OASIS Osteoarthritis Service Integration System

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OASISOsteoarthritis Service Integration System

• Provincial Arthroplasty Collaborative Learning
  Session 3
• October 2006

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Agenda

• Overview OASIS Program
• Primary Care Participation
• Listing of Community Services
• Education
• Knowledge Transfer
• Questions/Discussion

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Background

• Second most costly disease category in Canada
• Estimated 3 Million Canadians with symptomatic OA
  (Arthritis in Canada)
• 40-50 patients suffer intermittent pain, with
  10 suffering extreme pain (Krueger)
• Increasing prevalence of OA associated with aging
  expected increase in incidence of arthritis
  within next decade

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Gaps in Care

• Fragmentation of current services limited
  coordination between care providers
• Lack of coordinated capacity to respond to
  evolving demands
• Waitlist and wait time pressures (consults and
  surgeries)
• Gaps in care for non-operative patients
• Lack of knowledge regarding resources and
  supports available

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Gaps in Care (Contd)

• Limited emphasis on prevention and health
  promotion
• Prevailing model of hospital/acute focus rather
  than system wide/patient focus
• Rising consumer expectations of care
• Demographic trends need to develop capacity

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OASIS Program(OSTEOARTHRITIS SERVICE INTEGRATION
SYSTEM)

• Services
• Multi-disciplinary assessment of treatment
  education needs
• Personalized action plans
• Listing of resources available in public and
  private sectors
• Tools for self-management
• Coaching group education
• Coordination of referrals (optional)

• Target Populations
• Patients in early and advanced stages of
  osteoarthritis of the hip and knee
• - Non-operative cases
• - Surgical candidates
• - Individuals seeking information on options
• Source of Referrals
• primary care physicians
• orthopedic surgeons
• rheumatologists

• Benefits
• Enhanced Relationship with Primary Care
  Physicians
• Improved access to services
• Skills in self-management
• Improved quality of life and health outcomes
• Collaborative Partnerships
• Improved use of system resources expertise
• Linkages with other Chronic Disease Initiatives
  

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Purpose Statement

• To design a coordinated early access system that
  will ensure equity and fairness for patients
  waiting to be assessed and treated for
  osteoarthritis and to provide them with a
  multi-disciplinary assessment of their condition
  and the education and tools necessary to manage
  their condition non-operatively, as well as pre
  and post surgery, as the case may be.

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Goals of OASIS

• Limit the development and progression of OA
• Slow onset of complications that can cause severe
  disability
• Reduce avoidable declines in health
• Reduce variations in care

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Program Objectives

• Improve access, patient flow, quality and
  efficiency of services
• Build capacity of system to meet escalating
  demands
• Minimize time of patient suffering and disability
• Build the continuum of care
• Make cost-effective use of system resources
  expertise
• Enhance roles of the multidisciplinary care team
• Link multiple arthritis initiatives

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Features of OASIS Program

• Focus on continuum of care from prevention
  through medical supports to surgical intervention
  and post-operative care
• Target populations
• Information Only Cases
• Non-Operative Cases
• Surgical Cases
• Multidisciplinary needs assessment teams
• Personalized action and referral plans
• Timely education and information
• Patient navigation through the system

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Features (contd)

• Focus on needs of individuals, families,
  care-givers and communities
• Complex and long-term partnerships
• Builds on related initiatives
• Focus on assessment, triage and education

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OASIS Services

• Multi-disciplinary assessment
• Action Plan
• Inventory of Resources/ Service Supports
• Liaison with PCP
• Liaison with Surgeon
• Case tracking and follow-up with PCP
• Clinical patient navigator

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Service Delivery Structure

• Assessment Clinics
• Regional Education teams
• Partnerships
• Interactive Website

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Tools and System Supports

• PCP Screening / Referral Tool
• Multi-disciplinary assessment tools
• Triaging Criteria
• Care Pathways
• Telephone Video Conferencing
• Website

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System Benefits

• Enhanced access to services
• Multi-disciplinary Teams will redistribute
  workloads efficient use of staffing expertise
  and associated resources
• Improved patient flow
• System wide savings increased productivity and
  quality of life
• Rationalization of system wait lists
• Coordination point for related OA initiatives

