MSK Train the Trainer 1
Arthritis and Low Back Pain
Wireless: Westin-Meeting
Code: bcma2013
Westin Wall Centre
April 4-5, 2013
www.pspbc.ca
Welcome and Introductions
Dr. Diane Lacaille
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Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
- Grants/Research Support: PharmaCorp ABC
- Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
- Consulting Fees: MedX Group Inc.
- Other: Employee of XYZ Hospital Group
3
Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
- [Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
- [Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
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Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
5
Certification
 Up to 21 Mainpro+ Certified credits for GPs awarded upon
completion of:
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› At least 1 Action Period
› The Post-Activity Reflective Questionnaire (2 months after LS3)
 Up to 10.5 Section 1 credits for Specialists
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› The Post-Activity Reflective Questionnaire (2 months after LS3)
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Update/revise
Action Plan
Report of AP1
experiences &
successes
Payment for:
PMV (optional)
LS1
Action Period 1
7
Refine
implementation;
embed & sustain
improvements
attempted in
practice via
Action Plan +
AP2
requirements
Interactive
group learning
Finalize Action
Plan
Report of AP2
experiences &
successes
Payment for:
LS2
Action Period 2
LS3
Reflection
Interactive
group learning
Learning Session 3
Create Action
Plan (using
template)
Planning & initial
implementation
in practice;
review of Action
Plan &
improvements
attempted in
practice + AP1
requirements
Action Period 2
Interactive
group learning
Learning Session 2
Opportunity
for in-practice
visit to
introduce
applicable
EMR-enabled
tools &
templates prior
to LS1
Action Period 1
Learning Session 1
Pre-Module Visit
Learning Session & Action Period Workflow
Reinforce &
validate practice
improvements
GPs & Specialists
complete PostActivity
Reflective
Questionnaire
(PARQ) 2 months
after LS3 &
submit to PSP
Central
Payment Stream 1 (ideal)
Current Rates:
GPs
Specialists
MOAs
Hourly Rate
$125.73
$148.31
$20.00
Action Period 1
$880.10
$1,038.16
N/A
Action Period 2
$660.07
$778.62
N/A
Payment made after attending LS2
Payment made after attending LS3
GPs:
GPs:
PMV
= $125.73
LS2
= $440.05 ($125.73 x 3.5hrs max.)
LS1
= $440.05 ($125.73 x 3.5hrs max.)
AP2
= $660.08
AP1
= $880.10
LS3
= $440.05 ($125.73 x 3.5hrs max.)
TOTAL
$1,445.88
TOTAL
Specialists
Specialists
LS1
= $519.08 ($148.31 x 3.5hrs max.)
LS2
= $519.08 ($148.31 x 3.5hrs max.)
AP1
= $1,038.16
AP2
= $778.62
$1,557.24
LS3
= $519.08 ($148.31 x 3.5hrs max.)
TOTAL
TOTAL
MOAs
$1,816.78
MOAs
PMV
= $20.00
LS1
= $80.00 ($20.00 x 4hrs max.)
LS2
= $80.00 ($20.00 x 4hrs max.)
$100.00
LS3
= $80.00 ($20.00 x 4hrs max.)
TOTAL
TOTAL
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$1,540.18
$160.00
Faculty Introductions
 Our patients: Megan and Mary Beth
 Teaching faculty
› Arthritis: Diane Lacaille, Lori Tucker,
› Low back pain: Julia Alleyne, Brenda Lau
› Family practice: Bruce Hobson
› Patient self-management: Connie Davis
› Workshop and panelist faculty
 Moderator: Diane Lacaille, Garey Mazowita
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Housekeeping
 USB Keys
 Handouts
 Internet: Wireless: Westin-Meeting
Code: bcma2013
 Cell Phones, Bathrooms
 Breaks
 Credits
 Parking
 Mikes
 Evaluation
 Physician Reimbursement Form
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Ice Breaker
 What hat are you wearing?
 How does it fit?!
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Clicker Time
 Multiple choice questions
 Student response system
technology
 Audience answers
 Data filed
 Pre-post day comparison
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What hat are you wearing?
1. Family Physician
2. Specialist Physician
3. Medical Office Assistant
4. Rehabilitation Professional
5. PSP Coordinator/Manager
6. Administrator
7. Clinical Faculty
8. Patient
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Which area do you work in?
1. Vancouver Coastal Health Authority
2. Vancouver Island Health Authority
3. Northern Health Authority
4. Interior Health Authority
5. Fraser Health Authority
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What are the four pillars of osteoarthritis treatment?
Choose one
1. Rehab & exercise, weight management, pain management,
patient self-management
2. Exercise, pain management, imaging and investigations, patient
self-management
3. Rehabilitation, disability management, pain management,
patient self-management
4. Weight management, pain management, patient education,
early surgical referral
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Which key clinical features are NOT suggestive of
Inflammatory Arthritis?
