Achilles tendinopathy is a common pathology that is considered difficult to treat. At a time of austerity in the NHS it is essential to have carefully designed pathways that are monitored in terms of cost and effectiveness. However, a paucity of evidence exists for what the “best value” dedicated “joined up” pathway of care is for this difficult condition. Design, implement and evaluate the impact of a new therapist lead pathway for Tendon- Achilles Pain (TAP).
Demand, capacity and flow
A specialist fitness for work service: Advanced practice physiotherapist working as a first point of contact practitioner
An advanced practice occupational health physiotherapist introduced a new fitness-for-work service to manage clients with work- related or impacting musculoskeletal disorders. The purpose was to shorten waiting times for clients to access specialist physiotherapy, reduce the number of referrals to GPs, OHPs and OHAs and secondary care, reduce sickness absence and improve productivity, and maintain excellent service user satisfaction.
Priming elderly patients for surgery - the development of a pre-operative service for frail elderly patients
The Peri-operative Review Informing Management of the Elderly (PRIME) Clinic was developed in response to the increasingly frail population undergoing complex major surgery. Due to this, it was recognised that clinicians with advanced skills were required to manage and optimise this patient group pre-operatively, which led to the formation of a multi-disciplinary team consisting of consultant geriatricians, consultant anaesthetists, a senior physiotherapist and a senior occupational therapist. The aim of the team was to optimise patients from a medical, physical and social viewpoint.
The focus of physiotherapy input was to increase physical activity pre-operatively, improve respiratory function and identify falls risks in order to contribute to a reduction in post -op length of stay and improve patient function.
This service evaluation demonstrates the benefit of a highly specialised MDT model with frail elderly elective surgery patients.
The purpose of this project was to demonstrate the positive impact an Independent Prescriber Physiotherapist could have on the service delivery in outpatient spasticity clinics. The project aimed to demonstrate reduced patient waiting times for review appointments, reduced cost per appointment and demonstrate high patient satisfaction. The overdue waiting period for spasticity reviews is a long standing problem for the spasticity service and on the Trust risk register. Historically spasticity clinics were managed in multidisciplinary team (MDT) clinics involving a Consultant and a Physiotherapist. A proposal was put forward to the team and agreed. This proposal was for a single Physiotherapist Independent Prescriber, with experience in management of spasticity and neuropathic pain, to set-up a pilot period of Independent Physiotherapy led spasticity review clinics.
Recognising that there is limited funding for “doing more of the same” we looked at how we could increase our cardiac rehabilitation capacity by broadening our scope and expertise to encompass a range of long term conditions that cause a high impact on unscheduled care. We acknowledged that multi-morbidity is becoming increasingly prevalent.
We subsequently developed The Healthy and Active Rehabilitation Programme (HARP) and opened up referrals to include people affected by stroke, cancer, COPD, falls, diabetes, and other long-term conditions. HARP enabled us to widen our rehabilitation capacity to include cardiac groups which are typically excluded due to resource limitations: angina, arrhythmias and devices. We designed a programme that would embrace activity, self management and support lifestyle change, across all of these groups.
Thus, the overall aim of this project was to proactively support prevention and self-management in an ageing population with increasing prevalence of chronic multiple morbidities. To help reduce health inequality the project has specifically targeted deprived and rural communities.
- To develop an evidence base for multimorbidity rehabilitation that would support a new way of working
- To prove that this new model was sustainable
The number of thoracic surgical procedures performed in the United Kingdom continues to increase annually putting pressure on thoracic surgical bed capacity. Reducing hospital length of stay (LOS) following thoracic surgery can help to reduce pressure on hospital beds. The purpose of this service evaluation is to explore hospital and physiotherapy LOS for individuals following thoracic surgery at our hospital and identify whether any factors influence hospital and Physiotherapy LOS. The findings could potentially allow the identification of individuals at risk of longer LOS and help direct physiotherapy rehabilitation provision to these individuals.
A single point of referral was implemented in partnership between Allied Health Professionals Suffolk (AHPS) and Norfolk Community Health and Care (NCHC) forming the Integrated Therapy Partnership (ITP). This aimed to standardise the care pathways for musculoskeletal conditions and ensure primary care referrals are processed to the correct provider first time around. This should avoid unnecessary secondary care referrals, where patients are seen in secondary care, receive no treatment and are referred back to community providers. Referrals are triaged by senior physiotherapists. Similar models have been suggested as effective methods of service delivery by the British Orthopaedic Association (Lennox & Karstad, 2013). This was coupled with the implementation of online self-referral for physiotherapy and occupational therapy, where patients were issued advice and exercise within 24 hours. Advice and exercise are issued for patients triaged for physiotherapy through the single point of referral. AHPs are responsible all patient administrative tasks and provide the triaging clinicians. NCHC provide clinical physiotherapy, occupational therapy and orthopaedic triage services. This is contracted to the Norwich and South Norfolk Clinical Commissioning Group and they set key performance indicators for patients being seen. Routine patients to be seen in 28 working days, urgent patients to be seen in 7 days and orthopaedic triage patients to be seen in 14 working days.
To evaluate whether service improvements could be made to our community physiotherapy service through clinical streaming of patient referrals using underlying principles complexity science to consistently deploy the most appropriate member of the physiotherapy team to meet the needs of patients and improve the effectiveness of our service.
An audit on length of stay (LOS) for total knee replacement (TKR) patients following surgery highlighted that a number of patients were exceeding their predicted date of discharge (PDD), many due to not achieving traditional physiotherapy goals (90⁰ flexion, < 5 ° extension lack and good quadriceps function), despite being safely mobile and medically fit. This exposes patients to risk of harm due to prolonged stay within an acute hospital environment as well as inefficient utilisation of an in-patient bed. A Physiotherapy Supported Discharge Service (PSDS) had previously been piloted for six months. Phase 2 consisted of permanent service resign, continuing the PSDS and service evaluation.
Historically, provision of MSK Ultrasound diagnostics has been via a referral to Radiology. However, there is increasing evidence that assessment, investigation and initiating treatment at the initial appointment is shown to be cost-effective, increasing patient satisfaction. Utilising this approach also reduces repeated hospital visits for further diagnostics and appointment times for results. The aim of using Point of Care (POC) ultrasound is to enhance the patient experience through instant access to diagnosis, timely implementation of most appropriate clinical pathway and achievement of the optimal outcome in the shortest possible time.
This study aims to investigate the benefits of point of care (POC) and schedule ultrasound clinics using a proof of concepts approach in the orthopaedic setting.