www.pspbc.ca

MSK Train the Trainer 1Arthritis and Low Back Pain

Wireless: Westin-Meeting

Code: bcma2013

Westin Wall CentreApril 4-5, 2013

Welcome and Introductions

Dr. Diane Lacaille

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Our patients: Megan and Mary Beth

Teaching faculty› Arthritis: Diane Lacaille, Lori Tucker, › Low back pain: Julia Alleyne, Brenda Lau› Family practice: Bruce Hobson› Patient self-management: Connie Davis› Workshop and panelist faculty

Moderator: Diane Lacaille, Garey Mazowita

Faculty Introductions

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USB Keys

Handouts

Internet: Wireless: Westin-Meeting Code: bcma2013

Cell Phones, Bathrooms

Breaks

Credits

Parking

Mikes

Evaluation

Physician Reimbursement Form

Housekeeping

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What hat are you wearing?

How does it fit?!

Ice Breaker

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Multiple choice questions

Student response system technology

Audience answers

Data filed

Pre-post day comparison

Clicker Time

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1. Family Physician

2. Specialist Physician

3. Medical Office Assistant

4. Rehabilitation Professional

5. PSP Coordinator/Manager

6. Administrator

7. Clinical Faculty

8. Patient

What hat are you wearing?

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1. Vancouver Coastal Health Authority

2. Vancouver Island Health Authority

3. Northern Health Authority

4. Interior Health Authority

5. Fraser Health Authority

Which area do you work in?

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1. Rehab & exercise, weight management, pain management, patient self-management

2. Exercise, pain management, imaging and investigations, patient self-management

3. Rehabilitation, disability management, pain management, patient self-management

4. Weight management, pain management, patient education, early surgical referral

What are the four pillars of osteoarthritis treatment? Choose one

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1. Morning stiffness greater than 30 minutes

2. Bony enlargement

3. Synovial thickening

4. Joint involvement of hands and feet

5. Pain increased with rest or immobility

Which key clinical features are NOT suggestive of Inflammatory Arthritis?

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1. Acute joint swelling to rule out septic arthritis

2. Acute joint swelling to detect presence of crystals

3. To differentiate inflammatory from non-inflammatory causes of joint swelling

4. To relieve pressure of moderate joint hemarthrosis

5. To improve joint mobility and function

6. 1,2 and 3

7. 1,2 and 4

In which of the following situations would joint aspiration be clinically useful?

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1. Early initiation of prednisone medication

2. Prioritizing depression as a common co-morbidity

3. Early initiation of non-biological disease modifying anti-rheumatic drugs (dmard”s) to reduce joint damage

4. Referral to a rheumatologist prior to medication initiation

What is best practice for the management of Rheumatoid Arthritis?

Program Orientation

Dr. Diane Lacaille

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Patient’s journey

Gap analysis

Evidence-informed practice guidelines

Juvenile idiopathic arthritis

Clinical tools

Application to practice with video

Shared care panel

Practice implementation

Rheumatoid Arthritis and Osteoarthritis

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To discuss a comprehensive approach to improve FP care and supports for patients living with RA, OA and LBP demonstrated by:

› A reduction in pain

› An increase (or reduced decline) in patient functioning

› Informed and activated patients managing their condition to the best of their abilities

› Specialist support and consultation, when needed, is available in a timely manner

To review selected tools and provide an overview of how to access additional tools / information through either electronic or hard copy toolkits

To have a plan for the action period

Why are we here?

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MSK Project Charter: Scope of Work, Deliverables, Inclusions & Exclusions)

Needs / Gaps / Barriers to Care informed by: Incidence /prevalence of disease in BC

Arthritis Service Framework (2008)

Small survey of FPs

Input from experts / working groups

Review of relevant literature

Experience of other jurisdictions

Framed around evidence-based best practices: GPAC Guidelines (BC) for OA and RA

Alberta, New Zealand, UK Guidelines for LBP

Foundation of Work

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Paper-based vs. EMR office set ups

Alignment with currently used or planned tools

Office time constraints / workflow

Pattern recognition vs. algorithmic care

Recognition that management may precede diagnosis

Access to specialists and rehab experts

Awareness of education and community resources

Role of physician in dialogue / discussion of PSM

Time implications / alignment with physician fee schedule

Physician Issues / Considerations

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Practical & simple point of care tools / checklists

