Timely Access in Hip and Knee Bundled Care
Timely Access in Hip and Knee Bundled Care Kelly Mc. Crae, Brittany Lockwood, Andrew Nicholas Royal Victoria Regional Health Centre – Barrie ON Aim Statement By September 30 th 2018, reduce wait time for RVH ambulatory rehabilitation by 40% for patients with unilateral total knee replacement and by 10% for unilateral total hip replacement patients. QI Diagnostics Balancing measure 1: The number of no-show visits for the patients first ambulatory physio visit at RVH. Balancing measure 2: Impact on clinical workload Outcome measures: The wait time (days) from discharge to first ambulatory rehab visit Process measure: The number of patients discharged with a physiotherapy plan (date and location). Interventional Results Days 35 30 Average Wait 25 Target 20 15 10 5 Au 7 g 17 Se p 17 Oc t-1 No 7 v 17 De c 17 Ja n 18 Fe b 18 M ar -1 8 l-1 Ju 17 Ju n- 7 -1 ay M Ap r -1 7 0 Month of Surgery • The establishment of relationships and information sharing with community partners. • Creating shared clinical pathways to standardize care and drive quality 70 60 UCL 55 50 Navigator PDSA Implemented 40 CL 35 Next Steps 30 20 LCL 16 • Capture the patient experience through individual patient interviewing. Visualize the patient care journey, and understand patient stories and experiences to drive further opportunities for change 10 0 Intervention/Change Ideas Measures Average Wait Time to 1 st RVH Physio Unilateral Knee Replacement Time Between Discharge and First Ambulatory Visit (Hip) Pre and Post Navigator PDSA • During IDEAS we learned first hand the benefit of examining current internal processes, outpatient utilization and external community clinics and how that impacts clinical service delivery and quality care. • Less than 20% of patients who underwent a unilateral hip or knee replacement accessed RVH’s ambulatory rehab clinic. • More than 50% of patients were discharged with no plan for ambulatory care follow-up. • Understand where patients are pursuing ambulatory rehab and devise a tool to track utilization and post-discharge plans • Testing the benefit of navigator assistance prior to surgery to facilitate timely access to ambulatory rehab. • Evaluating opportunities to alter the model of care for ambulatory patients after total knee arthroplasty (TKA). • Development of a patient passport to increase patient experience while supporting timely access to care. Spread Interventional Results Cont’d Time from Discharge to First Physiotherapy Visit Currently, patients who have undergone primary elective total joint replacement are not accessing ambulatory rehabilitation according to Rehab Care Alliance (RCA) Guidelines. Opportunity exists to standardize processes to decrease variation and maximize efficiency of service delivery. Diagnostic Journey & Results A B C D E F G H I J K L M N O P Patient (Chronological based on Discharge Date) Q R S T U Time Between Discharge and First Ambulatory Visit (Knee) Pre and Post Navigator PDSA Time from Discharge to First Physiotherapy Visit Problem Statement 50 • Access patient knowledge and input in patient focus group sessions. Utilize patient experience co-design principles and strategies prior to implementation of patient passport 47 UCL 45 40 35 Navigator PDSA Implemented 30 26 CL 25 • Ongoing engagement of orthopedic surgeons to streamline and standardize LHIN-wide referral processes 20 15 10 RCA Target 5 0 7 4 LCL A B C D E F G H I J K L M N O P Patient (Chronological based on Discharge Date) Q R S Sustainability As a result of testing ideas of change the following processes were embedded to drive sustainability: 1. Changes to inpatient documentation to continually track ambulatory physio utilization and patient’s post-discharge plan. 2. Approval for the hiring of 2. 0 FTE hip and knee bundled care Patient Navigators. 3. Development of patient passport using patient codesign techniques. 4. Monitoring patient passport utilization at key timeframes (AIC, pre-op class) 5. Creation of MSK Steering Committee as well as bundled care working groups including relevant stakeholder participation and terms of reference. • Over half (52%) of patients accessing RVH ambulatory rehab exceeded RCA best practice guidelines with a FY 17/18 average wait time of 11 • Recognize the importance of engaging front line clinicians to generate ideas of change and days. participate in testing. • Implementing the Patient Navigator intervention • To diminish the gap between the way things are allowed us, for the first time, to trend the wait times and the way things need to be while balancing of community physio clinics. clinical demands. • Timely access to care for TKA patients was • Quality improvement is continuous; the ripple significantly improved with wait times decreasing effect of testing change ideas will ensure continuity of the QI process 28%, down to an average of 8 days from discharge. • Accessing patient navigation significantly improved Keeping the focus on connecting the dots. . the patient experience in coordinating community Patients Providers Outcomes and Quality physio follow-up and providing a point of contact Care throughout the continuum of care. • The development of a discharge tracking tool and embedding it into current documentation systems and clinical processes has resulted in 100% of patient’s being discharged with a post-op physio plan. T U • Refine model of ambulatory care after total hip arthroplasty to better align with RCA treatment guidelines • Ensure continual follow-up with front line staff and project stakeholders to keep the focus on quality improvement. Organizational Enablers Participation in this project would not have been possible without the participation and collaboration of RVH front line staff, senior leader sponsorship and support. Contact Name: Kelly Mc. Crae Title: Bundled Care Lead Organization: Royal Victoria Regional Health Centre Email: mccraek@rvh. on. ca Phone: 705 -728 -9090 x 46231
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