Download Team Management of Patients - St. Joseph`s Health Care London

Team Management of Patients
Janet Pope MD MPH FRCPC
Objectives
1. To determine how patient care is enhanced
with a team approach and which patients
would benefit from a team approach
2. To be comfortable with the resources
available in your area for team care
3. To understand what patients may be comanaged with rheumatology
What is desired in Chronic Disease
Management?
• The Ministry of Health and Long Term Care
(MOHLTC) has several goals for chronic
disease management:
• patient education and enablement,
• a chronic disease model to improve quality of
care,
– identify a best practice chronic disease model and
test it
There are Regional Barriers to
Best Practices In Ontario
Thus we need co-management
Facts
• In Southwestern Ontario, we see
– 3X more RA than the average in Ontario
• The mean age of rheumatologists is increasing
– Nearly 55 years old
• All suspected RA patients should be seen
within weeks of referral
– A delay of even 3 months of initiating DMARDs
decreases remission rate from 25% to 10%
Facts
• Targeting outcomes makes better disease
control
– Similar to
• HTN
• DM
• Lipids
• Thus we need novel ways to care for our area
Solutions
• Education
• Easy problems to be
managed without
consultation
• Co-management by
nurses, allied health
professionals, family
physicians
• Triage
• Get the right patient
seen by the right
professional at the right
time
• Lobbying for regional
care linkages
Solutions
• Successful pilot of NP
education
• Education of
rheumatologists
• Trial of targeted CME vs no
CME to improve practice
• Measuring more outcomes
systematically
• Making changes if a low
disease state is not met
• Results showed a
difference!
• Triage
• CART referral
• Canadian Arthritis Referral
Tool
• Co-management
• The Arthritis Society is
training therapists to work
with specialists to improve
inflammatory arthritis care
Case 1
• 49 year old man who works in construction
• Complaining of back pain, worse with activity,
radiating down his right posterior leg
• What is this?
• What would you do?
Mechanical back pain
• If less than 6 weeks of duration and no red
flags
– No investigations are necessary
• If back pain persists, there may be a role for
team management
Case 1
• Your patient returns, he now has 3 months of
back pain and is missing work. He has a job
for the next year at one apartment building
which is being completed.
• What would you do?
Treatment
• Usual medications
– Analgesics (NSAIDs, pregabalin, narcotics, etc)
• Physiotherapy
• Pain management (in an ideal world) is multidisciplinary
• Pain clinic / anesthesia for epidural steroids
• Imaging such as CT scan and MRI are still often
not indicated
• ?Work place assessment with The Arthritis
Society (TAS)
Discussion
• What resources have you got available in your
community to help co-manage chronic back
pain?
Case 2
• 33 year old woman who just had her second
(healthy) baby
• She has swollen knuckles of both hands, feet feel
in the morning like she is walking on pebbles
• It has been going on now for 11 weeks
• She has problems holding her baby and carpel
tunnel at night so she can’t sleep
• You do labs and she is RF negative, ESR 66
• What is the most likely diagnosis?
Case 2
• She likely has RA
• What would you do?
Case 2
• Urgent consult to rheumatology
– State: I suspect early RA
• Refer to OT/PT or TAS for education, splinting,
orthodics
• Consider starting prednisone and/or NSAIDs
(still OK if breast feeding)
• Consider DMARDs
Resources
• TAS has free therapy services and can see
patients quickly and also do joint counts
• We have a social worker for patients who
need help with disability, Trillium drug awards,
needing ODSP, etc.
Case 2
• The patient is seen quickly and is diagnosed
with early RA
• She has stopped breast feeding and is started
on
– Methotrexate 20mg/wk
– Hydroxychloroquine 200 mg BID
– Sulfasalazine 500mg BID
– Celebrex 200mg BID
Co-management strategies
• It is difficult for her to drive to London
frequently
• You are asked to see her in 6 weeks and the
rheumatologist again in 3 months
• Labs are done monthly at first
• Do you feel comfortable following the patient
with the rheumatologist for efficacy of
medication, side effects, symptom control,
ongoing education?
RA patients need a rheumatologist
for appropriate care
Case 3
• 42 year old woman who complains of joint
pain and total body pain
• She has no swollen joints and says her fingers
feel puffy and hurt all over
• She has poor sleep, she is a bit depressed
• Her CBC, ESR, TSH are normal
• You refer her to rheumatology and they reject
the referral
Case 3
• What is the most likely diagnosis?
• What can you do to manage her?
Case 3
•
•
•
•
Fibromyalgia
Education
Exercise
Amitryptylline,Gabapentin / Pregabalin,
Duloxetine
• Who can you refer her to?
Case 3
•
•
•
•
Therapists
Hospital, private, TAS
Websites for education
Some pain specialists, phys med rehab, others
have an interest in chronic pain
• Multiple referrals do not help the patient
Teams
• Multidisciplinary care in chronic disease
results in better outcomes
• Multidisciplinary Inflammatory Arthritis
Education Day
SJHC Rheumatology patients
• 288 consecutive patients with confirmed
rheumatic diseases were surveyed
• Half said they would attend a one-day
multidisciplinary information session about
their rheumatic disease.
• A quarter indicated that they would be willing
to attend a daily two-week multi-disciplinary
program to help in disease management
Rheumatology Education Days
• 30% who attend an education day, sign up for
an intensive 2-week program
• A key reason for their attendance is that it was
recommended by their rheumatologist.
• This is in keeping with other research where
the physician or health practitioner is
instrumental in the patient making a decision
about their disease.
Education Day:
London (Broadcast to Owen Sound)
• Education day consists of physician,
psychologist, OT, PT, a pharmacist, and a nurse
• Eligible patients include
• RA
• OA
• Seronegative arthritis
• CTD
• Fibromyalgia
Two to Four Week Programs
• We have programs that are evidence based for
improving self management in
• OA
• RA
• SLE
• Scleroderma
• Seronegative arthritis
• Fibromyalgia
Referral Tool
• CART
• Canadian Arthritis Referral Tool
• Something that the patient completes and the
person who is referring the patient
• This allows us to triage more appropriately
Pain Diagrams used on a Referral Tool
Future
• We are doing a televised testimonial from
health care providers about the Education Day
interspersed in the DVD of an actual education
day and will play it in random blocks to see if it
increases attendance
• We will also randomize those awaiting the two
or four week programs to sooner vs. later to
see if long term outcomes are maintained
Conclusions
• Team care is better care
• There are many valuable members of the
health care team for different problems
• Quality of team care is being evaluated to
determine if there are sustained benefits for
patients with MSK diseases
Questions, Discussion