TEAMS - towards integration of services
Rhian LewisYsbyty Gwynedd
Bangor
Chaos
TEAMSTargeted Early Access to Musculoskeletal Services
• Reorganisation of services
• Problems encountered
• Improvements achieved
Order
Bangor
North Wales
Challenges
• Difficulty in coping with referral demand • Long waiting lists• No acute back pain service• Patients on multiple waiting lists• Limited co-ordination of services• Inappropriate referrals in orthopaedics –
low surgical conversion rates
Wider environment
• WAG programme: Innovations in Care in orthopaedics
• Project group on accessibility of musculoskeletal services
TEAMS working party• GP representing local health group• Senior manager• Orthopaedic surgeon• Pain management consultant• Physiotherapist• Rheumatologist
Aims of TEAMS
• Improved access to services
•Reduced waiting times
•Timely surgery
Key features
• Common access point
• Triage into appropriate specialty
• Development of care pathways
• ESP-led Back Pain Service
• Community-based musculoskeletal clinics
• Fibromyalgia clinic
Integration of services
GP referral
Triage
Surgical advice
Chronic back
OA/soft tissue
Arthritis/CTD
Acute back
Physio assessment
Pain management
Rheumat- ology
Orthopaedic service
Difficulties to overcome
• Change is threatening
• Rheumatologists ?Take-over bid?
• Ortho objected to pooled referrals
• Delegation of responsibility
• Supporting new nurses time-consuming
Acute back pain
• New service: ESP (physio) triage• Reduce acute backs seen in ortho• Screen Red flags (fast-track to ortho) • Onward referral of Yellow flags to pain
clinic
• Weekly meeting of ESP with pain clinic MDT
Acute back pain pathwayGP Referral
Teams Co-ordinator RED Flags
ESP screening / telephoneRe-assessment
Pain Team/Epidural
Physio Treatment
ResolvingD/C
Further physio
Orthopaedics
• Telephone reviews• TENS and drug reviews by specialist
nurses• Greater emphasis on education,
exercise and self-management• Flare-up protocols• Weekly MDT meeting
Chronic pain - changes
Pain clinic - staff increases
• 3.5 Consultant sessions
• 0.5 Specialist nurse
• 0.5 Psychologist
• 0.5 Physiotherapist
Chronic pain - results
• Increased throughput – 400 -> 700/year• Waiting list of 2-3 months (down from
12 months)
• Acute referrals from ESP seen within 1 week
Rheumatology - changes
triage
GP referral
inflammatory non-inflammatory
rheumatology musculoskeletal
New programme - GPwSI
• 5 GP's with an interest in MSM• Work closely with ESP Physio• Triaged by rheumatology consultant• Overseen by clinical lead• Treatment of uncomplicated
musculoskeletal problems
Musculoskeletal clinics
• One clinic weekly in each geographical area
• Bangor, Llandudno, Holyhead, Pwllheli, Dolgellau
• 125 patients a month
• Monthly combined education programme
Rheumatology - results
• Reduced waiting times
• Greater responsiveness to patients
•More use of nurse-led, multidisciplinary review clinics
• Telephone helpline
Orthopaedics - changes
• LBP seen by ESP• Musculoskeletal to GPwSI and ESP• Reduction in out-patient waiting times
• Surgical conversion increased to 60%
Educational meetings
• Physio
• GPwSI
• Ortho trainees
• A and E staff
• GPs
Results in first year (2002)
• Total monthly referrals 400 --> 900 • Orthopaedic share 250 --> 200• Increase in pain, MSM, physio• Abolished duplicate referrals• Surgical conversion rate improved
Waiting time reductions (weeks) 2001-2002
T and O 52 --> 13
36 --> 9
52 --> 7Pain
Rheumatology
Current position 2007
• Improvements maintained• Referrals 890/month • Waiting times maintained
Pain clinic perspective
• Back pain service in place
• ESP and Pain clinicians
• Increase in:
– semi-acute backs
–MRI scans
– tertiary referrals
What did we learn?
• Integration improves services• Community clinics effective for
uncomplicated musculoskeletal problems• Nurse-led clinics can reduce W/L• Acute back pain service valued by GPs• Helpline valued by patients
TEAMS - the answer?
• One-stop shop for patients• Joined up services for practitioners
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