Back Pain

Hundreds of patients have been removed from the Neurosurgery and Orthopaedic Spinal Surgery outpatient waiting lists. Initial funding for this pilot was provided by Department of Health and Human Services (DHHS). The success of this pilot has enabled the Back Pain Assessment Clinic (BAC) to be awarded a further grant from DHHS to mentor other hospitals to implement similar projects. The team were awarded a Victorian Public Healthcare Award (2016) for ‘Excellence in providing alternative care paths’.

A collaborative model for improving the management of back pain and related disorders within the community was identified as a shared priority for our organisations as:

Low back pain is the most prevalent musculoskeletal condition in Australia, with four out of five Australians experiencing an episode in their lifetime
Low back pain places considerable demand on specialist surgical outpatient clinics, which may not be the most appropriate referral choice. Evidence based care for the majority of back pain cases indicates that there is a limited role for surgery and that this condition is best managed early in the community
Current models of care are not serving our community well. Better communication and timely care of patients with low back pain requires improved and more responsive models of care and workforce redesign.

The Royal Melbourne hospital and Merri Health Services were successful recipients of the Department of Health and Human Service (DHHS) Victoria Workforce Innovation Grants which facilitated development and implementation of community based specialist assessment clinics and an advanced practice physiotherapy management clinic.

The collaborative model for improving the management of back pain and related disorders within the community predominantly consists of Back pain Assessment Clinics (BAC) directed by The Royal Melbourne hospital and back pain management clinics conducted by Merri Health and cohealth.

The model shifts the locus of care for back pain from tertiary services to the community, reduces reliance on already overstretched hospital services, prevents unnecessary incoming referrals and promotes best practice care for patients. In addition, the model more appropriately utilises current tertiary and primary care physiotherapy and rheumatology workforces to manage suitable patients with back pain instead of surgical specialists.

Based on the success of the collaborative model, The Royal Melbourne Hospital and Merri Health have been successful in another DHHS workforce innovation grant to mentor and replicate the model to three other health services in Victoria in 2016.

Key achievements from the pilot project include:

MH removing all ‘in-catchment ’waitlist clients (n=522)
MH improving access to timely, expert clinical assessment and management. The mean time from referral to first review in BAC for new patient referrals was 9.8 weeks. Patients seen in BAC who were already on the waiting list for an appointment in neurosurgery clinic had been waiting a mean of 101 weeks, and the orthopaedic patients had been waiting for a mean of 71 weeks.
MH reducing the imaging costs with the BAC model (6.3% as compared to 90% of this patient cohort that normally have an MRI)
Demonstrated improved outcomes in patient function
Optimisation of the use of surgeon, rheumatologist and advanced practice physiotherapist skills resulting in improved job satisfaction, staff morale and retention and workforce sustainability
The Royal Melbourne hospital removing all ‘in-catchment ’waitlist clients (n=522)
The Royal Melbourne hospital improving access to timely, expert clinical assessment and management. The mean time from referral to first review in BAC for new patient referrals was 9.8 weeks. Patients seen in BAC who were already on the waiting list for an appointment in neurosurgery clinic had been waiting a mean of 101 weeks, and the orthopaedic patients had been waiting for a mean of 71 weeks.

MCHS offering new clinical services offered including a Grade 3 Musculoskeletal Physiotherapist led back pain management clinic and a multidisciplinary modified Pain Management Program
Successful credentialing of the MCHS Grade 3 physiotherapist and a subsequent honorary physiotherapist position at MH
Increasing the capability of the MCHS workforce to provide management to more complex clients (with > 70% experiencing moderate to severe levels of pain, and >60% experiencing moderate to severe levels of disability or stress)
Development of a localised Melbourne HealthPathway on “Low Back Pain in Adults’
The Royal Melbourne hospital reducing the imaging costs with the BAC model (6.3% as compared to 90% of this patient cohort that normally have an MRI)
Demonstrated improved outcomes in patient function
Optimisation of the use of surgeon, rheumatologist and advanced practice physiotherapist skills resulting in improved job satisfaction, staff
Merri Health have added additional Advanced Practice Social worker to provide psychosocial support to clients.