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Patient Care Giver Benefits

• Systems in place to support education
  development of self-management skills
• Client awareness
• Client support and motivation
• Individualized management plan

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Multiple Stakeholders

• Clients and caregivers
• Primary Care Physicians (PCPs)
• Allied Health Professionals
• Orthopedic Surgeons
• Rheumatologists
• Community Organizations
• Education Partners

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Primary Care Participation

• Pivotal role in coordinating access to services
• Relationship with clients understanding of
  client history and medical needs
• Limited time resources to identify service
  options
• No time to support client navigation through the
  system

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Benefits of OASIS for Primary Care

• Equitable access to services based on need rather
  than entry into referral queue
• Access to first available surgeon
• Up to date inventory of public and private sector
  services
• Standardized referral forms and assessment tools
• Client skills in self-management
• Personalized action plan for all clients
• Linkages with other chronic diseases
• Alignment with other CDM initiatives

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Engagement Strategies

• Participation in planning for system re-design
  implementation processes
• Focus Groups testing ideas
• Leadership of Depts. of Family Practice
• Multiple Vehicles for Communications and
  Engagement
• Beta-testing tools and processes
• Communications feedback loops
• Evaluation impact on physician practice
• Soft launch and incremental up-take

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Incremental Participation

• Primary Care Physicians with clients waiting for
  surgical CONSULT
• New referrals in early and advanced stages of
  osteoarthritis
• Referrals for information only
• Initial focus on Vancouver Coastal residents

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Multiple Stakeholders

• Clients and caregivers
• Primary Care Physicians (PCPs)
• Allied Health Professionals
• Orthopedic Surgeons
• Rheumatologists
• Community Organizations
• Education Partners

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Listing of Community Services

• Background
• Purpose
• Key Features
• How Did We Do It?
• Where are we Now?

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Listing of Community Services Background

• Focus groups patients, physicians and allied
  health
• Gaps identified
• Lack of information regarding available resources
• Pockets of Information
• No central location / coordination

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Listing of Community Services Purpose

• To provide a central location for information on
  services (treatment and self-management supports)
  available in both the private and public sectors
  to serve individuals with osteoarthritis

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Listing of Community Services Key Features

• Wide range of services, for example
• Rehab services
• Nutrition
• Transportation
• Exercise
• Education
• Education
• Core education - OASIS
• Partners

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Listing of Community Services Key Features

• Services reflect needs ranging from mild to
  severe OA
• Contact information
• Ability to sort by location, service type, etc.
• Access to Information (I.e. Website)

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Listing of Community Services How Did We Do It?

• Task Group
• Representation from various disciplines across
  VCH
• The Arthritis Society
• Gathered information on public and private sector
  services
• Template for storing and retrieving information
• Participation criteria
• Consent for inclusion
• Letters of intent
• Maintenance Procedures

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Listing of Community Services Where Are We Now?

• Receiving confirmations of participation
• OASIS Website
• Printed copies
• Flyers / Brochures

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Multiple Stakeholders

• Clients and caregivers
• Primary Care Physicians (PCPs)
• Allied Health Professionals
• Orthopedic Surgeons
• Rheumatologists
• Community Organizations
• Education Partners

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• Knowledge is power
• Sir Francis Bacon
• English Author Philosopher
• 1561-1626

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Education

• Education Team
• Patient Modules
• Provider Modules
• Delivery Structure

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Education The Clinic Team

• One-to-one sessions
• Identify learning needs
• Counseling/information specific to patient,
  including connection with peer support groups
• Group education sessions (emphasis on
  prevention, health self-management)

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Education The Regional Team

• Group education sessions (emphasis on prevention,
  health self-management)
• In clinic
• With partner organizations
• Traveling education sessions
• In a variety of venues
• Build relationships with partner organizations
• Evaluate education delivery patient/provider
  satisfaction

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Education Patient Modules
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Education Self Management

• What is self management?
• Self Management what the client does, to the
  best of their ability, on a daily basis to manage
  their disease and the impact it has on their
  life.
• Self Management Support what the care provider
  does to build that persons belief in themselves
  (self-efficacy) that they have the ability to
  manage their disease on a daily basis.

