InInflfalammmmaatotorryy A Arrththrritiitsis C Caarree P Paathth T Toooolklkiti t August, 2014 Table of Contents The Alliance intends that this web-based resource be regularly updated. Please contact us at [email protected] if you have an update or an addition to the toolkit. Introduction .............................................................................................................................................................................................. 2 BACKGROUND...................................................................................................................................................................................... 2 TOOL SELECTION ................................................................................................................................................................................... 2 HOW TO USE THIS TOOLKIT ................................................................................................................................................................... 2 DISCLAIMER ........................................................................................................................................................................................... 4 Toolkit ........................................................................................................................................................................................................ 5 IDENTIFICATION ..................................................................................................................................................................................... 5 PATIENT ....................................................................................................................................................................................................... 5 Patient Develops MSK Symptoms (Box 1)......................................................................................................................................... 5 Patient Self-Medicates (Box 2) ........................................................................................................................................................... 5 Patients Seeks Additional Information (Box 3) ................................................................................................................................. 6 PRIMARY CARE .......................................................................................................................................................................................... 6 Symptoms Resolve (Box 4) .................................................................................................................................................................. 6 Symptoms Persist (Box 5) ..................................................................................................................................................................... 6 Patient Seeks Care (Box 6) ................................................................................................................................................................. 6 REFERRAL .................................................................................................................................................................................................... 6 Physician or NP (Box 7) ........................................................................................................................................................................ 6 Patient Seeks Community Allied Health Professional (Box 8) ....................................................................................................... 8 SPECIALIZED CARE ACCESS ................................................................................................................................................................. 9 COORDINATED INTAKE AND TRIAGE ..................................................................................................................................................... 9 Initiate Referral (Box 9) ........................................................................................................................................................................ 9 Triage (Box 10)....................................................................................................................................................................................... 9 Non-IA (Box 11) ................................................................................................................................................................................... 10 Suspected IA (Box 13) ........................................................................................................................................................................ 10 MEDICAL MANAGEMENT ................................................................................................................................................................... 