Screening tools for early identification of inflammatory arthritis

Red and yellow flags and criteria for expedited referral

Supports for dealing with complex and chronic pain

Tools for responding to psychosocial needs of patients

Tools for Joint Action Planning

Awareness of programs, services, resources available

Areas of Focus - In the FP Office

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Access to specialists for quick advice (RACE telephone service)

Criteria for appropriate referrals / consults

Meaningful consult letters that support the FP in ongoing care for patients

Building the network of relationships at local / community level

Awareness of Provincial, regional and local programs and resources for patients and care givers

Areas of Focus – For Specialist / Community Support

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Management of co-morbidities and related issues

Readiness for self-management responsibilities

Alignment with currently used or planned PSM tools

Keeping tools comprehensive yet useable

Tools in a format that address issues of health literacy, ethnic diversity

Desire for hard-copy, printed materials to take away from visit

Awareness of and access to education programs and community resources

Use of patient health record

Patient Issues / Considerations

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FP survey

Cross-section of stakeholders on steering committee and working groups

Webinars and telephone consults

FP trial / test of OA, RA, LBP “point of care” tools

Focus groups

Physician & Patient Engagement in Content Development

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Shared Care Committee (SCC) General Practice Services Committee (GPSC) Specialist Services Committee (SSC) The Ministry of Health (Primary Care Division) The Arthritis Society Mary Pack OASIS Program Patient Voices Network Individual Physicians, Clinical Specialists, Patients

Acknowledgements

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Charter

Patient Journey

Ms. Meghan Smaha

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Gap Analysis:Why is MSK a tough nut to crack?

Dr. Garey Mazowita

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To be able to describe the common barriers

that physicians, patients and the health care

system are challenged by with MSK

conditions (RA, OA, JIA, LBP)

Objective

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Dealing with complex and chronic LBPDealing with complex and chronic LBP

Delayed RA diagnosisDelayed RA diagnosis

No “expectant” self-management strategies/resources for OANo “expectant” self-management strategies/resources for OA

Patient expectations for MRI & referrals

Psychosocial patient needs

Lack of patient educational resourcesLack of patient educational resources

Lack of tools in guideline recommendations

Defining work-related restrictionsDefining work-related restrictions

Rational use of therapeutic options including opioids

Primary Care Provider Barriers

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Understanding of investigative and referral rationaleUnderstanding of investigative and referral rationale

Funding for physiotherapy

Lack of Self-management strategiesLack of Self-management strategies

Medication focus

Work-related concernsWork-related concerns

Minimal or missing “functional” focusMinimal or missing “functional” focus

Mixed provider/media messages

Access to medical appointments

““Can’t do anything about arthritis” attitudeCan’t do anything about arthritis” attitude

Patient Barriers

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Poor communication between providers

Lack of coordinated patient education material

Lack of validated Web resources

Non-standardized care pathways

Who is the “right” specialist?

Access to specialists

Access to Allied Health

System Barriers

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Don't know

Specific guidelines

Exercise prescription

Specific rehabilitationSpecific rehabilitation

Differential diagnosis

Ordering of imagingOrdering of imaging

Work restrictionsWork restrictions

Common Practice Knowledge

Know

Red flags

Medications

No bed rest

Referral to

physiotherapy

Association of

depression

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Build on the foundation of GPAC Guideline

Tools supporting early identification of RA & screens for Tools supporting early identification of RA & screens for red flagsred flags

Provide guidance about appropriate prevention, assessment & intervention strategies for RA

Ability to initiate strategy for medical stabilization +/- referral criteria to Rheumatology

Engage patients in goal-setting and support patients in self-care responsibilities

Module Goals for RA

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Screen for RA to mitigate delays in treatmentScreen for RA to mitigate delays in treatment

Key Features of Inflammation suggesting RAKey Features of Inflammation suggesting RA

Laboratory InvestigationsLaboratory Investigations

Differential Diagnosis and key conditions to rule out before starting +/- Differential Diagnosis and key conditions to rule out before starting +/- referring for DMARDsreferring for DMARDs

