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Camden MSK - developing a pragmatic clinical stratification tool to decide upon telephone, video or face to face consultation at point of triage.
Following cessation of usual out patient community MSK services due to COVID 19 pandemic, all CATS appointments were initially conducted by telephone. Video consultation came online after 3-4 weeks, but was found too complex to switch to mid conversation for most patients and clinicians, and was therefore reserved for use as a follow-up appointment after initial telephone consultation where visual assessment was deemed necessary. This therefore increased the usual demand for follow-up appointments. In addition a very small number of patients required face to face clinical assessment (in PPE of course).
Evaluation of the first few weeks of telephone consultations identified a slightly elevated investigation rate (by percentage) - in all likelihood at least partly due to the limitations of telephone consultation, and an increase in defensive medicine for safety reasons. It is possible other factors e.g. stress and anxiety were also involved due to the context, concurrent part redeployment to critical care, weekend working etc.
In the short term almost all consultations will be remote, however in the medium/long term we expect the reintroduction of routine face to face consultation. The permanent addition of remote consultation media offers service efficiencies due to working from home options and reducing the estates burden - a very significant issue in central London, improved patient experience due to improved access and convenience. It is imperative that these are used appropriately. At present a few consultations are video first, but these decisions are uncommon, ad hoc and this scattered/unpredictable behaviour increases the administrative workload.
The development of a consultation medium decision tool which is an addition and complement to existing triage criteria, ensures the most efficient and sustainable service. IT hardware and connectivity limitations mean video consultation is not always an option so clinics where this is required must be planned for, as must face to face assessment clinics, whereas telephone is theoretically available anywhere. That is not to say many clinics cannot contain a mix of some/all media. The criteria will therefore minimise follow-up appointments required, ensure the most appropriate outcome from CATS appointments - getting it right first time, optimal investigation and onward referral rates, and optimise patient experience. Patient choice and the availability of IT hardware and connectivity will of course also be taken into account - hence the pragmatic nature.
What is needed to sustain the change?
Audit of pre and post change investigation rates, onward referral rates, follow up appointments. Possible changes to consultation medium decision tool as part of audit cycle.
Improved IT hardware and infrastructure - webcams, sufficient bandwidth
Stakeholder engagement with permanent addition of remote consultation
Appropriate patient information for all types of consultation including explanation of decision on consultation type
What is your region?
London
A new and challenging way of working but also with long term benefits and flexibility as a positive outcome. Developing a Decision making tool/ guideline with scope for clinical discretion would be key in the long term success of remote consulting for all parties concerned.
Reply 3
This is great Paul!
Reply 1
We have had a very similar experience in Salford - I would be interested to determine whether you have noticed that there are patterns of clinical scenarios where video first would had added value ??
Our local experience of telephone consult only has largely been well received by patients during Covid- as 'something is better than nothing' -but most when asked would still prefer F2F v virtual.
Reply 3
This sounds great Paul- as you say it ius dependent on the quality of referrals- how have you cracked that nut?
Reply 0
Status labels added: Choice, Collaboration, Community Care, Effective Team Working, Health & Wellbeing, Information Sharing, Integration Of Resources, Patient Activation, Patient Selection, Referral Pathway Redesign, Technology (Software/ Apps), Telephone Advice, Video Consulting, Horizon 1
Reply 0
Status labels added: Infrastructure, Investment In Technology, Pathway Redesign, Shared Decision Making, Staff & Patient Collaboration, Telephone Consulting, Upskilling Of Staff, Virtual Consulting
Reply 0
The idea has been progressed to the next milestone.
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The idea has been progressed to the next milestone.
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Status labels removed: Choice, Collaboration, Community Care, Effective Team Working, Health & Wellbeing, Information Sharing, Infrastructure, Integration Of Resources, Investment In Technology, Pathway Redesign, Patient Activation, Patient Selection, Referral Pathway Redesign, Shared Decision Making, Staff & Patient Collaboration, Technology (Software/ Apps), Telephone Advice, Telephone Consulting, Upskilling Of Staff, Video Consulting, Virtual Consulting
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