10 CONSULT .................................................................................................................................................................................................. 10 Subsequent Care (Box 12) ................................................................................................................................................................ 10 Consult With Rheumatologist (Box 14) ............................................................................................................................................ 10 DIAGNOSIS MADE ................................................................................................................................................................................... 14 Non-IA (Box 11) ................................................................................................................................................................................... 14 IA Diagnosed (Box 15) ....................................................................................................................................................................... 14 TREATMENT PLAN..................................................................................................................................................................................... 14 Treatment Options (Box 16) .............................................................................................................................................................. 14 Re-Assess (Box 17)............................................................................................................................................................................... 16 Inadequate Response (Box 18) ....................................................................................................................................................... 18 Responder (Box 19) ............................................................................................................................................................................ 20 SHARED CARE ..................................................................................................................................................................................... 23 ONGOING CARE..................................................................................................................................................................................... 23 Shared Care (Box 20) ........................................................................................................................................................................ 23 Copyright © 2014 Arthritis Alliance of Canada Publication date: August 21, 2014 Introduction Background It is estimated that one million Canadians live with inflammatory types of arthritis (IA). Its most common forms include rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and juvenile idiopathic arthritis. The current pattern of health care delivery to those living with IA is in crisis: the economic burden is expected to double within a generation, and the number of rheumatologists in Canada is already insufficient to provide timely care. A pan-Canadian Approach to Inflammatory Arthritis Models of Care has been prepared by the Arthritis Alliance of Canada (AAC) in response to these challenges, to improve the way health care is delivered to patients with IA. This document describes the framework for models of care for IA in Canada. AAC acknowledges that this is an important first step in improving the care of individuals with IA. Additionally, the AAC has developed this “Care Figure 1 Path for Inflammatory Arthritis”, a comprehensive map of a patient’s journey through the health care system, along with a toolkit for each step along the way. This can be found on the AAC website (www.arthritisalliance.ca) and is meant to be a living document in the sense that the tools will be continually adapted and modified over time. Tool Selection This toolkit was developed to provide a list of relevant, available tools to assist in the movement of the patient through the Care Path. All relevant tools as identified by the various stakeholders engaged in this project are included here. The validation of all tools provided in this toolkit is beyond the scope of this project. How To Use This Toolkit Two formats of the toolkit are available; Inflammatory Arthritis Care Path Toolkit 2 1. The web version of this toolkit, available at www.arthritisalliance.ca. This version allows the user to scroll over the boxes and select tools from a dropdown menu, as shown in Figure 1: The web version also contains an alternate view, whereby, the user can click a specific section (i.e. Identification) and view a complete list of tools pertaining to only that section, as shown in Figure 2. Figure 2 2. The second version of the toolkit is this living document, organized by order of the Care Path, boxes 1 through 20, with a resource link for each tool. The Alliance intends that this web-based resource be regularly updated. Please contact us at [email