7/02/2015

Community physiotherapy +
working in teams
OPPORTUNITIES FOR
PHYSIOTHERAPISTS
Loretta Andersen

http://www.forbes.com/sites/theyec/2012/12/12/can-working-in-teams-build-your-intelligence/

Explore

Thinking about where CDM is best delivered

Who are CDM team members.
What role does physiotherapy have in CDM.
What opportunities exist for
physiotherapists
working in CDM teams
ExampleOsteoarthritis chronic Care Program
(OACCP)

Learning Outcomes
2. Justify the role of PT in the prevention +/or
management of chronic illness or disease
3. Critically reflect on the contributions of an
interdisciplinary team
4. Research + determine a client-centred
approach in the design of a physiotherapy
management plan for the management of CD

7/02/2015

Explore

Thinking about where CDM is best delivered

QUIZ
ACUTE HEALTH CARE

CHRONIC HEALTH CARE

Diabetes

Specialist care

emotional

Adhere to treatment

Chronic Care
Monitor
Manage impact
CVD
Self
management

PATIENT
& Carers

Respiratory
Education

Primary Care

Weight control

Physical Activity

MSK

cancer

functional

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Levels of
health care in
CD

Level 1
High complexity

Level 2
High Risk
Disease management

Level 3
Self-management

70-80%

Where can CDM be provided

GP surgeries
Homes
Workplaces
Schools / Playgrounds
Social + Sport clubs + Youth Centres
Outpatient clinics
Specialist program venues
Hospitals

OPPORTUNITIES
CHALLENGE EXISTING PHILOSOPHIES of
PRACTICE + DELIVERY

7/02/2015

Explore

Who are CDM team members.

Individual with
Chronic Disease

diabetes

cardiac
CVD

Medical

Nursing

arthritis
MSK

Dietician

respiratory

Physio
Ex. Phys.

cancer

Occupat.
Th

cognitive/
emotional

Psych
Social W.

Ms. M
54 year old lady, advanced hip OA, smoker
Married with 2 x children: Ages 8 and 14
(aspergers)
Husband. Works FT. Ms. M reports little empathy
Carer for in-laws both with dementia (live in own
home + declining provided package of care)
Works part time as cook in ACF
Awaits left total hip replacement. Requires crutches x
2 to ambulate secondary to extreme pain
Difficulties driving due to pain
MHx: HT, tingling in both feet past 3/12 + 1 x recent
fall, recent weight gain 5kg.

7/02/2015

Who might you want /need on your

team and why..

OPPORTUNITIES
CHALLENGE EXISTING PHILOSOPHIES of
PRACTICE + DELIVERY

BROADEN + BUILD TIES WITH TEAMS

COMMUNITY SUPPORT + PROVIDERS

Explore

What role does physiotherapy have in CDM.

7/02/2015

Ms. M
54 year old lady, advanced hip OA, smoker
Married with 2 x children: Ages 8 and 14
(aspergers)
Husband. Works FT. Miss M reports little empathy
Carer for in-laws both with dementia (live in own
home + declining provided package of care)
Works part time as cook in ACF
Awaits left total hip replacement. Requires crutches x
2 to ambulate secondary to extreme pain
Difficulties driving due to pain
MHx: HT, tingling in both feet past 3/12 + 1 x recent
fall, recent weight gain 5kg.

What questions need to be

clarified ?
Medical History, meds + CD Managet
plans
Social situation + responsibilities
Function + Mobility + exercise/ activity levels
Support networks (services)
Emotional wellbeing / support/ needs
Priorities / goals
Values/ beliefs/ barriers/ facilitators

Physiotherapy roles

broad based needs assessment / screening

treatment / advice (professional boundaries)
Referral / interdisciplinary approaches
Build personal capacity
health-coaching (goal setting)
harm-minimisation
health promotion
Assisted navigation service delivery systems

7/02/2015

Where can I get more information?