1. Morning stiffness greater than 30 minutes
2. Bony enlargement
3. Synovial thickening
4. Joint involvement of hands and feet
5. Pain increased with rest or immobility
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In which of the following situations would joint
aspiration be clinically useful?
1. Acute joint swelling to rule out septic arthritis
2. Acute joint swelling to detect presence of crystals
3. To differentiate inflammatory from non-inflammatory causes of joint
swelling
4. To relieve pressure of moderate joint hemarthrosis
5. To improve joint mobility and function
6. 1,2 and 3
7. 1,2 and 4
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What is best practice for the management of
Rheumatoid Arthritis?
1. Early initiation of prednisone medication
2. Prioritizing depression as a common co-morbidity
3. Early initiation of non-biological disease modifying antirheumatic drugs (dmard”s) to reduce joint damage
4. Referral to a rheumatologist prior to medication initiation
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Program Orientation
Dr. Diane Lacaille
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Rheumatoid Arthritis and Osteoarthritis
 Patient’s journey
 Gap analysis
 Evidence-informed practice guidelines
 Juvenile idiopathic arthritis
 Clinical tools
 Application to practice with video
 Shared care panel
 Practice implementation
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Why are we here?
 To discuss a comprehensive approach to improve FP care and
supports for patients living with RA, OA and LBP demonstrated by:
› A reduction in pain
› An increase (or reduced decline) in patient functioning
› Informed and activated patients managing their condition to the best
of their abilities
› Specialist support and consultation, when needed, is available in a
timely manner
 To review selected tools and provide an overview of how to access
additional tools / information through either electronic or hard copy
toolkits
 To have a plan for the action period
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Foundation of Work
 MSK Project Charter: Scope of Work, Deliverables, Inclusions &
Exclusions)
 Needs / Gaps / Barriers to Care informed by:
 Incidence /prevalence of disease in BC
 Arthritis Service Framework (2008)
 Small survey of FPs
 Input from experts / working groups
 Review of relevant literature
 Experience of other jurisdictions
 Framed around evidence-based best practices:
 GPAC Guidelines (BC) for OA and RA
 Alberta, New Zealand, UK Guidelines for LBP
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Physician Issues / Considerations
 Paper-based vs. EMR office set ups
 Alignment with currently used or planned tools
 Office time constraints / workflow
 Pattern recognition vs. algorithmic care
 Recognition that management may precede diagnosis
 Access to specialists and rehab experts
 Awareness of education and community resources
 Role of physician in dialogue / discussion of PSM
 Time implications / alignment with physician fee schedule
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Areas of Focus - In the FP Office
 Practical & simple point of care tools / checklists
 Screening tools for early identification of inflammatory arthritis
 Red and yellow flags and criteria for expedited referral
 Supports for dealing with complex and chronic pain
 Tools for responding to psychosocial needs of patients
 Tools for Joint Action Planning
 Awareness of programs, services, resources available
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Areas of Focus – For Specialist / Community
Support
 Access to specialists for quick advice (RACE telephone service)
 Criteria for appropriate referrals / consults
 Meaningful consult letters that support the FP in ongoing care for
patients
 Building the network of relationships at local / community level
 Awareness of Provincial, regional and local programs and
resources for patients and care givers
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Patient Issues / Considerations
 Management of co-morbidities and related issues
 Readiness for self-management responsibilities
 Alignment with currently used or planned PSM tools
 Keeping tools comprehensive yet useable
 Tools in a format that address issues of health literacy, ethnic diversity
 Desire for hard-copy, printed materials to take away from visit
 Awareness of and access to education programs
and community resources
 Use of patient health record
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Physician & Patient Engagement in Content
Development
 FP survey
 Cross-section of stakeholders on steering committee and working
groups
 Webinars and telephone consults
 FP trial / test of OA, RA, LBP “point of care” tools
 Focus groups
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Acknowledgements
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Shared Care Committee (SCC)
General Practice Services Committee (GPSC)
Specialist Services Committee (SSC)
The Ministry of Health (Primary Care Division)
The Arthritis Society
Mary Pack
OASIS Program
Patient Voices Network
Individual Physicians, Clinical Specialists, Patients
Charter
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Patient Journey
Ms. Meghan Smaha
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Gap Analysis:
Why is MSK a tough nut to crack?
