Exploring different ways of working in a Multidisciplinary team - - PowerPoint PPT Presentation

Weight Management Service: Exploring different ways of working in a Multidisciplinary team

Physiotherapy: Emer O’ Malley Dietetics: Cathy Breen Psychology: Ruth Yoder 19th November 2020

Agenda

• Overview of the Weight Management Service
• WMS multidisciplinary team
• Physiotherapy
• Psychology
• Dietetics
• Physiotherapy, Dietetic and Psychology experiences
• Changes to service delivery
• Getting set-up
• What went well
• What did not go well

The Weight Management Service

200 0 new patie atients nts a ye year ar

• 6 new patients/week

tients/week

• Tier 3 service – Behavioural

intervention

• Tier 4 service – Surgical

Jan – mid d Mar arch: h:

• 1:1 & group appointments
• Small number of TH calls e.g.

surgical & in-patient programme follow-up, medications review

Weight Management Service MDT

Dietetics Physiotherapy Psychology Nursing & Medical Admin & Support

Physiotherapy

Physical Activity Levels PMHx, Meds Social Hx Readiness & barriers Screen Time Sleep & OSA: ESS & STOPBang QOL, Falls, ADLs PARQ Musculoskeletal Ax Obesity Related Chronic Lymphoedema-like swelling Surgical Preference Sub-maximal fitness Ax & repeat: Cardiorespiratory health, Balance, Strength & function - TUAG, 90 sec step test, 6MWT Goal Planning, SM strategies Physiotherapy Level 3 Assessment:

• Proforma and repeat Ax

Service Introduction:

• Explaining role of PA in
• besity management

Level 3 Intervention:

• Individualised PA plan
• MSk Ax and Rx
• Sleep hygiene/OSA
• Cardioresp. Ax and Rx
• LL swelling mgt
• Goal setting
• Monthly review

Change to service delivery

Pri rioritisation ritisation of se services vices:

• Initial cessation of all F2F appts
• 100% telehealth (Mar-May)
• Proforma development
• Resource folder & MDT huddles
• F2F:

F: New w & review ew patient ient clinics inics

• NPC: Bloods, physical & functional Ax

(May-July)

• RPC: 3 time slots – 9 patients (Sept)
• 3 appointment

ntment options:

• ns:
• TH call, F2F appt, MDT Atte

tend nd Anywher where e (Dec)

Physiotherapy: What we did

• Designate patients for 1/52 or 1/12 between MDT
• 2 options

tions for r TH: : Phone call & Attend Anywhere (preference)

• E-mail/post resources: HEP

, sleep hygiene, stress management, goal setting

• Contact MDT: discipline specific requests, sleep study referral,

medication review, bariatric surgery

• Atten

end d Anyw ywhe here: e: Call first, set time & provide link. Helpful for musculoskeletal Ax

• AA: Appropriate space, background, technology (head sets)
• NPC:

C: Completed subjective assessment

What went well

• Continuation of service
• Helpful for those cocooning – patient support
• Tracking patient pathway
• Medications, Sleep study, Bariatric surgery referral
• Reduced DNA/UTA rate
• National service – reduced travel
• Appointment options - Patient preference
• Enab

ablers: Engagement of MDT, regular review, HSE training

22nd of May

152 179 148 141 20 40 60 80 100 120 140 160 180 200

January May August September Attended Did not attend Cancelled

Attendance

66% 91% 89% 7% 5% 7% 27% 5% 5% Usual care Telehealth Telehealth & F2F New Patient Clinic Telehealth & F2F NPC & Reviews 91% 89% 84% 4% 11%

What did not go well

• Some technology challenges
• Patient preference
• Revert to phone
• Some MSK, LL swelling assessment challenges
• Less specificity in Rx – global HEP
• Unable to repeat functional tests
• Can be tiring
• Ba

Barrier ers: Space, equipment, objective Ax & Rx, body language & empathetic touch

Pre-covid psychology service

• 10 sessions including intake & assessment of suitability for bariatric

surgery, if indicated.

• Sessions varied in length, from a 10 minute check-in, to a full hour,

depending on need. Typically, they were about 30 minutes long.

• Additional 1:1 sessions offered to a small number of patients with

additional psychological needs, especially those who met diagnostic criteria for Binge Eating Disorder Earl rly y Telehealt lehealth – phone e only

• Patients happy to be contacted, felt cared about, others felt cut-off or

abandoned

• Some had difficulty accepting telehealth as 1 of their 10 appointments –

they requested more

• Some declined telehealth, preferred to postpone until face-to-face

resumed (not many)

Outcomes

• It has been possible to provide a comprehensive psychology

service to most patients by AA

• Younger patients or those who are already working from

home, using video calls for work or socially, generally more at ease with this medium.

• Some intuitive indication of buy-in when preference is for AA

rather than phone. However, the patient may be at work or lack privacy especially when the call comes at a time other than their scheduled appointment time.

Barriers

• Poor connection, lack of technical ability or confidence using

technology have been barriers.

• Some body language cues lost when only head is visible, e.g.

