Temora Virtual Fracture Clinic: Telehealth for Fracture Follow-up in Murrumbidgee LHD Presented by Duncan McMaster- Physiotherapist
Temora Virtual Fracture Clinic:Telehealth for Fracture Follow-up in Murrumbidgee LHD
Presented by Duncan McMaster- Physiotherapist
Acknowledgements• The traditional custodians of the land in which we live and work, the
Wiradjuri people. We acknowledge the value of culture and beliefs and try to be reflective as we develop health services that positively affect everyone.
• Presentation adapted from Annie Nichols and Ellen McMaster’s previous presentations
• Gloria the patient who kindly agreed to share her story
• Jill Ludford and MLHD Executive for supporting innovation initiative through the Edison Program
• The project team – extensive
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Murrumbidgee Local Health District Temora Virtual Fracture Clinic
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BackgroundTemora is located around a hours drive from WaggaSpecialist Orthopaedic team is located in WaggaWe were successful in getting approval + support to trial the Temora virtual Fracture ClinicWagga specialists telehealth to staff and patient at Temora
Project Overview
• Problem identified• Patient journey was mapped• Idea of the Virtual Fracture clinic in MLHD • Project team identified• Stakeholder map completed• Scope of project identified. • Consultation with stakeholders and planning.• Set up – working with staff at Wagga and at Temora, Telehealth
implementation manager, EMR team, communicate with GP’s.• Implementation commenced (October 2018 – current)• Evaluation
Identifying the problem
• Patient story• Time of travel
• Unsure of where to go
• Difficulty parking
• Lots of traffic
• Long waiting times at Wagga clinic
• Waiting in full waiting room
• Cost to travel
• Burden on family
• Traveling home late in afternoon/ night
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Patient Journey Mapping
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Patient Diagnosis:Acute Fracture [#]
Clinical Care
Does the patient require
Orthopaedic review or
management ?
GP: Clinical Management of
Fracture
Referral to physiotherapy with
specific and appropriate fracture
management instructions
ED Dr/GP contacts WW Orthopaedic Registrar for advice/treatment options
Via 02 59431000
Yes
• Day: Friday• Time: 1230hrs.• Ortho Team to consult and develop
clinical management plan with each patient
• XRAY
Patients not appropriate for referral to Temora VFC • Ortho Assessment required • Out of scope • Need for special equipment
MLHD FRACTURE CLINIC @ WW
No
Murrumbidgee Local Health District Temora Virtual Fracture Clinic
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Data Collection & Review: Wagga Wagga # Clinic Attendances by Home Location 2017/2018 [Fin.year]
Location Presentations
Ardlethan 3
Ariah Park 7
Barmedman 5
Condobolin 4
Cootamundra 16
Harden 10
Lake Cargelligo 26
Murrumburrah 7
Springdale 3
Stockinbingal 2
Temora 16
Trungley Hall 2
Tullibigeal 2
West Wyalong 17
Wombat 4
Wyalong 3
Young 16
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Our Team
• Annie Nichols- Temora Physiotherapist and Project Lead
• Ellen McMaster- MLHD Allied Health Rural Generalist Pathway supervisor
• Duncan McMaster- MLHD Allied Health Rural Generalist Pathway supervisor and Wagga Wagga Base Hospital Orthopaedic Senior Physiotherapist
• Shane Delves- Telehealth Implementation
• Annie Williams- A/Director, MLHD Strategy & Planning
• Orthopaedic Specialist team in Wagga
• Administration staff in Wagga and Temora
Murrumbidgee Local Health District Temora Virtual Fracture Clinic
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Project Scope
In Scope Out of Scope
Simple uncomplicated fractures – referral from Orthopaedic Consultant/registrar
Complicated fractures that may require further intervention
Follow up consultations Initial consultations for fractures
Patients within 80km radius of Temora Pathological fractures/complex patient
To run in conjunction with WWBH fracture clinic
Fractures requiring surgery/ post-op
Patient Diagnosis:Acute Fracture [#]
Murrumbidgee Local Health District Temora Virtual Fracture Clinic [TVFC]
SERVICE:• Align with Wagga
Fracture Clinic times ( Friday 1300-1500hrs)
• Contact with Wagga Ortho team as needed
• Physio coordinated• Nurse• AHA• Ortho team Wagga on
standby via VC (PEXIP platform)
• VMO on call
ED Dr/GP contacts WW Orthopaedic Registrar for advice/treatment options
Via 02 59431000
Clinical Care
ED Dr/GP completes Care Coordinator clinical
assessment and REFERRAL
Does the patient require
Orthopaedic review or
management ?