OPPORTUNITIES
CHALLENGE EXISTING PHILOSOPHIES of
PRACTICE + DELIVERY
BROADEN + BUILD TIES WITH TEAM
COMMUNITY SUPPORT + PROVIDERS
EXTEND TRADITIONAL ASSESSMENT +
TREATMENT ROLES, SKILLS +
KNOWLEDGE

Explore

Where CDM is best deliverer

Who are CDM team members
What role does physiotherapy have in CDM
What opportunities exist for physiotherapists
working in CDM teams

7/02/2015

Tsunami of chronic disease

By 2020 of all deaths will be

from chronic disease
WHO

78% with arthritis report having at least one other chronic disease

Managing Arthritis with the

OSTEOARTHRITIS CHRONIC
CARE PROGRAM
http://www.aci.health.nsw.gov.au/models-of-care/osteoarthritis-chroniccare-program

Background
Unsustainable increase in personal, societal +
health care costs (ageing, obesity and injury)
Increasing burden
( OA leading cause of disability among older Australians)

International/National/State = ACTION

7/02/2015

EVIDENCE:
Zhang et al 2010, OARSI recommendations for the management of hip and knee osteoarthritis Part III: changes in evidence following systematic cumulative
update of research published through January 2009, Osteoarthritis and Cartilage, vol, 18, no. 4, pp. 476-499.
Hochberb et al , 2012, American college of Rheumatology 2012 recommendations for the use of Non- pharmacologic and Pharmacologic
Therapies in Osteoarthritis of the hand, Hip and Knee, Arthritis care & Research, vol. 64, no. 4, pp. 465-474.
EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis, 2013, Ann Rheum Dis, vol. 72, pp. 1125-1135

Exercise (aerobic + resistance): land or water

Injury avoidance
Weight control
Pharmacologic treatment
Timely access to surgery
Psychosocial

safe and cost effective TREATMENT

Osteoarthritis chronic care program

OACCP

Point of access
Conversation
Interdisciplinary
Co-ordinated
Conservative
Responsive

OACCP aims:

Manage symptoms
Optimise function / QOL
Limitation disease progression
Screen/ Identify co-morbidity risk
Maximise self-management
Dispel myths about OA
Effective health care utilisation

7/02/2015

Target areas

Arthritis education
Healthy weight control
Physical exercise/activity
Harm minimisation
Co-morbidity risk identification/management
Emotional well-being
Pharmacologic control

Levels of
health care in
CD

Level 1
High complexity

Level 2
High Risk
Disease management

Level 3
Self-management

70-80%

Chronic Disease Management:

Builds personal capacity by:
building confidence
increasing knowledge
identify needs + preferences
translates needs + preferences into realistic
and relevant goals
Supports navigation and access to systems +
resources
Raising self-efficacy

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7/02/2015

PHILOSOPHY
Access to safe, effective and timely care
Participants are expert opportunity
Health practitioners are facilitators
advise support guide
Self-management is key
you have + are the solution
Window of opportunity

What CAN I do ??
Unalterable

Age
Gender
Race
Genetics

Modifiable

Body Weight
Diet
Muscle Weakness
Injury
Mechanical load
Control of other
chronic disease

Timeline:

Family
Doctor

Surgeon =
Ortho waiting
list for joint
replacement

Surgery

11

7/02/2015

Timeline:
Medication

Family
Doctor

Surgeon =
Ortho waiting
list for joint
replacement

Surgery

Timeline:

Family
Doctor

Surgeon =
Ortho waiting
list for joint
replacement

Surgery

Walking aids

Timeline:
Healthy Eating /
Weight Control

Family
Doctor

Surgeon =
Ortho waiting
list for joint
replacement

Surgery

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7/02/2015

Timeline:

Family
Doctor

Surgeon =
Ortho waiting
list for joint
replacement

Surgery

Negative Emotions

Timeline:
Exercise

Family
Doctor

Surgeon =
Ortho waiting
list for joint
replacement

Surgery

Timeline:

Family
Doctor

Surgeon =
Ortho waiting
list for joint
replacement

Surgery

Other
Conditions

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7/02/2015

Timeline:
Medication

Healthy Eating /
Weight Control

Exercise

Family
Doctor

Surgeon =
Ortho waiting
list for joint
replacement

Surgery

Negative Emotions
Walking aids

Other
Conditions

Learning
CHALLENGE EXISTING PHILOSOPHIES
of PRACTICE + DELIVERY
Shared decision-making
Building personal capacity
Thinking outside the box
Work in teams of partnership

