The ACPAC program is an opportunity to lead change in the transformation of arthritis care in Ontario and beyond

Overview

The Advanced Clinician Practitioner in Arthritis Care (ACPAC) Program is a unique post-licensure academic and clinical educational program. It prepares experienced physical therapists, occupational therapists and nurses for extended practice roles using advanced training in the diagnosis and management of patients with arthritis.

The ACPAC program was developed in response to:

  • A well-recognized need for an enhanced interprofessional approach to care that will allow more efficient management of a growing population of patients with arthritis (rheumatoid arthritis and osteoarthritis)
  • A progressive decline in number of traditional arthritis care specialists resulting in inappropriate wait times for care
  • A need to retain and more appropriately utilize existing health professionals with expertise in the musculoskeletal field to improve wait times and efficiency of arthritis care.

The program prepares experienced physical therapists, occupational therapists and nurses for extended practice roles and facilitates the development of innovative models of arthritis care across various clinical settings in Ontario and beyond.

This innovative, interprofessional program is hosted in Toronto Canada by St. Michael’s Hospital in collaboration with The Hospital for Sick Children. It is a certificate-based program offered at the post-licensure level in association with the Office of Continuing Professional Development, Faculty of Medicine, University of Toronto.

'Without the help of the ACPAC program-trained practitioners, managing the demand for rheumatology services in Northwestern Ontario would be impossible.'

-Dr. Wes Fidler
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ACPAC's System Level Impact

The ACPAC program was established in 2005. Since its inception, 100% of graduates have been satisfied with the program and found it extremely relevant to their clinical practice. Information on the early but extensive health services evaluation of ACPAC program graduates can be found in the ACPAC System Level Outcome Report which was presented to the Ministry of Health and Long Term Care Ontario in January, 2012.

An outline of the key implications of the ACPAC system-level evaluation for healthcare provision by ACPAC trained ERPs identified positive changes in terms of access (particularly in rural and remote regions), strengthened healthcare capacity, perceived impact on patient outcomes, and opportunities for further role promotion and expansion. The ACPAC program and its graduates (n=69) have been continuously responsive to a rapidly evolving healthcare environment with on-going evidence of improved, context-driven processes and positive outcomes.

Improving access in rheumatology: Evaluating the validity of a paper triage process involving an advanced practice physiotherapist through a retrospective chart review
Kristin Bignell MScPT, Cassie Bender MScPT, Aviva Lichtenstein MScPT, Brad McArthur MScPT, Kristin E. Musselman PT, PhD, Theresa Kay PT, MHSc & Chandra Farrer PT, MSc
Published on 20 Jun 2018.
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Objectives: This study evaluated a standardized paper triage process conducted by an advanced practice physiotherapist (APP) at a rheumatology center. The aims were to (1) determine the concordance between paper triage priority assignment and the rheumatologist’s diagnosis; (2) determine the sensitivity and specificity of the paper triage process; and (3) assess reasons for incorrect priority ranking. Methods: Referrals were triaged by a formally trained APP into one of the three priorities, guided by a priority referral tool. A retrospective review of 192 charts was performed. Raw proportion of agreement between paper triage and rheumatologist’s diagnosis was supplemented by a prevalence-adjusted bias-adjusted kappa (PABAK). Priority categories were collapsed to calculate sensitivity and specificity. For discordant cases, additional information was collected from the referral and chart to identify potential features leading to discrepancy.

Results: Overall agreement was 76%. The PABAK was 0.80 [95% confidence interval 0.70–0.90]. Sensitivity ranged 0.64–0.92 and specificity ranged 0.81–0.94, depending on the priority category. Forty-six cases were discordant, with the APP choosing a higher priority in 37 cases. An incorrect diagnosis from the family physician with no supporting information for the paper triage led to discordance in 16 cases. Conclusion: A standardized paper triage process conducted by an APP showed substantial concordance, sensitivity, and specificity.

Triage of Rheumatology Referrals Facilitates Wait Time Benchmarks
Chandra Farrer*, Liza Abraham, Dana Jerome, Jacqueline Hochman and Natasha Gakhal
The Journal of Rheumatology November 2016, 43 (11) 2064-2067;
DOI: Accessed March 28, 2017
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In an academic, urban hospital setting, referrals from September to November 2012 were retrospectively triaged by a rheumatologist and compared to referrals triaged by an ACPAC-trained APP from January to March 2014. Each referral was assigned a priority ranking and categorized into one of 2 groups: suspected IA/CTD, or suspected non-IA/CTD. Time to initial consult and time to notification from receipt of referral were assessed.

Traditional rheumatologist model: Mean wait times in 2012 for patients suspected to have IA was 33.8 days, 95% CI 27.8–39.8, compared to 37.3 days, 95% CI 32.9–41.7 in suspected non-IA patients.

ACPAC trained ERP* Triage Model: Mean wait times in 2014 for patients suspected to have IA was 15.5 days, 95% CI 13.85–17.15, compared to 52.2 days, 95% CI 46.3–58.1 for suspected non-IA patients. Time to notification of appointment improved from 17 days to 4.37 days.

Conclusion: Centralized triage of rheumatology referrals and quality improvement initiatives are effective in improving wait times for priority patients as determined by paper referral.

The Effect of Triage Assessments on Identifying Inflammatory Arthritis and Reducing Rheumatology Wait Times in Ontario [abstract].
Bombardier C, Brooks S, Bell M, Cesta A, Kendzerskaya T, Sweezie R, Widdifield J, Fullerton L, Ahluwalia V, Karasik A. Arthritis Rheumatol. 2016; 68 (suppl 10). Accessed January 23, 2017.
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Triage by an ACPAC trained ERP resulted in a high number of patients with suspected IA/CTD being correctly prioritized for a rheumatology consultation. For prioritized patients, the wait time was less than the provincial median. These results suggest that an ERP working in a triage role can improve access to rheumatology care for patients with suspected IA.