Dr. Garey Mazowita
35
Objective
To be able to describe the common barriers that
physicians, patients and the health care system are
challenged by with MSK conditions (RA, OA, JIA,
LBP)
36
Primary Care Provider Barriers
 Dealing with complex and chronic LBP
 Delayed RA diagnosis
 No “expectant” self-management strategies/resources for OA
 Patient expectations for MRI & referrals
 Psychosocial patient needs
 Lack of patient educational resources
 Lack of tools in guideline recommendations
 Defining work-related restrictions
 Rational use of therapeutic options including opioids
37
Patient Barriers
 Understanding of investigative and referral rationale
 Funding for physiotherapy
 Lack of Self-management strategies
 Medication focus
 Work-related concerns
 Minimal or missing “functional” focus
 Mixed provider/media messages
 Access to medical appointments
 “Can’t do anything about arthritis” attitude
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System Barriers
 Poor communication between providers
 Lack of coordinated patient education material
 Lack of validated Web resources
 Non-standardized care pathways
 Who is the “right” specialist?
 Access to specialists
 Access to Allied Health
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Common Practice Knowledge
Don't know
Specific guidelines
Exercise prescription
Specific rehabilitation
Differential diagnosis
Ordering of imaging
Work restrictions
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Know





Red flags
Medications
No bed rest
Referral to physiotherapy
Association of depression
Module Goals for RA
 Build on the foundation of GPAC Guideline
 Tools supporting early identification of RA & screens for red flags
 Provide guidance about appropriate prevention, assessment &
intervention strategies for RA
 Ability to initiate strategy for medical stabilization +/- referral criteria to
Rheumatology
 Engage patients in goal-setting and support patients in self-care
responsibilities
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RA Content
 Screen for RA to mitigate delays in treatment
 Key Features of Inflammation suggesting RA
 Laboratory Investigations
 Differential Diagnosis and key conditions to rule out before starting +/referring for DMARDs
 RA-related examination, management, follow-up and patient selfmanagement considerations
 Tools for assessing disease activity and treatment targets
 Criteria for referral to a Rheumatologist
 Guidelines for management of co-morbidities
 Multi-disciplinary care for RA; allied health access and utility
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RA Content
 Utility / value of clinical tools and checklists at point of care
 Decision support tools for patients regarding medication options
and lifestyle management
 Screening for patient depression and self-management issues
 Points for discussion with patients
 Organization of provincial rheumatology services for
expedited access
 Promotion of best practices
43
Goals for the JIA MSK Module
 Improve the early recognition of juvenile arthritis
 Provide clinicians with tools to assist in the diagnosis of MSK
complaints in children
 Suggest pathways for referral of children with MSK
complaints when needed, and increase awareness among
GPs of accessibility of care for children and teens with
arthritis in BC
44
Module Goals for OA
 Build on the foundation of GPAC Guideline and Tools
 Address gaps/barriers to care from Arthritis Service Framework
(2008)
 Include criteria for making an accurate diagnosis with functional
assessment
 Optimize pain and function through education, rehab,
medication and referrals (as required)
 Emphasize physician-supported pro-active patient self
management, not passive acceptance
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OA Content
 Office efficiency / workflow alignment
 Relevant examination skills
 Pattern recognition and algorithmic care
 Address patient expectations re joint deterioration and joint
replacement
 Deal with psychosocial needs of patient
 Make coordinated patient education materials &
awareness of resources available
46
OA Content
 Electronic toolkit & education materials – to add value & enhance
working relationships
 Provincial alignment/fit
 Evidence-based best practices
 Early common pathway - red flags first
 Management can precede diagnosis
 Patient ownership & PSM
 Address occupational issues
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OA Content
 Patient questionnaires
 Electronic tools that fit with office work flow
 Consistency in approach between provider assessment and
treatment
 Coordinated system for access to specialists and rehab expertise
 Alignment with physician fee schedule
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Module Goals for LBP
 Patient engagement: a therapeutic relationship
 Strategies for both acute and chronic
 Dealing with burden of suffering
 Dealing with patient expectations
 Best practice management
 Involving other health care practitioners
 Resources
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LBP Content
 Identifying specific etiology
 Dual management – cause + pain
 Dealing with expectations for investigations and referrals
 Identifying psychosocial needs of patients
 Address co-morbidities of mood, sleep, function, adverse drug
effects
 Accessing coordinated patient educational resources
 Negotiating work related restrictions
 Role of medication (including opioid management)
 Identification of responsibility for ongoing care
50
LBP Content
 Initial screening for pain and pain-related disability or limited
function
 Built-in reminders to reassess pain, function, adverse effects over
time with embedded pain management guidelines
 RACE telephone hotline and mentor-mentee networks to
support GP linkage to pain specialists
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Patient Self Management
Action Planning
Define self-management,
self-management support,
and self-efficacy
Describe what is known about
assessing confidence and the
effect on patient behavior and
health
52
Patient Passport
 Effective patient tool
 Applicable in multiple conditions
as it is based in the value of
health and lifestyle
 Patient passport tool for
individuals managing long-term
chronic conditions like RA and
OA
Right Care
Right Time
Right Way
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