Establishing a virtual eating disorders service in a large child - PDF document

5/03/2015 Establishing a virtual eating disorders service in a large child and youth mental health service Ms Tania Withington – CHQ CYMHS Director of Social Work Ms Judi Krause – CHQ CYMHS Divisional Director Date: 23.02.2015 Queensland Hospital and Health Services http://www.health.qld.gov.au/maps/ 1

5/03/2015 The Lady Cilento Children’s Hospital LCCH opened November 2014 The Lady Cilento Children's Hospital is the largest and most advanced paediatric facility in Australia. Located in South Brisbane, the Lady Cilento Children's Hospital is the public hospital for children in Brisbane and Queensland's tertiary referral facility. Continuum of Care for Eating Disorders Inpatient Unit FBT-AN Psychiatric Referral Community Review Discharge CYMHS CBT-E Community CYMHS 2

5/03/2015 Journey of Family Based Treatment in CYMHS for Eating Disorders Individual Clinician Interest Clinicians Specialist with FBT and specialist FT Clinic training Individual Specialist Clinician FBT and Interest FT Clinic Clinicians with specialist training Learnings from the Journey » Challenges with relying on individual clinician interest » Problems maintaining knowledge and skill in service » Problems maintaining fidelity of EB model » Limited capacity to provide EB Intervention » Perceived isolation of identified clinicians » Loss of momentum in service provision of EB model » Inefficiencies in resource utilisation » Limited accessibility and visibility of service » Challenging accessing physical resources and funding » Challenges bedding research into practice 3

5/03/2015 Re-establishing a Specialist Clinic » Review: » Service based data » Training, supervision and mentoring requirements » Clinic structure and practices » Resource requirements and efficiencies » Physical space, staffing, administration, medical equipment » Utilising shared resources and existing systems » Research Agenda » Alignment of Model with HHS Mission, Values, Pillars » Profile, credibility, visibility » Internal and external networks Challenges and solutions » No money » No allocated staff » No allocated clinical space » No resources at all So…. » Utilise staff from existing teams to join specialist clinic team one day a week » Negotiated psychiatry input across greater service » Negotiated space in existing CYMHS clinic » CYMHS/QUT Partnership enabled access to live supervision » One-off funding for training and supervision » One-off funding for supervision for Accreditation 4

5/03/2015 FBT-AN Clinic Description » Embedded in a community CYMHS clinic » One day a week identified CYMHS clinicians form virtual team » One new intake per week (incorporates Psychiatric review, nursing assessment, family interview) » One new case a week (session one and family meal) » Co-therapy model » Through the mirror live supervision, recorded session supervision, peer supervision, Supervision for Accreditation » Clinic Coordinator » Multiple sessions across day in planned timetable Unleashing Potential CHQ Australia Day Award 2014: Eating Disorders Team (CYMHS) 5

5/03/2015 First Annual Review » Increased referral rates (X5) » Reduced length of inpatient hospital admission » Reductions in re-admission inpatient rates » Length of community treatment shortened (12-18months) » Improved rates of treatment completion and reductions in re- admission to community services » Improved model fidelity » Improved Team cohesion » First Research Grant achieved Dedicated resources – staffing/equipment » » FBT-AN supervision for accreditation with Institute of Eating Disorders Chicago underway Second Annual Review Calender Year Accepted Referrals Percentage of F50.0 Number of Average Length of to FBT Completed Cases in District referred Stay in Psychiatric to FBT Inpatient Unit (excludes EDNOS and (bed days CFTU) BN) 2012 11 66% 1 40 2013 31 75% 22 2014 35 80% 21 22 • Identified need for nursing assessment at intake and across phases Developed research project to investigate model fidelity • Introduced Dietician consultation • Established Clinic in CYMHS service structure • Established Clinic Budget • Established CYMHS Eating Disorder Portfolio 6

5/03/2015 Critical Components of FBT Clinic Model » Critical relationships » Managing FBT Team capacity › Inpatient and Community » Co-therapy model of service Teams delivery › Consultation Liaison Teams » Importance of time and patience › General Practitioners › » Managing Risk Accident and Emergency Services » Importance of top down and bottom up drivers » Role of Nursing in FBT Team » Portfolio identification across › Medical parameters at broader service assessment and across treatment » Role of Research › » Role of Dietician in FBT Team Projects, grants, service evaluation, service › Staff consultation and development professional development What attracts staff to FBT Team » Recognition of specialist knowledge and skill » Live supervision » Supervision for accreditation » Support for tertiary education » Observable clinical outcomes » Transferable expertise (family therapy) » Professional development » Skill development in supervision and mentoring » Team risk management strategies 7

5/03/2015 Inpatient Care » Medical and Psychiatric admission » Consultation Liaison team » Pediatric and adolescent psychiatric units » Structured ED protocols Inpatient Care » Diagnostic assessment » Management of medical crisis » Nutritional resuscitation to 85% IBW » Psycho-education » General support for the young person and their family » Clear discharge plan to appropriate follow up community treatment to support recovery 8

5/03/2015 CBT-E » Newly introduced evidenced-based intervention model » Works alongside FBT-AN and Community CYMHS » Identified clinicians situated in community clinics » Group training and supervision » Single point of coordination » Shared group training with FBT-AN Clinic Team » Learnings to date: › Engages older adolescents moving to independence › Engages adolescents with established ED > 3years Inclusion/Exclusion Criteria FBT- AN/CBT-E CBT-E FBT Age 14 or above Age <18 years Inclusion Significant eating disorder Significant eating disorder with psychopathology (BN, EDNOS, restriction (AN EDNOS, BN) BED) but not less than 85% of Living with family expected weight) Family commitment Willing to engage in CBT-E Medically stable Medically stable Exclusion Less than 85% of expected body Living independently of family weight Current DV or abuse in family Severe clinical depression (should context first be managed with medication Unmanaged parental mental where appropriate) illness or substance misuse Persistent substance misuse (if likely to present intoxicated) Parental significant cognitive impairment Significant cognitive impairment Active (non-eating disorder related) Active (non-eating disorder related) psychosis psychosis Unwilling to engage in CBT-E 9

5/03/2015 Future Challenges and Directions » Service amalgamation » Funding Models/Data alignment of clinical » Clinical Partnerships pathways/ continuum of » Research Partnerships care » Consultation-Liaison » Aligning inpatient care » LCCH state-wide role » Shift in culture » Specified positions » Sustainability » New EB Interventions: » Resources › ABFT and FBT-AN Accreditation – clinician/ » › MFBT-AN supervisor/trainer › New Maudsley approach Tania Withington, Director of Social Work Judi Krause, Divisional Director Richard Litster, Eating Disorder Specialist Salvatore Catania, Consultant Psychiatrist Child and Youth Mental Health Service Children’s Health Queensland Hospital and Health Service tania.withington@health.qld.gov.au 07 33109444 http://www.health.qld.gov.au/childrenshealth/ http://www.health.qld.gov.au/rch/professionals/cymhs.asp 10