Allied Health Professionals delivering “one–stop” foot

Rheumatology clinics by direct access to services

Dr Mhairi Brandon Consultant Physiotherapist

Glasgow Royal Infirmary

Empowering allied health professionals (health and care)

9th December, 2014 London

NHS Scotland

ResearchNHSGGC

One-stop clinics

AHP VISION for "one-stop” foot rheumatology clinics

by direct access to services

Political Drivers

Framework for adult rehabilitation / AHP

National delivery plan

18 week RTT

NHSGGC catchment

area over 1.2 million

people

Interface of primary

and secondary care to

ensure a seamless

pathway of care across

both sectors

Improve the patient

journey to reduce

number of hospital

visits (including

diagnostic imaging)

Direct Access to

services and fast track

to specialist

rheumatology AHPs.

Case management to

prevent unnecessary

hospital admissions

Interdisciplinary AHP

team to develop a

clinical - academic

partnership

• Physiotherapists

• Podiatrists

• Sonographers

• Orthotists

Foot disease prevalence

• Point prevalence ~60%

• Disease course prevalence ~90%

Grondal et al 2008, van der Leeden et al 2008, Otter et al 2010

Swelling Active disease Stiffness Joint damage Deformity

The foot will be involved in almost all patients with inflammatory arthritis

Disease mechanisms

Greater understanding of disease mechanisms has supported advances in targeted foot therapy

Dr Debbie Turner, ARUK Senior Lecturer in Podiatry, GCU

Turner et al, 2010; Turner et al 2008; Turner et al, 2008a; Turner et al, 2008b

Foot-related impairment & disability

InflammationAltered

mechanics

18 WEEK RTT “One – Stop” Foot Clinics

“One-stop” Visit

reduce patent journey from 24 wks wait and 5 visits to 4 wks and 1 visit

lean thinking - bottom-up approach

Diagnostic musculoskeletal ultrasound imaging (MSUS)

imaging and interventions remove the “bottle neck” of the waiting times arthrocentesis and MSUS guided injection therapy

Direct access

early bird from 7.30 / designated helpline / self referral /GP referral

preventing hospital admissions bypassing A&E e.g. gout, joint sepsis

18 Week RTT ‘One-Stop’ Foot Clinics

A clinical /academic partnership

Undergraduate

Placements (physiotherapy, podiatry, occupational therapy [vocational rehabilitation])

Postgraduate

10 PG Cert Ultrasound (5 podiatrists, 2 physiotherapists, 2 physicians, 1 nurse)

10 CPD placements in injection therapy (8 podiatrists, 2 physiotherapists)

PhD students

Foot and Ankle Research Group Glasgow Caledonian University

6 (4 rheumatoid arthritis, 1 juvenile chronic arthritis, 1 psoriatic arthritis)

International visitors

Centre of Excellence Centre for Rheumatic Diseases

8 (Norway, Australia, Romania, Singapore, Holland)

Other activities

20 Peer Reviewed Journal Articles

Hosted British Society for Rheumatology Ultrasound AHP Session Spring 2013

Interdisciplinary Training and Education

Advancing AHP Practice

Learning new skills

Team Structure

Core Staff

Physiotherapy

Principal physiotherapist (lead clinician) Dr Mhairi Brandon (sonographer/ injection therapist/ microscopy)

Physiotherapy advanced practitioner Lorraine Friel (injection therapist /exercise/ hydrotherapy)

Physiotherapy assistant practitioner Sharon Morrison (lower limb casting / exercise classes)

Podiatry

Podiatry senior lecturer/ practitioner Dr Debbie Turner (sonographer/ injection therapist/ orthotics)

Podiatry advanced practitioner Violet Butters (supplementary prescriber/ injection therapist)

will be Independent prescriber from March 2014

Associated Staff

Vocational Rehabilitation Susan Webster (occupational therapist when required)

Independent prescriber Sister Moira McDonald (when required)

