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

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

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

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

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

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

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!!)

To Improve the Eating Disorder Service and Client Outcomes

Expand the service delivery for whole of life (0-65years)

Develop a range of treatment options – offering choice Increase clinicians knowledge through training and education

Improve access

Improve integration of care between medical and psychiatry

Improve therapies

Develop clear clinical pathways to facilitate a seamless journey

Utilise evidence based assessment and treatment tools

Promote data collection and analysis

Develop partnerships with clients, carers and stakeholders

Transfer knowledge to clinicians working in the face of eating disorders

Assist all professionals to identify, refer and support

Develop programs for carers / consumers

Enhance operational capabilities

Implement training

Enhance professional development and learning

Develop and embed research into practice

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

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.

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

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

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

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.

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