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