Supporting Remote Follow up Post Hip and Knee Surgery to Improve Patient Flow
Florence has been introduced to Sherwood Forest Hospital Foundation Trust to support patient flow across the hospital and offer a safe and convenient alternative to attending the outpatient clinic for follow up 12 months post hip or knee replacement.
Results show fewer, but more appropriate, appointments in follow-up clinic with clinicians feeling that patients have at least the same confidence as if they were followed up face-to-face in clinic.
Positive patient feedback was provided and 72.2% of patients were able to be discharged by the nurse remotely without having to attend clinic releasing 490 clinic appointments equating to 24 clinic sessions.
Carol Turner, Florence Project Manager working across Nottinghamshire supported by the East Midlands Academic Health Science Network was invited to showcase the outcomes at the British Orthopedic Association Congress in September 2016 at the Belfast Waterfront Conference Center.
Carol has also presented the outcomes with Vikram Desai, Orthopedic Consultant at the ‘Outpatient Services: 2016 Innovative Models’ Conference in Manchester.
Context
In 2014/15 there were 680 hip and knee replacements carried out at the Sherwood Forest Hospitals NHS Trust impacting negatively on the new to follow up ratio of 1:2.8 which was above the figure recommended by the local Clinical Commissioning Group of 1:2.
An alternative to face-to-face clinic appointments was to exploit the benefits of Flo to provide alternative solutions to patients and clinicians whilst achieving a more cost effective solution to care delivery.
Deliverables
Flo was utilized amongst a cohort of suitable patients (those who match the acceptance criteria) over a period of 8 months, from the initial ‘go live’ date of the 4th September 2015 to 4th May 2016. Patients’ needs were identified before enrollment onto Flo and they were offered the appropriate protocol and information pack.
An enhanced referral process was utilized in order to achieve immediate evidence gathering for the purpose of the project. The Flo Project Manager facilitated specific ‘Flo’ clinics to meet with those patients whose 12 month follow up appointments were pending and ensured it coincided with their x-ray investigation so as not to increase their visits to hospital unnecessarily.
The individual patients were given an explanation (verbal and written) of the Flo service and subsequently enrolled onto the system. As Flo can be easily adapted to suit individual needs the timings of the protocol were managed and edited to allow for the text messages to be delivered within a couple of days of the appointment at the convenience of the Patient.
Apace with this 166 Patients were enrolled onto Florence at their 6 week follow up appointment for their future 6 and 12 month review.
- Reduced number of face-to-face clinic follow-up appointments
- Flo evaluation feedback questionnaires completed by clinician
The most reliable and sustainable way to improve both quality and cost is to systematically redesign processes of care’[1]. By utilizing Florence as a means to review patients post-operatively it has demonstrated an effective resource for reducing capacity in out-patient clinics and changing practice.
On the basis of the aforementioned figures, the projection is (based on a total number of hip/knee replacements of 680 per annum [2014]) that 490 clinic appointments could be avoided.
This equates to approximately 24 outpatient clinic sessions per year for this cohort of patients, allowing for more effective use of clinic resources, staffing and cost savings/avoidance.
- It is difficult to give an exact figure for the cost of the service for each individual Team as this is always fluctuating dependent on % patient usage per organisation and apportioned across the 6 CCG’s in Nottinghamshire (the more patients and organisations throughout Nottinghamshire that use Flo, the less the cost per service).
All parties were made aware of the potential constraints/risks that may impact on the successful delivery of the project and the achievement of its objectives.
- Patient cognitive ability and willingness to take part
- Team members understanding of the Flo system
- Time constraints with respect to the collection of the necessary data for evaluation purposes
Impacts
To ensure that the implementation of Flo suitably demonstrated the impact on the SFHFT Orthopaedic service and its users, a variety of methods were used to facilitate this.
Improved patient pathways
Flo evaluation feedback questionnaires were completed by both patient and clinician
Of the 115 patients who used Flo during the life of the project, patient feedback data was available for 98 (85%) patients [50 female, 48 male with an age range of 43-90 years]
It was evident from the feedback that the implementation of Flo achieved a positive response to the service’s ambition of improving the patient pathway.
Patients strongly agreed/agreed to the following statements:
- 67% – ‘Florence is improving my overall care experience’
- 78% – ‘I feel that Florence supports the existing care I receive’
- 89% – ‘I find Florence very convenient’
- 87% – ‘Florence is easy to use’
79% of patients using Flo ‘believe that Florence should become a standard service in the future’ and ‘would recommend Florence to a friend or family member’.
Clinician Feedback:-
- 85% said they had fewer contacts with their patients because of Florence.
- 84% said their contacts had been more appropriate because of Florence.
- 70% believed using Florence had given the patient the same level of confidence as ‘a face-to-face’ appointment’ would have.
Of 115 patients enrolled onto Flo via the enhanced referral process
- 72% were discharged at 12 months without the need for a face-to-face clinic appointment with a Consultant/Specialist Nurse.
- 4% remained on Florence for a follow-up appointment at a later date
- 24% required a clinic appointment
Case study
A 73 year old lady who was diagnosed with osteoarthritis of her left knee underwent left Total Knee Replacement in March 2015.
With her agreement she was enrolled onto Flo for her 12 month review as part of the enhanced referral process and consented during a ‘Flo’ clinic at a time convenient to her.
At first she had some reservations, being slightly nervous at the thought of having to reply to the text messages but by having her daughter with her at the time of the receipt of the text messages, she explained that her fears were unfounded and she managed to reply without issue and actually said she thought it was easy to do!
The Nurse Specialist reviewed the lady’s orthopedic score (which was 36 out of 48) and her x-ray during a ‘virtual’ clinic and discharged her without the need for her to have a face to face appointment.
A previous history of right Total Knee Replacement in 2002 and right Total Hip Replacement in 2012 allowed the lady valuable insight into the improved pathway. She stated she had wished her past experiences could have been as smooth and convenient, particularly as the last time she had been a carer for her sick husband and it would have been far easier via Telehealth, using Florence.
Conclusion
It is often those closest to the processes that are best placed to provide valuable feedback on how current services can be improved. As patients are the ones who experience the process first hand, they have a unique, highly relevant perspective.
The patient experience in this instance was a positive one highlighting that there is an understanding that there was a need to change and a willingness to adapt to this change.
For patients, convenience and choice in accessing their local x-ray department at a time and place that suited them, was not only beneficial to them but also the hospital which avoided the ‘clogging up’ of the radiography department and ultimately reduced the wait in outpatient clinics for others.
With regards to the financial implications of implementing Florence for the ‘6/12 month joint replacement follow up’ service there was a reduction of 490 face to face clinic appointments equating to approximately 24 clinic sessions, freeing up consultants to see review patients without delays (within the 18 week RTT target).
This could potentially enable the service to increase new patient appointments and/or allows for increased Operating Theater sessions optimizing staff resources/skills. Using the above figures and current tariff payment there was an immediate saving of approximately £14,500 per annum for the local CCG.
According to the SFHFT Orthopedic Business Manager Florence
‘ has enabled the SFHFT Orthopedic service to be lower than the contracted and national average with regards to the new to follow up ratio’.
Carol Turner – East Midlands Academic Health Science Network
