Transcript Nurse Practitioner Candidate Eating Disorders

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Background to the NP development
Role of the Steering Committee
Service Drivers
Current SH Eating Disorder Service
Service gaps
Key NP Principles
SH strategies for Eating Disorders and how they align
with the NP directives
NP Model of Care
SH ED Model and where the NP fits
Examples of cases
Questions
2009 Southern Health recognised that the
demands for Eating Disorder Services were
exceeding their current resources to
provide best practice and cost effective
care
 An overview of the eating disorder service
resulted in the “southern health mental
health body image and eating disorder
service: an integrated service through the
lifespan”
 Key being to develop the right workforce
 NP position was identified as a priority
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October 2009 received funding from the
Victorian Department of Health Nurse
Practitioner Project round 4.6
Enabled employment of a project officer
Began with a gap and growth corridor analysis
(key stakeholders, general medicine, mental
health, community access)
SH endorsed the MHED NP Model of care
developed by the SH MHEDNP Steering
committee in June 2010 (established at onset
of the project officer)
Commenced role in August 2010 as a
candidate
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Consists of key stakeholders from general medicine,
mental health executive, southern health executive,
clinical director of primary partnerships, director of
CAMHS and adult, head of medicine (adult and
adolescent), director of consumer and carer
relations, manager of nursing strategy, dietetics,
pathology, and pharmacy
Ensure alignment of the new service model and
strategic frameworks of the MHEDNP
Developed a governance structure for the role
Identified key supports
Conducted a risk analysis
To provide ongoing support
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Because Mental Health Matters Reform Strategy
(2009)
National Eating Disorders Collaborative Framework –
phase 1
Fourth national mental health plan
Southern Health Strategic Planning
Southern Health Nurse Practitioner Framework
Need to respond to increased demand for early
prevention, detection, integrated pathways and
specialist services for the adult population with
moderate to severe cases
Decrease incidence of chronic mental and physical
health across the community
Pockets of service dispersed throughout the
hospital (adolescent medicine outpatient
and inpatient unit, BDP for 12-24 yr olds, 2
inpatient beds for all of Southern region,
and no male access or adult service)
 Services generally not integrated
 Clinical Expertise ad hoc
 Variants between ages and services
significantly different
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MHEDNP Service gaps were explored
through the utilisation of an NP model
development tool
In: what clients, when, when not, where, by
whom?
How, what: advanced assessment,
diagnostics, therapeutic interventions, and
advanced technical skills
Out: referrals, admissions, discharge, and
transfers
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No service wide integration between adolescent and adult
No clear leadership or co-ordination
Lack of consumer and family involvement
No shared care model – multiple streams
Lack of identification and service
Multiple referral pathways between medicine and psychiatry
No funded outpatient service or day program for the adult
population
No adult specialist stream
Different care models
Limited beds and location (inadequate)
Lack of clinical expertise both inpatient and community
Lack of accurate data
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Model does not replace existing services
Not to care for the “easy/simple cases” or to take
over other peoples roles / responsibilities
Designed to be an adjunct to the current service
Designed to utilise the advanced clinical knowledge
and skills in psychiatric, physical and nutritional
assessment and treatment
Although autonomous, given the nature of
complexities and co-morbidities a collaborative MDT
is essential
Model is living and dynamic – expected to develop
and adjust (has done in last 3/12!!)