EXTEND TRADITIONAL
ASSESSMENT + TREATMENT
ROLES, SKILLS + KNOWLEDGE
Broad based needs based assessment
Dual expert role
Goal orientated evidence based treatment
Recognition of professional boundaries + limits
Communication quality and content
Explore wide + varied learning opportunities

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7/02/2015

BROADEN + BUILD TIES WITH

TEAM COMMUNITY SUPPORT +
PROVIDERS
Identify and nurture key partnerships
Refer appropriately + timely
Think more broadly than health for
partnerships
Be familiar with support networks + local
champions
Advocate

Learning Outcomes
2. Justify the role of PT in the prevention +/or
management of chronic illness or disease
3. Critically reflect on the contributions of a
interdisciplinary team
4. Research a client-centred approach in the
design of a physiotherapy management plan
for the management of CD

The bottom line

Not rocket science
Complex + Challenging
Dual expert role
Extend self as practitioner
Highly Rewarding
Community based:
anywhere and anytime
Wont have all the answers
Building personal capacity
Foster partnerships of care
Have fun

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7/02/2015

References:
1. Australian government: Department of Health and Ageing, National Physical
Activity Guidelines, accessed September 10th 2011,
http://www.health.gov.au/internet/main/publishing.nsf/Content/healthpubhlth-strateg-phys-act-guidelines#rec older
2. Depression Anxiety Stress Scale (DASS (21)
viewed: 26th January 2013
http://www2.psy.unsw.edu.au/groups/dass//
3. Euro Quality of life (EQ-5D-5L)
viewed 26th January 2013
http://www.euroquol.org/
4. Hip and Knee disability and osteoarthritis outcome score (HOOS)
viewed 26th January 2013
http://koos.nu/index.html
5. Levels in healthcare
viewed 26th January 2013
http://www.health.gov.au/internet/main/publishing.nsf/content/7E7E9140A3D3A3BCCA257140007AB32B/$File/stratal3.pdf
6. National Health Priority Action Council (NHPAC) 2006, National Chronic Disease Strategy
viewed 15th March 2010,
http://www.health.gov.au/internet/main/publishing.nsf/Content/7E7E9140A3D3A3BCCA257140007AB32B/$File/stratal3.pdf

References:
7.

NSW Chronic Care Program: rehabilitation for chronic disease volume 1.& 2, (2006), NSW Department of Health: North
Sydney

8.

Osteoarthritis Chronic care Program

Viewed 17th September 2012
http://www.aci.health.nsw.gov.au/models-of-care/osteoarthritis-chronic-care-program

9.

Taylor, Foster & Fleming, 2008, Health care Practice in Australia, Oxford University Press, Oxford, UK

10. The Dreaded Stairs

Viewed 26th January 2013,
http://www.youtube.com/watch?v=Qx_8gxh76iM
11. Zhang, W, Moskowitz, R, Nuki, G, Abramson, S, Altman, R, Arden, N, Bierma-Zeinstra, S, Brandt, K,Croft, P, Doherty, M,
Dougados, M, Hochberg, M, Hunter, D, Kwoh, K, Lohmander, S & Tugwell, P 2008, OARSI recommendations for the
management of hip and knee osteoarthritis, Part 2: OARSI evidence-based, expert consensus guidelines, Osteoarthritis and
Cartilage, vol. 16, pp. 137-162
12. Zhang, W., Nuki, G., Moskowitz, r.W., Abramson, S., Altman, r.D., Arden, N.k., Bierma-Zeinstra, S., Brandt, k.D., Croft, P.,
Doherty, M., Dougados, M., Hochberg, M., Hunter, D.J., kwoh, k., Lohmander, L.S. and Tugwell, P. (2010), OArSI
recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic
cumulative update of research published through January 2009. Osteoarthritis and Cartilage. 18(4):
p. 476-499

Screening tools:
1.
2.
3.
4.
5.

DASS(21)
Mini mental state examination (MMSE)
Timed up and Go (TUG)
Mini nutritional Assessment (MNA)
Opioid risk tool (ORT)

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