protected] if you have an update or an addition to the toolkit. Inflammatory Arthritis Care Path Toolkit 3 Disclaimer The Arthritis Alliance of Canada (AAC) is very pleased to support and make the Inflammatory Arthritis Care Path Toolkit available for download. The toolkit was a collaborative project designed to assist professionals as they assist adult patients through the continuum of care. It is intended to help design systems/care paths to assist in the movement of the patients through the continuum of care, with supporting tools. Important Disclaimer to the Inflammatory Arthritis Care Path Toolkit The Toolkit is intended to be an educational tool and a useful resource for care providers, patients and other stakeholders. It is not a substitute for qualified and competent advice or the exercise of professional and clinical judgment. This Care Path is intended for use with adult patients, the age of majority and older. The Inflammatory Arthritis Care Path is not recommended for use in paediatric patients. While care was used in the preparation of the Toolkit, the AAC disclaims any warranty as to the accuracy and completeness of the Toolkit. Neither AAC nor the contributors to the Toolkit assume any liability or responsibility for any harm, damage or injury (including death) to you, other persons or property arising from any use of any product, information, idea or instruction contained in the Toolkit or any other content or services provided to you by AAC. The information presented by the AAC is not intended to take the place of your personal physician’s advice and is not intended to diagnose, treat, cure or prevent any disease. Discuss this information with your own physician or healthcare provider to determine what is right for you. All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions. The information should not be assumed to be complete and should not be used in place of advice of your physician or other health care provider. We do not recommend the self-management of health problems without explicit advice of a physician that it is safe to do so. Should you have any health care-related questions, call or see your physician or other health care provider promptly. You should never disregard medical advice or delay in seeking it because of something you have read in the Toolkit. By accessing or downloading the Toolkit you are agreeing to the above terms. Inflammatory Arthritis Care Path Toolkit 4 Toolkit Identification PATIENT Patient Develops MSK Symptoms (Box 1) ERASE (E-triage RA study in Early Arthritis) tool A Web-based Screening Tool for Early Rheumatoid Arthritis – ERASE: the E-triage RA study in Early Arthritis. http://www.arthritisdoctor.ca/erase.php Early Inflammatory Arthritis (EIA) Detection Tool An 11-question self-administered questionnaire (Early Inflammatory Arthritis [EIA] Detection Tool) was developed to help family doctors and healthcare workers identify people with possible diagnosis of early IA. http://www.arthritis.ca/research/summary/EIA http://www.biomedcentral.com/1471-2474/11/50/figure/F4 The SIMPLE Questionnaire Screening for inflammatory pain in lower back. http://carearthritis.com/tools/tools_html.launch?toolid=1&refid=/patient.php%23tab1 RASQ – self administered RA screening questionnaire Seven weighted questions and diagram. The self- administered rheumatoid arthritis (RA) screening questionnaire (RASQ) is a simple and simple and effective tool to detect RA patients. Ann Rheum Dis 2010;69(Suppl 3):374. http://www.abstracts2view.com/eular/view.php?nu=EULAR10L_FRI0180 Arthritis ID ArthritisID is the most comprehensive free arthritis app for consumers, featuring the most current, evidence-based arthritis information to help detect, treat and manage arthritis. https://itunes.apple.com/us/app/arthritisid/id457961189?ls=1&mt=8 Patient Self-Medicates (Box 2) A consumer’s Guide to Arthritis Medications The Arthritis Society http://www.arthritis.ca/document.doc?id=341 An introduction to complementary and alternative therapies The Arthritis Society http://www.arthritis.ca/document.doc?id=323 Patient Self-Medicates (Box 2) Inflammatory Arthritis Care Path Toolkit 5 Arthritis ID ArthritisID is the most comprehensive free arthritis app for consumers, featuring the most current, evidence-based arthritis information to help detect, treat and manage arthritis. https://itunes.apple.com/us/app/arthritisid/id457961189?ls=1&mt=8 How to use NSAIDS http://rheuminfo.com/medications/non-steroidal-anti-inflammatory-drugs-nsaids Patients Seeks Additional Information (Box 3) Arthritis ID ArthritisID is the most comprehensive free arthritis app for consumers, featuring the most current, evidence-based arthritis information to help detect, treat and manage arthritis. https://itunes.apple.com/us/app/arthritisid/id457961189?ls=1&mt=8 About Arthritis Diseases http://www.arthritis.ca/aboutarthritis PRIMARY CARE Symptoms Resolve (Box 4) Symptoms Persist (Box 5) Patient Seeks Care (Box 6) REFERRAL Physician or NP (Box 7) ERASE (E-triage RA study in Early Arthritis) tool A Web-based Screening Tool for Early Rheumatoid Arthritis – ERASE: the E-triage RA study