Team Management of Patients

1. Team Management of Patients Janet Pope MD MPH FRCPC

2. Objectives • To determine how patient care is enhanced with a team approach and which patients would benefit from a team approach • To be comfortable with the resources available in your area for team care • To understand what patients may be co-managed with rheumatology

3. 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

4. There are Regional Barriers to Best Practices In Ontario Thus we need co-management

5. 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%

6. Facts • Targeting outcomes makes better disease control • Similar to • HTN • DM • Lipids • Thus we need novel ways to care for our area

7. 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

8. 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

9. 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?

10. 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

11. 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?

12. Treatment • Usual medications • Analgesics (NSAIDs, pregabalin, narcotics, etc) • Physiotherapy • Pain management (in an ideal world) is multi-disciplinary • 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)

13. Discussion • What resources have you got available in your community to help co-manage chronic back pain?

14. 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?

15. Case 2 • She likely has RA • What would you do?

16. 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

17. 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.

18. 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

19. 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?

21. RA patients need a rheumatologist for appropriate care

22. 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

23. Case 3 • What is the most likely diagnosis? • What can you do to manage her?

24. Case 3 • Fibromyalgia • Education • Exercise • Amitryptylline,Gabapentin / Pregabalin, Duloxetine • Who can you refer her to?

25. 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

26. Teams • Multidisciplinary care in chronic disease results in better outcomes • Multidisciplinary Inflammatory Arthritis Education Day

27. 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

28. 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.

29. 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

30. Two to Four Week Programs • We have programs that are evidence based for improving self management in • OA • RA • SLE • Scleroderma • Seronegative arthritis • Fibromyalgia

32. 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

33. Pain Diagrams used on a Referral Tool

35. 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

36. 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

37. Questions, Discussion