Clenched fists, fidgeting, tapping feet. Some patients reluctant to be seen & give reasons such as not properly dressed, hair not done, no make-up. Due to stigmatizing nature of obesity, we may have underestimated the level of preparation patients put into a clinic visit.

Dangers

• Beginning to talk about—and therefore to think about—experiences that

have long been repressed can increase symptoms and harmful behaviours before they get better or go away. One of the major dangers

• f online therapy is opening a can of worms that cannot be adequately

contained and makes things worse instead of better. It is very important to assess risk of self-harm in patients with histories of trauma or major depression.

• On-line therapy may not be the best fit for patients with serious and

enduring mental illness, other than for a check-in.

• These patients require a safer space than this. E.g. Patients with PTSD

dont have enough scope to scan the environment for potential threats when not face-to-face, and therefore their guard remains up and therapeutic work doesn’t happen. The psychologist may not be aware

• f this, as the patient is unlikely to offer this information, but merely say

that they are “fine”.

Enabler: Creating a safe space

• The term “safe space” means that the psychologist stays with

your narrative throughout the session without judgment or attempting to fix you, allowing you to feel supported, safe and empowered, which in turn allows you to explore yourself more deeply, which is when the best work happens.

• Challenge in how to accommodate leaving emotions behind in the

therapy room, when the patient is already at home. The physical removal from the room where secrets were disclosed & emotions expressed & change explored, provided a clear boundary. This challenge can be met by other means, such as inviting patients to create another boundary e.g. Go outside after the session.

Dietetics within the WMS

• 5 RDs
• 2 Senior RDs
• 2 Entry level RDs
• Clinical Specialist RD
• Posts split between:
• WMS
• Diabetes Service
• Acute wards

Dietetics

Dietetics within the WMS

Level 3 Assessment:

• Anthropometry & Biochemistry
• Screen for ED
• Dieting history
• Q’s / 10 day food diary

❖ Individual F2F → Individual F2F Level 3 Intervention:

• Individualised food planning
• Monthly review + treatment escalation

❖ Individual F2F → Individual TH + Individual F2F @ midway and final appt Service Introduction:

• Explaining role of nutrition in
• besity management

❖ Group F2F → Group TH Level 4 Assessment:

• Suitability for bariatric surgery

❖ MDT → F2F with TH option Level 4 Intervention Pre-op:

• Group dietary education (+ MDT)

❖ Individual + Group F2F → Individual + Group F2F

• Individual dietary education

❖ Individual RD TH → Individual RD TH Level 4 Intervention Post-op:

• Support with dietary changes

❖ Individual RD TH → Individual RD TH

• Support with dietary changes in MDT clinic

❖ Individual F2F→ Individual F2F Cookery Club:

• Practical nutrition skills for

health & obesity management ❖ Group F2F → Group TH

Level 3 Dietetic intervention

• First appointment (1 hour)
• Individualised energy, protein & fibre

requirements

• Treatment of nutritional deficiencies
• Stabilisation of meal pattern
• Non-conflicting advice with other

complications e.g. T2DM, sleep apnoea, liver or kidney disease

• Self-monitoring
• Goal setting
• Workbook format
• Attend Anywhere
• Feedback doc emailed ahead of time
• Screen share

Level 3 Dietetic / MDT intervention

• 1-2 monthly review appointments:
• Problem solving & skill development
• Sharing nutrition knowledge
• Review dietary behaviours / self-monitoring

records

• Relative to energy, protein, pattern targets
• Advising & assisting
• Goal setting
• Arrange MDT r/v if needed
• Escalating treatment
• Adding medications, referral for surgery
• Proforma driven
• Underpinned by usual behavioural

framework for service delivery + optimal MDT working

WMS behavioural intervention

HCP communication skills Collaborative assessment Behavioural intervention strategies Ongoing review and support

Level 3 Dietetic intervention

• F2F appointments needed for:
• Initial assessment
• Screen for disordered eating
• Anthropometry & biochemistry
• Beliefs about food and obesity
• Anthropometry & biochemistry checks
• Communication / technology difficulties
• Patient preference

Level 3 Dietetic intervention – next steps

1. Attend Anywhere MDT clinics

❖Individual F2F → Individual TH

• 2. Service Introduction:
• Explaining role of nutrition in obesity

management

• Pre-recorded videos with slides + RD available for

interactive Q&A

• ? Workshop in the future / small number F2F

❖ Group F2F → Group TH

3. Cookery Club

• Practical nutrition skills for health & obesity

management

• Live demonstrations by RD + interactive Q&A

❖Group F2F → Group TH

TH Dietetic interventions – challenges and successes

• Lots of ground work to do (in a stressful environment)
• Agreed new ways of working within MDT
• Mapping out timetables; meetings
• PPPGs + SOPs
• Access to clinical / office space, telephones, laptops, headsets, cameras,

internet access

• Continued delivery of a high quality service
• Triage what needed to be F2F vs. TH
• TH options for MDTs something we probably always should have had!
• Advantages for patients
• Safety, less travel, in their home

Thank you

• Questions?