INTRODUCTION

A care plan is a living document that describes the treatments discussed with the individual with OA and chosen to address their health concerns and goals. Each care plan is tailored to the individual and should account for their socio-economic status.

The conservative osteoarthritis (OA) care plan describes the treatments discussed with the individual and chosen to address a range of items. A care plan is a living document: it will evolve over time. Standard 3 describes how to tailor care over time after the initial care plan is created.

A care plan is developed considering the person’s:

• Assessed health concerns
• Readiness for change
• Goals
• Values and preferences
• Overall wellbeing and
• Prior experiences with OA conservative treatments

While keeping all the items described above in mind, an OA care plan will be built by:

1. Selecting specific Core Treatment(s)
2. If required: selecting a combination of specific Adjunct Treatment(s) to support participation in Core Treatments
3. Attaching SMART goal(s) to the selected treatment(s) and
4. Choosing a specific follow-up plan (Standard 3) and revising the care plan as necessary, based on the individual’s needs and preferences.

Building a Care Plan

Each individual seeks care at different points in their disease activity, their symptomology, and with varying levels of knowledge about OA.

The Conservative OA Treatments are provided below. They are structured to:

1. Promote the trialling of Core Treatments,^1-41Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.
   ²Gay C, Chabaud A, Guilley E, Coudeyre E. Educating patients about the benefits of physical activity and exercise for their hip and knee osteoarthritis. Systematic literature review. Annals of Physical and Rehabilitation Medicine. 2016;59(3):174-83.
   ³Rice D, McNair P, Huysmans E, Letzen J, Finan P. Best evidence rehabilitation for chronic pain part 5: Osteoarthritis. Journal of Clinical Medicine. 2019;8(11):1769.
   ⁴Wellsandt E, Golightly Y. Exercise in the management of knee and hip osteoarthritis. Current Opinion in Rheumatology. 2018;30(2):151-9. which have the strongest evidence for conservative OA management; and
2. Use Adjunct Treatments to support the return to these Core Treatments throughout a care journey

Core Treatments can be tailored to the individual’s needs and preferences. They include:

1. Education¹¹Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47. to provide knowledge and skills that empower the individual with OA to understand the disease and available evidence-informed treatments – See Standard 4.
2. Exercise and Physical Activity^1,31Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.
   ³Rice D, McNair P, Huysmans E, Letzen J, Finan P. Best evidence rehabilitation for chronic pain part 5: Osteoarthritis. Journal of Clinical Medicine. 2019;8(11):1769. to encourage the individual to foster movement to influence joint health and achieve their activities of daily life – See Standard 5.
3. Weight Management^1,31Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.
   ³Rice D, McNair P, Huysmans E, Letzen J, Finan P. Best evidence rehabilitation for chronic pain part 5: Osteoarthritis. Journal of Clinical Medicine. 2019;8(11):1769. to support the individual to prevent increased joint loading to influence joint health and achieve movement for their activities of daily life – See Standard 6.

Adjunct Treatments can also be tailored to the individual’s needs and preferences. They are used to support the trials of and achievement of Core Treatments. See Standard 7 for more information.

These tables provide examples of specific treatments in every treatment category to assist the clinician with the building of a care plan. More detail is available for clinician guidance on stepping through the conservative OA treatments toolbox. Shared decision-making techniques are evidence-based and promote satisfaction and success with the care plan.

The OA Self Management Toolkit is for individuals with OA. This document is an education booklet with introductory information about OA, and three tools for the individual: a Report Card, a Treatment Menu and an example Resource Inventory. These tools can support and empower the individual in choosing their own preferred treatment options and can promote self-management of conservative OA management in the long term.

It is important to keep in mind that each individual with OA seeks care at different points in their OA journey. Chronic disease management can be overwhelming to individuals with OA, particularly when individuals try to change too much at one time. For individuals that are ready, encourage them to start with setting one to two goals that are important to them, and breaking them down into smaller steps. Ultimately, the complexity of the care plan should be proportional to the individual’s experience and enthusiasm, while remaining realistic.