RA-related examination, management, follow-up and patient self-RA-related examination, management, follow-up and patient self-management considerationsmanagement considerations

Tools for assessing disease activity and treatment targetsTools for assessing disease activity and treatment targets

Criteria for referral to a RheumatologistCriteria for referral to a Rheumatologist

Guidelines for management of co-morbidities

Multi-disciplinary care for RA; allied health access and utilityMulti-disciplinary care for RA; allied health access and utility

RA Content

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Utility / value of clinical tools and checklists at point of care

Decision support tools for patients regarding medication options and lifestyle management

Screening for patient depression and self-management issues

Points for discussion with patients

Organization of provincial rheumatology services for Organization of provincial rheumatology services for expedited accessexpedited access

Promotion of best practices

RA Content

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Improve the early recognition of juvenile arthritisImprove the early recognition of juvenile arthritis

Provide clinicians with tools to assist in the diagnosis of MSK complaints in children

Suggest pathways for referral of children with Suggest pathways for referral of children with MSK complaints when needed, and increase MSK complaints when needed, and increase awareness among GPs of accessibility of care for awareness among GPs of accessibility of care for children and teens with arthritis in BCchildren and teens with arthritis in BC

Goals for the JIA MSK Module

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Build on the foundation of GPAC Guideline and Tools

Address gaps/barriers to care from Arthritis Service Framework (2008)

Include criteria for making an accurate diagnosis with functional assessment

Optimize pain and function through education, rehab, Optimize pain and function through education, rehab, medication and referrals (as required)medication and referrals (as required)

Emphasize physician-supported pro-active patient self Emphasize physician-supported pro-active patient self management, not passive acceptancemanagement, not passive acceptance

Module Goals for OA

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Office efficiency / workflow alignment

Relevant examination skillsRelevant examination skills

Pattern recognition and algorithmic care

Address patient expectations re joint deterioration and joint replacement

Deal with psychosocial needs of patient

Make coordinated patient education materials & Make coordinated patient education materials & awareness of resources availableawareness of resources available

OA Content

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Electronic toolkit & education materials – to add value & enhance working relationships

Provincial alignment/fit

Evidence-based best practices

Early common pathway - red flags firstEarly common pathway - red flags first

Management can precede diagnosisManagement can precede diagnosis

Patient ownership & PSMPatient ownership & PSM

Address occupational issuesAddress occupational issues

OA Content

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Patient questionnaires

Electronic tools that fit with office work flow

Consistency in approach between provider Consistency in approach between provider assessment and treatmentassessment and treatment

Coordinated system for access to specialists and rehab expertise

Alignment with physician fee schedule

OA Content

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Patient engagement: a therapeutic relationshipPatient engagement: a therapeutic relationship

Strategies for both acute and chronicStrategies for both acute and chronic

Dealing with burden of sufferingDealing with burden of suffering

Dealing with patient expectationsDealing with patient expectations

Best practice management

Involving other health care practitionersInvolving other health care practitioners

ResourcesResources

Module Goals for LBP

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Identifying specific etiology

Dual management – cause + pain Dual management – cause + pain

Dealing with expectations for investigations and referrals

Identifying psychosocial needs of patients

Address co-morbidities of mood, sleep, function, adverse drug Address co-morbidities of mood, sleep, function, adverse drug effects effects

Accessing coordinated patient educational resources

Negotiating work related restrictionsNegotiating work related restrictions

Role of medication (including opioid management)

Identification of responsibility for ongoing careIdentification of responsibility for ongoing care

LBP Content

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Initial screening for pain and pain-related disability or limited function

Built-in reminders to reassess pain, function, adverse effects over time with embedded pain management guidelines

RACE telephone hotline and mentor-mentee RACE telephone hotline and mentor-mentee networks to support GP linkage to pain specialistsnetworks to support GP linkage to pain specialists

LBP Content

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Action PlanningDefine self-Define self-management, self-management, self-management support, management support, and self-efficacyand self-efficacy

Describe what is known about assessing confidence and the effect on patient behavior and health

Patient Self Management

Patient Passport Effective patient tool

Applicable in multiple conditions as it is based in the value of health and lifestyle

Patient passport tool for individuals managing long-term chronic conditions like RA and OA

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Right CareRight TimeRight Way