This collaborative model has been able to demonstrate:

Effective and safe models of care with no adverse incidents or patient complaints
Improved patient access with diversion of appropriate patients to community care and timely identification of patients with red flag conditions fast tracked to specialist surgical care
Streamlined care pathways
Strong stakeholder engagement
Cooperation with sharing of clinical expertise, mentoring and greater multidisciplinary integration
Potential cost savings to the health care system
High levels of patient, staff and referrer satisfaction

Key outcomes from the project (Royal Melbourne Hospital and Merri Health data):

This data incorporates the pilot phase (2014/2015) and two years of ongoing operation (2015-2017).

Access

578 patients triaged to BAC and removed from outpatient surgical waiting lists annually
322 new patients seen in BAC annually
Patients assessed within 6 weeks of referral receipt and referred to community services within 10-28 days
Neurosurgery and orthopaedic outpatient waitlists reduced from an average of 2 years to 6 months.

Appropriate and safe care

92.8% of patients are seen by the same clinician from their first to their second visits in BAC
12% of BAC patients referred to surgical services or another specialty.
Surgical conversion rates for BAC referrals to surgical clinics is 62%, compared to state average of 5-10%
40% of patients referred for community physiotherapy
24% of patients discharged after initial assessment

Efficiency

Reduction in the proportion of patients undergoing MRI from 90% to 40%, giving a potential annual $90,000 cost-saving.

Workforce optimisation and integration

Specialist and advanced practice physiotherapist presence in the community
More efficient use of surgeons’ time and skills
Upskilling of community health physiotherapists to manage clients with increasing complexity

Communications and Promotion

Referenced in the 2015 Travis report as having merit in expanding this model to other health services and conditions.
Winner 2016 Public Healthcare Awards for ‘Excellence in providing alternative care paths’
Multiple presentations and publications including Medical, Allied Health and Primary Care conferences, DHHS and the Health Workforce Reform Implementation Taskforce chaired by Dr Brendan Murphy

Cost

Pilot project analysis showed the BAC service was cost neutral when compared to the equivalent Neurosurgical Consultant led clinic. The BAC service saw a slight increase in cost of $23.80 per patient seen but this was offset by improved access and reduced cost of investigations (e.g. an annual saving of approximately $52,000 in less MRI scans ordered) under the BAC service model. The running cost of a BAC session (3.5 hours) is calculated at $1029.

Initially the BAC service was placed under a SACS funding stream but since July 2017 has been moved across to Tier 2 funding stream, receiving the medical tier 2 funding weighting for each occasion of service. Under the current funding scheme a BAC session generates $2640, accounting for both a 20% patient DNA rate and review appointment as opposed to new patient appointment weighting.

The back pain management services at Merri Health are funded within the existing Community Health, Home and Community Care (HACC) and Commonwealth Home Support Program (CHSP).

Future Direction/Research

The Royal Melbourne Hospital BAC team is currently:

Collaborating with the Nuclear Medicine Department to undertake novel research to investigate the clinical utility of SPECT/CT scanning for the diagnosis and management of low back pain, comparing scan findings between asymptomatic and symptomatic populations.
In discussions with the Emergency Department about developing an assessment and management guideline for back pain in ED, and the opportunity to undertake further research into evaluating the impact of establishing an acute sciatica management pathway that contrasts the BAC model of care with existing referral pathways to surgical outpatient services.
Developing a research database using REDCap that will facilitate collection of both patient reported and ICHOM mandated core outcome measures for back pain, that will ultimately allow research into the comparative efficacy, cost-effectiveness, and safety of BAC in contrast with traditional spinal surgical services in delivering care for patients referred for tertiary level assessment and management of spinal conditions.
The Royal Melbourne Hospital and Merri Health are:
Currently partnering with the North Western Melbourne Primary Health Care Network to update the adult low back pain HealthPathways and to also host a continuing professional development day for general practitioners to upskill them in the assessment and management of low back pain.
Exploring options for physiotherapy workforce rotations between the organisations.