Connected care – Routine Followup of Patients – Western Health Orthopaedic Department

Routine followup of patients after THR, TKR and ACL-R

Preop questionnaires are collected in Clinic D – managed by Eugenie Ng
Post-surgical questionnaires are collected at 6 months, 1 year, 2 years, 5 years, 10 years – managed by the research team (Eugenie, Minh and Natali).
REDCap (research data collection platform) is used to collect these via email or SMS link.
Process:
- All patients who sign a surgical consent (RFA, the blue form) are sent to Clinic D.
- Patients will complete pre-op surveys here (on their own phone or on paper), and may be recruited to studies and offered further information about their procedure.
- Email and mobile contact details are confirmed.
- After the patient’s operation is completed and entered in Sunray, the team set up automated email invitations via REDCap. These emails contain links to complete the relevant PROM.
- Patients complete surveys (Oxford Hip Score, Oxford Knee Score) and tell us if they have issues related to the operated joint.
- Patient’s responses determine if they will get telehealth from JMOs and/or a face-to-face appointment with the consultant (see below matrix).
- JMOs submit new EMR internal referrals to ASC for bookings, and authorise discharge.
- Adult Specialist Clinic (ASC) will then action appointment booking and discharge requests as per usual Referral Management Centre process.
  - When actioning an outcome, ensure the ASC outcome is documented
    - When discharging a patient, note if they had an appoint which was cancelled (“Cancelled not rebook-Referral closed”) or that they did not have an existing appointment (“Discharged from clinic-Referral closed”)
    - When a new appointment is made (“Booked to clinic”)
  - ASC will notify patients regarding new appointment or discharge via SMS letter.

Registrars will call patients who have scored 27 or below on their PROMS and/or want to speak to a doctor.
Login to Sunray using routine username and password (ortho, orthoreg)
Click on “Connected Care” tab
The dashboard you will encounter is seen below including patient demographics, date of surgery, consultant, mobile number, date that PROMS response occurred.
Registrar will call the patient who meets the above criteria and ultimately decide if:
- Keep current appointment (has appointment already booked and wants to keep it)
- New appointment to be booked (does not have an appointment but patient would like one, admin team will action this and book an appointment within 3 months, next available)
- No appointment needed (does not have an appointment and does not want one)
- To be discharged (has appointment already booked but does not want to keep it, admin team will action this and cancel the appointment)
Registrar will then
- Fill in details in the right-hand columns on the dashboard – “Dr comments” only if patient does not answer (e.g. “No answer 4/3/24) or needing to communicate something specific to admin team (e.g. “Patient is overseas until August, please postpone current appt until September”)
- write a note in the patient’s EMR file
- request follow-up if appropriate.
Administration team will action clinical decisions.
- Airish Ong and Dianne Mutimer (via NUM Vikki) are the go-to ASC nurses
If a patient is called on 3 separate occasions and does not pick-up, they should continue their current management (i.e. “Keep current appointment” or “No appointment needed”), write a EMR note highlighting this including the dates on which the calls were made.