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PSDA
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make that
will result in improvement?
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Education Provider Modules

• Orientation to OASIS
• Evidenced-based osteoarthritis knowledge
• Train the Trainer Sessions for teaching core
  program
• Pharmacological complementary therapy
  management
• Change management skills
• Nutrition weight management
• Exercise Physiotherapy

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Education Delivery Structure

• Staffing Model
• Partnerships
• OASIS Core Sessions
• Education Venues
• Teaching Modalities
• Provider Education

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Education Next Steps

• Identify Education available
• Identify gaps
• Partnering
• Develop modules (core specific)
• Traveling education
• Evaluation

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Knowledge Transfer

• Just a taste today
• HA leadership team
• Knowledge transfer sessions
• May 2006
• October 2006
• Visit to each HA in 2007

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FAQ

• What is the difference between CSI and OASIS?
• CSI is a provincial initiative to address long
  surgical waitlists and wait times
• Focus of CSI is on patients waiting gt26 weeks for
  hip or knee surgery
• OASIS is a new program launched at the same time
  as CSI it services all OA clients in VCH, not
  just those having surgery at UBCH
• OASIS focuses on assessing service needs and
  providing education for clients in all stages of
  the disease not just advanced stage where
  surgery is required.

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FAQ

• How can the OASIS Program be applied in rural
  settings?
• Web-based screening and assessment tools
  available to primary care physicians and allied
  health
• Assessment Clinics (staffed by multidisciplinary
  teams) that travel on scheduled basis into
  isolated communities
• Inventory of local services (public private) to
  participate and/or partner with

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FAQ

• Physicians do not seem to be part of the
  multi-disciplinary team.
• Physicians are an integral part of the
  multi-disciplinary team although not physically
  present at the time of the OASIS assessment.
• Significant input and involvement in
• Development of approach and tools used in
  assessment
• Criteria used for triaging / streaming clients
• Orientation of OASIS staff in assessment
  techniques
• Consultation regarding unique client situations
• Participation in follow-up actions / referrals

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FAQ

• Would OASIS not benefit from a one-stop shop
  approach?
• A one-stop shop approach ideal for the client
  where can see a range of specialists / experts in
  one location.
• Logistically this model is difficult to implement
  and sustain as a distinct model primarily due
  to competing priorities for experts time and
  resourcing requirements
• Opportunity for OASIS to be more integrated into
  community health units

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FAQ

• What is expected of other HAs with respect to
  OASIS?
• Government announcement February 2006 was
  twofold
• Implement OASIS in VCH
• Share model / learnings with other HAs
• Other HAs to plan for OASIS-type models
• One-size will not fit all tailor to local needs

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FAQ

• What is the relationship between OASIS and the
  Surgical Patient Registry (SPR)
• For surgical candidates, the OASIS data
  collection process ends with a referral to the
  Orthopedic Surgeons for a consultation for
  surgery
• Surgeons complete the SPR prioritization tool and
  forward along with booking information to OR
  Booking Offices
• OASIS will extract a sub-set of data points from
  ORMIS re dates of referral, bookings, etc. for
  use in routine reporting and evaluation of
  waiting times, etc.
• SPR focuses on all surgical cases OASIS captures
  data only on those choosing to participate in the
  Program
• Opportunity for sharing components of the
  data-set (both directions)

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FAQ

• How does OASIS align with the Collaborative?
• OASIS is a system redesign initiative with
  emphasis on coordination of services across the
  continuum of OA care, a virtual single point of
  entry and needs-based access to service
• The Collaborative is a vehicle to bring clinical
  staff together to share quality improvement
  initiatives at the front line that improve care
  delivery and care pathways, with particular
  emphasis on individuals in the acute episode of
  arthroplasty care
• OASIS forms the conceptual umbrella of
  integrating services under which a range of
  services are delivered including arthroplasty care

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Thank you and Questions