HOPE, for clinicians and administration staff.
- Co-identifying and mitigating risks and issues.
- Co-developing a schedule for ‘go lives’, including roles, responsibilities and timelines.
- Adopting a ‘train the trainer’ approach to encourage champions within the respective services and reduce overall workload.
The PRMs program is sustained through ongoing education and refresher training, regular check-ins with clinical services, and presenting at service meetings. Data reports are shared widely, to inform ongoing service delivery.
Organisational structure
Governance
The Value Based Health Care Executive Steering Committee, involving NBMLHD directors, oversees all value-based healthcare programs, projects and initiatives, including the PRMs program across the district. The PRMs Program Lead provides a report to the committee at quarterly meetings.
The PRMs Program Lead engages with local services to encourage the uptake and use of PRMs and HOPE. In collaboration with the local service team, they provide a quarterly report to the local service governance committee.
The lead presents on the success of PRMs and HOPE implementation; highlights any risks and issues; and works to mitigate these via the governance structure. All stakeholders involved in the PRMs program are responsible for raising awareness of PRMs within their relevant teams and networks.
Acknowledgements
We acknowledge and thank the following for their participation in this project:
- Sharon Hammad, Multidisciplinary Orthopaedic Clinic (MDOC) Coordinator
- Cathy Crowe, Executive Sponsor, Director Community & Integration
- Larissa Hoyling, Sponsor, Principal Manager Value Based Healthcare
- Kate Norman, Patient Reported Measures Project Lead
- Rebecca Francis, Patient Reported Measures Project Officer