PUTTING A CARE PLAN INTO ACTION

As soon as feasible after an OA diagnosis, the individual with OA will have:

1. A documented care plan
2. Direction on actions to take to begin the care plan
3. Begun trialling at least one treatment option and
4. A plan for follow-up (more in Standard 3)

An example of how a multi-disciplinary team may be used to achieve an actioned care plan quickly is provided.

The exception to this is if the individual is a candidate for immediate referral to an orthopaedic surgeon (Standard 1). In which case a conservative treatment plan should still be created but in complement with the surgeon’s orders. Standard 8 talks more about how surgery may only be one step in the ongoing journey of conservative management of OA.

SMART GOALS

SMART goals are a tool of shared decision-making and are becoming more common in healthcare. The use of SMART goals can promote adherence to the non-surgical osteoarthritis (OA) management Care Plan by meeting the individual where they are at in their readiness to change. Meet the individual where they are at by tailoring the scope of the goal appropriately. This also helps both the individual and the clinician attach accountability to the changes. SMART goals are:

SMART goals take practice to write and are most successful when they are created in collaboration between a clinician and an individual with OA (shared decision-making). For some clinicians the skills required for the collaborative care described in these standards may be new territory. The following are suggestions for additional training that clinicians may find beneficial:

• This toolkit for learning more about shared decision-making techniques
• Health Change Methodology
• Motivational interviewing
• Any training that focuses on ‘family and patient centered care’

CONSERVATIVE OA TOOLBOX

To start the development of a care plan: understand the health priorities, goals, values, preferences, overall wellbeing and experiences with conservative treatments of your individual with osteoarthritis (OA) of the hip or knee. Use shared decision-making techniques with your individual to identify the most important problem to address and this will help guide the initial care recommendations you make.

Each individual seeks care at different points in their disease activity, their symptomology, and with varying levels of knowledge about OA. The Conservative OA Treatments should be tailored to the individual’s needs:

1. Many individuals with OA will begin their journey early in their disease and can use the Conservative OA Treatments systematically, increasing the intensity and/or the intrusiveness of the treatments, as their disease progresses.
2. Other individuals with OA will be seeking clinician support later in their disease progression and will immediately require a more complex care plan with a combination of Adjunct Treatments (Standard 7) to support some exploration of Core Treatments (Standard 4, Standard 5, and Standard 6).

For all individuals with OA, effective management requires trial and error with the evidence-based conservative treatments. Not all treatments will work for all individuals. Some treatments may work for a short period of time and then not again. Some treatments can be returned to after a long break and may be more successful when the individual’s goals, preferences or symptoms have changed.

The Conservative OA Treatments allow the clinician to use their expertise to combine any number of treatments to ultimately support:

• Ongoing engagement in Core Treatments; and
• Self-management

The following are instructions for how to use the Conservative OA Treatments to build a care plan. Also use these tables for specific examples of each sub-category of treatments.

1. Choose Core Treatments first
   1. They have the strongest evidence for OA management.
   2. They should be emphasized every time a care plan is modified (Standard 3).
2. Use Adjunct Treatments for additional symptom management
   1. The use of Adjunct Treatments enables the individual with OA to continue to participate in Core Treatments.
   2. Use clinical judgement to combine any treatments that will support the individual to participate in Core Treatments.
   3. Discuss with the individual the difference between the use of active treatments as opposed to passive treatments.
3. Work with the individual with OA to set SMART goals for their selected treatment.
4. Use your local Resource Inventory to discuss how and where the individual will trial the selected treatments.
5. Document the care plan and discuss a specific plan for follow-up appointments (Standard 3).
   1. Provide the individual with a copy of the care plan and the follow-up plan to promote self-management

While the Conservative OA Treatments are a tool for clinicians, clinicians should not use it in isolation without collaborating with the individual. Shared decision-making techniques can be used to build the individual’s care plan. The Treatment Menu and the Resource Inventory from the OA Self Management Toolkit are the individual-facing tools that align with the Conservative OA Treatments.

Note: if the individual with OA presents with symptoms that require immediate referral to surgery (see Standard 1), then the building of a care plan should be structured to complement the orthopaedic surgeon’s orders, whether the individual is a surgical candidate or not. See Standard 8 for more details: the conservative OA management journey does not end with surgery.