Developing BackPAC: Utilising stratification, shared decision making and promoting self-management to optimise service delivery

Purpose

· Optimise evidence based management (EBM) and stratify low back pain patients (24% of caseload)

· Improve patient access

· Enable shared decision making (SDM)

· Engage staff to enable innovative and sustainable service redesign

Approach

A project group including physiotherapists and advanced practitioners assured breadth of clinical experience and knowledge for service redesign. A literature review of EBM for lower back pain was undertaken. Education, weight management and exercise were recommended alongside stratification to identify appropriate treatment dependent on level of risk. BackPAC (Back Primary Access Class) evolved from merging existing models of service delivery. It was identified that a class format could be utilised, inclusion/exclusion criteria was determined and a presentation including the Chartered Society of Physiotherapy (CSP) Back Pain Myth Busters was created. Patients were triaged at the point of referral and, where appropriate, booked in the class within 2 weeks, bypassing the waiting list and allowing early red flag screening. Screening for sinister pathology included an unsuccessful trial of telephone triage and was replaced by a self-completed form, adapted from Gerraghty AW, Stanford R, et al. The Keele STarT Back Screening Tool was utilised for stratification. Within the class, patients were reviewed individually following the presentation and undertook SDM to determine their ongoing management. Options included; being discharged to self-manage with the advice provided in the session with a 6-week SOS period; participation in a ‘Back Rehab’ class; or one-to-one physiotherapy. High risk patients also had the option to be referred to see an Advanced Practitioner or Pain Management specialist in the local MSK service. BackPAC was piloted over 4 months with changes made in response to clinician feedback and Patient Reported Experience Measures (PREMs). Friends and Family test (FFT) was used to collect this. A questionnaire to establish long term effectiveness and capture further PREMs is in development

Outcomes

Results: During the period between August 2019 and February 2020, 174 patients attended BackPAC. Stratification demonstrated that 38% of patients were low risk, 31% medium risk and 31% high risk. This is in line with the Keele STarT Back research. 53 patients chose to self-manage after attending the class with an SOS period. FFT demonstrated that 95% of patients would recommend/highly recommend the service.

Conclusion(s):

· Recommended EBM and stratification is fulfilled for all patients

· Timely red flag screening and safeguarding

· Quick access

· Data is required to determine how many patients return to the service following their SOS period

· Further PREMS are being collected to ascertain the longer term effectiveness of the class via a questionnaire

Cost and savings

Implementation of the BackPAC class presents a cost saving on tariff for the local CCG for our service of £9,463 for every 518 patients referred with lower back pain. Additionally this improves efficiency by releasing 0.6 WTE physiotherapy capacity to manage other conditions.

Implications

· Effective staff engagement

· Sustainable service

· Improved efficiency

· Reduced wait times service-wide

Top three learning points

No further information. 

Funding acknowledgements

Sussex MSK Partnership East (SMSKPE) part funds the Highly Specialist Physiotherapy (Quality) post to support service development and sharing of outcomes with the local network to reduce unwarranted variation. SMSKPE utilised the CQUIN framework to assure stratification for lower back pain.