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To Improve the Eating Disorder Service and Client Outcomes
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Expand the service delivery for whole of life (0-65years)
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Develop a range of treatment options – offering choice
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Increase clinicians knowledge through training and education
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Improve access
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Improve integration of care between medical and psychiatry
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Improve therapies
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Develop clear clinical pathways to facilitate a seamless
journey
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Utilise evidence based assessment and treatment tools
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Promote data collection and analysis
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Develop partnerships with clients, carers and stakeholders
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Transfer knowledge to clinicians working in the face of
eating disorders
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Assist all professionals to identify, refer and support
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Develop programs for carers / consumers
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Enhance operational capabilities
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Implement training
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Enhance professional development and
learning
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Develop and embed research into practice
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Redesign processes so that data is
embedded
Entering the MHEDNP Care:
 Referrals from clients, families, clinicians and stake
holders accessing navigation through the ED service
(one point of access)
 Clients requiring psychiatric and/or physical
assessment and treatment
 Resource and support for clients, families and service
providers
 Referrals from psychiatric triage, outpatient access,
inpatient settings such as general medicine and
psychiatry, emergency departments, consultation
liaison, primary care, community health centres,
private care, and case managers
Care Provided:
 assessment, treatment and diagnostic
clarification, clinical care coordination,
case management, consultations (primary,
secondary and tertiary including internal
and external), research, education,
leadership and service development
 Resource and support for clients, families
and service providers such as primary care
and medicine
Transition:
 general practice, private, community
health centres, and generic case
management
Ordering tests such as pathology, xrays,
bone density scans, ECG, and
Echocardiograms
 Medications – anxiolytics,
antidepressants, antipsychotics, mood
stabilisers, and nutritional supplements
 Admissions, referrals, transfers and
discharges
 Advanced Physical Health monitoring
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Southern Health Eating Disorder service is
currently under review and redevelopment
The vision being that the NP ED will be at the
forefront of the service
Roles including Intake and engagement.
This will entail the person to undertake a full
medical, physical, nutritional and
psychological advanced assessment.
Formulating a diagnosis and developing a
clear and precise treatment plan that fits
within evidence based practice.
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A.S is a 52 year old single lady. Presented to ED
with complaints of neck pain. Patient planned
to be discharged home but dietician on call
noted low weight.
On further review patient weighed 21kg
On 90mg methadone
Medical seeking psych admission
Psych seeking medical admission
Informed medical tests within normal
parameters
Request need for refeeding on a medical ward
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Review in C/L while on General Medical Unit
Conflict of decision of treatment
In hospital 6 weeks ( three weeks taken to formulate
a diagnosis and treatment plan)
Eventually NGF
Then D/C to psych IPU with a diagnosis of Anorexia
Nervosa
During admission complex needs – had to have head
shaved due to state of hair, reduced methadone as
intoxicated on the dose, utilities at home had not
been paid for months and at client was at risk of
eviction following complaints from neighbours
Long term plan – case management and CTO
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27 year old recently arrived in Melbourne from
Sydney to study art therapy.
On newstart allowance
Referred by private dietician to NPC due to low
weight and request for further support
Presented with a long hx of AN from age 14 with over
10 admissions all involuntary in USA, Perth and Sydney
Medically stable and biochemistry within normal
parameters.
Patient agreeing with outpatient treatment though
30kg (BMI 11)
Patient has private health insurance
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Private unable to accept for treatment / admission as
client under a BMI < 16
Day Program in area stops at 24yrs old
Plan – further Ax by NPC over a course of a number of
weeks, to ensure engagement with the service, to ensure
medical monitoring was undertaken, and to engage the
client in treatment
Over 4 weeks, emergence of further complexities: Chaotic
and disorganised, moved house x 3, ? Hyomanic, safety
issues at home (leaving iron and stove on), exercise ++,
……but client engaged and compliant with all
appointments and treatment plan
Recommended to take low dose Olanzapine – had been
on prior and had shown improvement in cognitions and
behaviour.
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During the treatment client then moved OOA
NPC referred patient to the eating disorder service in
the area
Ax agreed – during which patient was
recommended under the Mental Health Act on
grounds of hypomania. Though beds available in
Eating Disorder Unit patient was refused admission as
acutely disturbed. Admitted to adult inpatient acute
psychiatry bed as an involunary patient
During admission the treatment focus was the
hypomania.
No Management of her Eating Disorder was followed
despite intensive consultation with the ward
And on discharge – client was transferred
again OOA with the view that she would
initiate engagement with the eating
disorder services in that area