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 19 th 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 Physiotherapy Surgical Preference Musculoskeletal Ax Physical Activity Levels Readiness & barriers Service Introduction: Obesity Related Chronic • Explaining role of PA in Lymphoedema-like swelling PMHx, Meds obesity management Level 3 Assessment: • Proforma and repeat Ax Sub-maximal fitness Ax & repeat: Social Hx Sleep & OSA: Cardiorespiratory health, Balance, Level 3 Intervention: ESS & Strength & function - TUAG, 90 sec • Individualised PA plan Screen STOPBang step test, 6MWT • MSk Ax and Rx Time • Sleep hygiene/OSA • QOL, Falls, ADLs Cardioresp. Ax and Rx Goal Planning, SM • LL swelling mgt strategies • Goal setting PARQ • 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: ons: • 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 22 nd of May

Attendance Telehealth Telehealth & F2F 200 New Patient Clinic 179 Telehealth & F2F Usual care 180 NPC & Reviews 152 160 148 91% 141 91% 140 89% 120 84% 89% 66% 100 80 60 27% 40 11% 7% 20 7% 5% 5% 5% 4% 0 January May August September Attended Did not attend Cancelled

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

Dietetics within the WMS Service Introduction: • Explaining role of nutrition in Level 3 Intervention: obesity management • Individualised food planning ❖ Group F2F → Group TH • Monthly review + treatment escalation ❖ Individual F2F → Individual TH + Individual F2F Level 3 Assessment: @ midway and final appt • Anthropometry & Biochemistry • Screen for ED Level 4 Intervention Pre-op: • Dieting history • Group dietary education (+ MDT) • Q’s / 10 day food diary ❖ Individual + Group F2F → Individual + Group F2F ❖ Individual F2F → Individual F2F • Individual dietary education ❖ Individual RD TH → Individual RD TH Level 4 Assessment: • Suitability for bariatric surgery Level 4 Intervention Post-op: ❖ MDT → F2F with TH option • Support with dietary changes ❖ Individual RD TH → Individual RD TH Cookery Club: • Support with dietary changes in MDT clinic • Practical nutrition skills for ❖ Individual F2F → Individual F2F 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 Ongoing review and support Behavioural intervention strategies Collaborative assessment HCP communication skills