Ontario Health had a chance to catch up with Suzanne Denis, Advanced Practice Physiotherapist, Holland Bone and Joint Program, Sunnybrook Health Sciences Centre, to learn how she and her team are adopting the Osteoarthritis Quality Standard while adapting to our new reality.
Can you describe the Bone and Joint Program at Sunnybrook?
The Bone and Joint Program offers comprehensive care for hip and knee arthritis, orthopaedic trauma, rheumatology, rehabilitation and more.
Specifically, the Hip and Knee Arthritis Program offers comprehensive care for patients with hip and knee arthritis through access to assessment services with an Advanced Practice Provider (APP), education, and referral to self-management programs and other treatment programs, including consultation with an orthopaedic surgeon as needed and post-operative follow up.
What types of patients do you usually see?
Usually, patients with greater than mild hip and knee arthritis visit a health care provider in the community (such as a physician, nurse practitioner, or even a back specialist or rheumatologist etc.) and are then referred to our program. We triage referrals for most of the Toronto region, but also receive referrals from outside the GTA.
If a patient is appropriate for our program, we provide them with an appointment to be seen by an Advanced Practice Physiotherapist or Occupational Therapist (APP) at our Rapid Access Centre (RAC). If not, we provide information to primary care providers about where their patients can go for help. For example, a patient might benefit from a spine screen rather than being seen in our program.
After taking a thorough history and physical exam, our goal is to help guide patients and their primary care providers to optimize hip or knee arthritis non-surgically.
How have you used the Osteoarthritis Quality Standard to inform your practice?
When most patients come to see us, they are not yet optimized non-surgically. About 30-40% of patients are not appropriate for surgery or don’t want it, so we focus on providing patient education and referrals to community programs based on patients’ specific needs as suggested in the Quality Standard.
Here at the Holland Bone and Joint Program, we’ve put together a library of key exercises that we select from to meet specific individual needs identified during the assessment as well as patient education resources for hip and knee osteoarthritis. With the Arthritis Society, videos were developed providing detailed guidance for activity and exercise for those with osteoarthritis. We have some trusted websites to which we refer patients, including the Arthritis Society.
Not everyone has access to an interprofessional team (like a chiropractor, physiotherapist, occupational therapist, registered dietitian etc.) or perhaps patients live in a remote location. These types of resources are essential in these situations.
The GLA:D programprovides arthritis education as well as a progressive neuromuscular strengthening program. Some clinics are offering the program virtually as well as in person. We also recommend local community services focused on fitness, healthy aging, nutrition/weight management, falls prevention, and diabetes education.
We provide a summary note of the assessment and recommendations, which is sent to the referral source, family physician and GLA:D program if applicable. Patients also have access to their health record and can share it with other health care providers.
If there is a 3-month follow-up appointment scheduled, we review what recommendations/treatments helped and what didn’t. We redo parts of the assessment where there were challenges for the patient, for example, muscle weakness, movement limitations, etc. We provide patient feedback then put a modified plan into place to address these challenges and/or offer them to consult with a surgeon if non-surgical management has not been successful.
All of these resources, supports, and coordination of services help to optimize patients’ health, which aligns with what the Quality Standard recommends.
Can you describe if, and how, your practice has changed over the past six months due to the pandemic?
Initial assessments and surgeries were paused, but we continued doing follow-up appointments virtually (either using video teleconferencing or telephone) depending on patients’ preferences. We followed up with resources using email or regular mail. If a patient was not doing well, we’d see them in person as needed depending on what COVID restrictions were in place.
We then started doing virtual initial assessments again back in June. We take a history, review patients’ pain score, their lower extremity function scale, and discuss how they are coping. We’re able to guide patients to do the chair-sit-stand test if deemed safe based on history and if they feel safe to do so. By listening to patient’s descriptions of how they are walking or moving, we can obtain reasonable information about their function even if we may not be able to see them in person. Here’s a great resource on physical performance measures from OARSI.
If the appointment includes a video component, we can see swelling, assess patients’ range of motion, gait and how they rise from a chair. We focus on a patient’s functional ability.
Do you have any advice for primary care providers on delivering care in our new reality?
Patients can be feeling isolated and abandoned during this time and most are quite happy to have any contact and guidance through virtual care. A quick phone call can tell us what the urgent care needs are and how to help patients – for example, if they need to visit the emergency department, come back to the office, or see the surgeon.
Be ready to shift your practice and be flexible on how you conduct assessments. For example, for hip range of motion, you can ask whether a patient can cut their toenails or put socks on. This might give you the information you need to help your patient in lieu of what you have been able to do in the past during in-person visits.
We completed an informal satisfaction survey with 82 patients that had a virtual rather than in-person three-month review following their Rapid Access Clinic visit. Fifty-eight percent of those that responded would choose a virtual visit in the future and 39% were undecided. Interestingly 71% were “completely satisfied” with the recommendations and plan provided and 26% were “quite a bit satisfied.”
What this told us is that you need to ask patients and can’t make assumptions about what they find acceptable or beneficial. In many cases, there’s no reason you can’t provide this service and do a lot of good virtually.
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