in Early Arthritis. http://www.arthritisdoctor.ca/erase.php Early Inflammatory Arthritis (EIA) Detection Tool An 11-question self-administered questionnaire (Early Inflammatory Arthritis [EIA] Detection Tool) was developed to help family doctors and healthcare workers identify people with possible diagnosis of early IA. Developed by Mary Bell V:\CAPRICA\AAC\Committees\Models of Care Committee\Inflammatory MoC\Care Map\20140611-html\tools\EIA Detection Tool.jpg The SIMPLE Questionnaire Screening for inflammatory pain in lower back. http://carearthritis.com/tools/tools_html.launch?toolid=1&refid=/patient.php%23tab1 Psoriatic Arthritis Screening Questionnaire PASQ is composed of a diagram and 10 questions to aid in the detection of arthritis in patients with psoriasis. The final score indicates whether the person has a high probability of having psoriatic arthritis. Those who have a positive result from the screening test will need further evaluation with subsequent diagnostic tests or procedures. An app has been created and is available on iTunes for use on an iPhone or iPad. https://itunes.apple.com/ca/app/pasq/id402206647?mt=8 Rheuminfo.com Diseases http://rheuminfo.com/diseases Physician or NP (Box 7) Inflammatory Arthritis Care Path Toolkit 6 A consumer’s Guide to Arthritis Medications The Arthritis Society http://www.arthritis.ca/document.doc?id=341 An introduction to complementary and alternative therapies The Arthritis Society http://www.arthritis.ca/document.doc?id=323 Arthritis ID ArthritisID is the most comprehensive free arthritis app for consumers, featuring the most current, evidence-based arthritis information to help detect, treat and manage arthritis. https://itunes.apple.com/us/app/arthritisid/id457961189?ls=1&mt=8 Getting a Grip: Arthritis Best Practice Guidelines This tool for health care providers outlines arthritis treatment guidelines. The treatment guidelines are based on the arthritis best practices developed by the Getting a Grip on Arthritis program. http://www.arthritis.ca/document.doc?id=100 Getting a Grip on Arthritis Prescription Pad Arthritis prescription to patients newly diagnosed with arthritis to refer them to The Arthritis Society for more information, to an exercise program or to a weight management program. There is room at the bottom for your notes and on the back there is information on healthy choices for your patient. http://www.arthritis.ca/document.doc?id=138 How to use NSAIDS http://rheuminfo.com/medications/non-steroidal-anti-inflammatory-drugs-nsaids Choosing Wisely http://www.choosingwiselycanada.org/ Examination of Joints Rheumatology Physician Tools http://rheuminfo.com/physician-tools A Primer on Musculoskeletal Examination , Dr. Evelyn Sutton http://sutton.medicine.dal.ca/ Musculoskeletal Examination, Dr. Jean-Luc Tremblay http://www.internationalpubmarket.com/clients/esk/books/BookDetail.aspx?productID=383348 Physical Examination videos, Dr. Raj Carmona http://www.rheumtutor.com/msk-examination-videos-2/ Swollen Joint Count: 44 joint homunculus https://www.carearthritis.com/tools/tools_html.anonlaunch?toolid=8&refid=/physicians.php%23tab2 Disease Activity Score in 28 Joints http://www.rheumatology.org/assets/0/116/525/605/eaf54d09-6258-48c3-9244-58d565bfeabd.pdf Comprehensive Arthritis Referral Tool (CART) The Comprehensive Arthritis Referral Tool (CART) is and optional tool for general practitioners to fill out when referring to a rheumatologist. http://rheuminfo.com/wp-content/uploads/2011/04/Canadian-Arthritis-Referral-Tool-CART.pdf ACR Referral Guidelines for Adult Rheumatologist http://www.rheumatology.org/Practice/Clinical/Position/Position_Statements/ Priority Referral Score Priority-setting criteria for the full range of rheumatology referrals and the determination of relative urgency for referral. http://onlinelibrary.wiley.com/doi/10.1002/acr.20366/pdf Physician or NP (Box 7) Inflammatory Arthritis Care Path Toolkit 7 Rapid Access to Consultative Expertise (RACE) Rapid Access to Consultative Expertise (RACE) is a program available in British Columbia that is designed to increase family physician access to specialist consultation and to improve communication and knowledge transfer between different care providers. https://www.doctorsofbc.ca/rapid-access-consultative-expertise-race-program Early Referral guideline ≥3 swollen joints. MTP/MCP involvement (squeeze test positive). EMS ≥ 30 min http://ard.bmj.com/content/61/4/290.full.pdf Path to Care Directory Calgary Zone: Specialty specific guidelines: Rheumatology Triage (See pages 187-189) The purpose of the Specialty Specific Guidelines section is to ensure that specialty clinics receive all of the information, tests and investigations required to triage patients appropriately. The Specialty Specific Guidelines also provides referring physicians with an approximate timeline in which a patient will be seen depending on the urgency of referral. http://www.departmentofmedicine.com/mas/documents/specialty_specific_guidelines.pdf Patient Seeks Community Allied Health Professional (Box 8) Exercising safely with arthritis Video: https://myhealth.alberta.ca/health/Pages/HealthVideoPlayer.aspx?HWvideoCat=Exercising%20Safely%20With%20Arthritis&HWvideoTop=Bo ne%20And%20Joint%20Health&hwid=abo5585 Getting a Grip on Arthritis: Resource kit for people with arthritis Booklet provides information about arthritis and its management. There is information about health care providers who can help you manage your arthritis through exercise, healthy eating, and medications. http://www.arthritis.ca/document.doc?id=664 Getting A Grip on Arthritis Training workshops for primary health care providers to improve their ability to diagnose arthritis and provide helpful advice to patients. http://www.arthritis.ca/page.aspx?pid=988 Getting a Grip on Arthritis Prescription Pad Arthritis prescription to patients newly diagnosed with arthritis to refer them to The Arthritis Society for more information, to an exercise program or to a weight management program. There is room at the bottom for your notes and on the back there is information on healthy choices for your patient. http://www.arthritis.ca/document.doc?id=138 Getting a Grip: Arthritis Best Practice Guidelines This tool for health care providers outlines arthritis treatment guidelines. The treatment guidelines are based on the arthritis best practices developed by the Getting a Grip on Arthritis program. http://www.arthritis.ca/document.doc?id=100 Early Referral guideline ≥3 Swollen joints. MTP/MCP involvement (squeeze test positive). EMS ≥ 30 min http://ard.bmj.com/content/61/4/290.full.pdf Examination of Joints Rheumatology Physician Tools http://rheuminfo.com/physician-tools A Primer on Musculoskeletal Examination , Dr. Evelyn Sutton http://sutton.medicine.dal.ca/ Musculoskeletal Examination, Dr. Jean-Luc Tremblay http://www.internationalpubmarket.com/clients/esk/books/BookDetail.aspx?productID=383348 Physical Examination videos, Dr. Raj Carmona http://www.rheumtutor.com/msk-examination-videos-2/ Patient Seeks Community Allied Health Professional (Box 8) Inflammatory Arthritis Care Path Toolkit 8 Specialized Care Access COORDINATED INTAKE AND TRIAGE Initiate Referral (Box 9) Comprehensive Arthritis Referral Tool (CART) The Comprehensive Arthritis Referral Tool (CART) is and optional tool for general practitioners to fill out when referring to a rheumatologist. http://rheuminfo.com/wp-content/uploads/2011/04/Canadian-Arthritis-Referral-Tool-CART.pdf ACR Referral Guidelines for Rheumatologist http://www.rheumatology.org/Practice/Clinical/Position/Position_Statements/ Path to Care Directory Calgary Zone: Speciality specific guidelines: Rheumatology Triage (See pages 187-189) The purpose of the Specialty Specific Guidelines section is to ensure that specialty clinics receive all of the information, tests and investigations required to triage patients appropriately. The Specialty Specific Guidelines also provides referring physicians with an approximate timeline in which a patient will be seen depending on the urgency of referral. http://www.departmentofmedicine.com/mas/documents/specialty_specific_guidelines.pdf Triage (Box 10) Advanced Clinician Practitioner in Arthritis Care (ACPAC) Program http://www.stmichaelshospital.com/programs/mobility/acpac.php EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis http://ard.bmj.com/content/early/2011/10/28/annrheumdis-2011-200185.full.pdf+html Comprehensive Arthritis Referral Tool (CART) The Comprehensive Arthritis Referral Tool (CART) is and optional tool for general practitioners to fill out when referring to a rheumatologist. http://rheuminfo.com/wp-content/uploads/2011/04/Canadian-Arthritis-Referral-Tool-CART.pdf ACR Referral Guidelines for Rheumatologist http://www.rheumatology.org/Practice/Clinical/Position/Position_Statements/ Path to Care Directory Calgary Zone: Speciality specific guidelines: Rheumatology Triage (See pages 187-189) The purpose of the Specialty Specific Guidelines section is to ensure that specialty clinics receive all of the information, tests and investigations required to triage patients appropriately. The Specialty Specific Guidelines also provides referring physicians with an approximate timeline in which a patient will be seen depending on the urgency of referral. http://www.departmentofmedicine.com/mas/documents/specialty_specific_guidelines.pdf Swollen Joint Count: 44 joint homunculus https://www.carearthritis.com/tools/tools_html.anonlaunch?toolid=8&refid=/physicians.php%23tab2 Disease Activity Score in 28 Joints http://www.rheumatology.org/assets/0/116/525/605/eaf54d09-6258-48c3-9244-58d565bfeabd.pdf 15Min Allied Health Professional Triage Form http://www.arthritisalliance.ca/images/caremap/en/tools/15min-AHP-Triage-Form.pdf 1 Smart Form Ontario Rheumatology Association Rheumatoid Arthritis Detailed Active_External Meds http://www.arthritisalliance.ca/images/caremap/en/tools/1-Smart-Form-ORA-RA-Detailed-Active-External-Meds.pdf 4 Smart Form Ontario Rheumatology Association Ankylosing Spondilitis Psoriatic Arthritis Name of Meds_Dosage http://www.arthritisalliance.ca/images/caremap/en/tools/4-Smart-Form-ORA-AS-PSA-name-of-Meds-Dosage.pdf Triage (Box 10) Inflammatory Arthritis Care Path Toolkit 9