No
Yes No
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Yes
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GP: Clinical Management of
Fracture
Referral to physiotherapy with
specific and appropriate fracture
management instructions
TEMORA VIRTUAL FRACTURE CLINIC
ROLE:• Plan actioned by Temora
team• ED protocol for clinical
escalation• Cast application• Cast removal• CAM boot or equipment• Gait correction
/assessment/walking aids
• Rehab appointment• Post cast care
Physiotherapy Assessment and
indicated management align with GP
request
Initial Management at WWBH ORTHO WARD/CLINIC/ED
• Plan• X-ray Referral
Liaise with GP or if GP not available, Ortho
team
• Day: Friday• Time: 1230hrs.• Ortho Team to consult and develop
clinical management plan with each patient
• XRAY
Patients not appropriate for referral to Temora VFC • Ortho Assessment required • Out of scope • Need for special equipment
MLHD FRACTURE CLINIC @ WW
Booking toWWBH # Clinic
or TVFC through WWBH Outpatient Clinics
Clarification?
Patient chooses to
attend WWBH
Murrumbidgee Local Health District Temora Virtual Fracture Clinic
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Temora Virtual Fracture Clinic - Official Launch 7th Nov
Murrumbidgee Local Health District Temora Virtual Fracture Clinic
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Data Collection & Review: Temora Virtual Fracture Clinic Attendances by Home Location (From 12th Oct 2018 to Feb 2019)
Location Ortho Consult (Telehealth) Face to face consult
Ariah Park 2 2
Cootamundra 6 6
Temora 1 5
Stockinbingal 1 1
Young 2 2
Boorowa 1 1
West Wyalong 3 3
16 21
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Evaluation – Feedback
• “Quicker, more convenient”• How would you describe your telehealth consultation with the orthopaedic doctor?
“Excellent” • “Less time out of school” • “10/10”• How long after the scheduled appointment time did your appointment actually start?
“Started straight away”
Telehealth: What, where, who, when and why ?
WHAT WHERE WHO HOW WHY WHEN
Laptop, PEXIP + Integrated webcam+ iMEd imaging, + eMR
Wagga Ortho Doctor Usual clinics ExpertFracturemanagement
Clinic day+ email for patient ID
Wagga Physio (facilitates thinking about the VFC)
Usual clinics Assist Doctors with telehealth.Support Temora PT
Clinic day
Wagga Admin Usual clinics Set up Telehealth Booking pt’sthroughout week + Clinic day
Laptop + good webcam + eMR + xray + equipment + persistence & resilience
Temora (patient end)
PatientPhysioAHA(Nurse)(Radiographer)(GP)
VFC Provide a service closer to home when it is neededEg cast off and check xray, refer to physio.
Concurrently with Wagga clinic(Dr access)
Considerations for setting up project
• Case for change- important to selling to executive/ funding/ managers/ specialists
• Scope of practice – doctors aware of physios and telehealth capabilities
• Effective and thorough planning- avoid complications and difficulties which may reduce the chance of success
• Embed change- to increase sustainability
• EMR and processes – how to adapt the tools to fit the needs
• Knowledge and confidence - Staff upskilling and commitment to skill development and resources.
• Communicate with referrers for appropriate patients – including GP’s for scope of the service
• Workforce changes and availability/contingency planning
• Infrastructure: Considered privacy, acoustics, camera/sound, waiting room, consult area located near casting equipment/physio service
• Scheduling –timing with doctors (time to run clinic concurrently with Wagga)
• Scheduling patient/Dr/physio – how will it work? Need coordination even for a small scale.
Lessons Learned so Far….
• Feedback: Integrated camera and microphone on laptop not as good as when using the plug-in Webcam.
• Patients very happy to be part of the pilot and happy with the service. The patient knows the physio and specialist doctor are working together.
• The most important and hardest person to engage was the Orthopaedic specialist. This is an ongoing challenge. Importance to have in-scope and out of scope criteria and clear plans.
• Admin support or AHA support is needed due to clinics booking system/ setting up
• We are still working on identifying suitable patient processes at the Wagga end as the Virtual clinic is not embedded into practice yet – process of change has started but the physio at the remote location is still chasing up the ortho team with the list of potential follow-up patients every week.
Moving forwards
• Sustainability considerations include: • Embed systems/ processes into practice
• Transferability – Young, other
• Minimum staff requirement at rural site = physio (up-skilled in fracture management) AHA, radiographer, nurse availability at clinic time, admin support).
• Minimum staff support required at Ortho team location: Orthopaedic specialist, Registrars, Physiotherapist, NUM, Admin
• ? Option of a Telehealth Coordinator (Qld model) one per district. Coordinates patients/health professionals/room/equipment and scheduling for all telehealth patients so the clinicians can focus on the patient and clinical thought processing.
Questions ??
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