Interdisciplinary Team – Clinical Academic Partnership

Person Centred

Care

Interventions: injections /casts /orthoticsAssessment/MSUS Imaging

Rehabilitation/Exercise

Interdisciplinary “One-Stop” Foot Clinic

Inflammatory Arthritis: A “Diagnostic Dilemma”

Advancing practice for AHP sonographers (physiotherapists, podiatrists, radiographers)

MSUS imaging is inexpensive, non-invasive, non-ionising and readily accessible in the

clinical setting (AHP departments/clinics)

MSUS imaging as an additional diagnostic tool “MSK stethoscope” is a useful adjunct to

the routine clinical examination

MSUS Imaging has been shown to be a useful assessment tool for the detection of bone

and soft tissue foot abnormalities.

ankle joint tibialis posterior tenosynovitis

MSUS in Clinical Practice

Audit : MSUS and injection therapy Foot Clinic

2009- 2014 (n=2000 interventions)

Joints Assessment of Inflammatory arthropathies (RA, PSA, OA, Gout) Doppler imaging - grading synovial hypertrophy (743) Joint injections - hind, mid foot forefoot (703) Joint effusion aspiration (RA, gout) (79)

Tendon tenosynovitis (151) Achilles tendonitis (103)

Nerve Mortons neuroma /other (299)

Other plantar fasciitis (35) ganglion / bursitis (9)

Surgery onward referral to foot surgeon (31)

MRI Imaging/ Bone scan 9 MRI / 2 bone scan(11)

Assessments

MSK ultrasound 77%

Biomechanical / Gait assessment 54%

Pressure studies 39%

Vascular assessment 6%

Neurological assessment 4%

Treatments

Orthotics 67%

Footwear 29%

CS Injections 37% (17% previous unguided recent injection)

Below knee casting 8%

Foot Clinic – Assessments and Interventions

Future Developments: One-Stop Clinics

Capacity

New one-stop Clinics - 6 will be replicated across city partnership acute and primary care clinicians

(mobile team)

the patient experience was very positive but further evaluation is required to capture feedback on

access and clinic locations across the sector areas.

Patient experience and impact data

increase the capacity for new patients by 50% to over 2000 patients per year reducing the number

of appointments required from 5 to 1

Robust impact data will be collected during the rollout process within Glasgow for 6 “one-stop”

facilities

Develop one-stop methodology

Replicate model for rheumatological conditions of the hands involving the occupational therapists

and vocational rehabilitation

Scoping of skill mix required for future service including clinical specialist orthotists and assistant

practitioners

Training and Education

Engage with NHSNES and Universities to increase training capacity and funding for MSUS course

linking with advanced practice (national shortage of sonographers)

Investment in training and education across the various professional groups.

Vocational rehabilitation and occupational therapists

Future challenges

Think

differently

Disease mechanisms

Impairment

Disability

Enabling technologies

Effective Interventions

Advances in clinical understanding

Institute for Applied Health Research

The Centre for Rheumatic Diseases

AHP

Infrastructure

Expertise

Investment

Training & Mentorship

Research Community

Acknowledgements

Glasgow Royal InfirmaryFoot Clinic

Lorraine Friel, Advanced Physiotherapy Practitioner

Violet Butters, Advanced Podiatry Practitioner

Sharon Morrison, Assistant Physiotherapy Practitioner

Rheumatology Day ward

Moira McDonald , Lead Clinical Nurse Specialist

(microscopy)

Susan Webster , Clinical Specialist Occupational Therapist

(vocational rehabilitation)

Glasgow Caledonian UniversityAnkle and Foot Research Group

Professor Jim Woodburn / Dr Debbie Turner

Doctorates

Dr Gordon Hendry

Dr Mhairi Brandon

Dr Ruth Barn

Dr Lisa Newcombe

Dr Kym Hennessy

Dr Kellie Gibson

Dr Elaine Hyslop