gillette children’s specialty healthcare · pmr (physical medical ......

Gillette Children’s Specialty Healthcare

16Sep~27Sep 2013

Katrine Chau, QEH

Sanne Fong, PMH

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Multi-disciplinary visit 2 Occupational Therapists Katrine Chau, QEH Sanne Fong, PMH 4 Nurses

Overseas Corporate Scholarship Program for AH Professionals 13/14 –


on 16Sep~27Sep 2013

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Why we choose Gillette Children’s Specialty Healthcare (GCSH) to visit?

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GCSH provides the highly specialized care that children who have disabilities and complex conditions need. The expertise’s are known worldwide. Gillette Children's is always changing to meet the needs of children, adolescents and young adults, providing medical treatment and technology to care for children with disabilities and chronic conditions

Objectives

1. Compare and contrast the service organization and care delivery model between overseas and Hong Kong

2. Explore the feasibility of adopting new service model / protocols/ guidelines in Hong Kong

3. Acquire an understanding of the disease / condition management 4. Appreciate the collaboration of the multi-disciplinary team in

related care service 5. Gain an understanding on the inter-facility communication and

coordination to ensure continuity of care 6. Identify the areas where training needs to be improved and able to

set up associated training curriculum for service development 7. Evaluate the effectiveness of related services through Allied Health

quality framework

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Date Course / Remarks

Day 1

(16/9) General Orientation Program of Gillette

Children’s Specialty Healthcare, U.S.A. Introduction of the Neuro-rehabilitation,

rehabilitation with advanced technology Transition from in-patient to out-patient

rehabilitation and community rehabilitation Day 2

(17/9) In-patient Rehabilitation Round Complex Movement Disorder Clinic In-Service training: Psychiatric & Behavioral Management of Post Concussive Syndrome in Children & Adolescents

Day 3

(18/9) OT Advance & Competencies

Day 4

(19/9) Burnsville Clinic -Seating clinic, OT, PT, ST, ATD, Rehab medicine physicia

Day 5&6

(20~21/9) Feeding course

Get Permission Approach to Sensory Mealtime Challenges

22/9 Sunday 5

Program Content

Services

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Services of the center Rehabilitatioin Therapies

Upper-Extremity Therapy Services

Seating and Mobility Evaluations

Assistive Technology Services

Feeding clinic ~ Information for Familites and Health-care Providers

Neurotrauma Clinic

Center for pediatric Neurosciences

Gillette Lifetime Specialty healthcare: St. Paul – Phalen clinic

Center for Gait and Motion Analysis

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Burnsville Clinic

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Remote convenient clinic of Gillette service

Serve outpatients around the local region

Including multidisciplinary services

Seating evaluation, seating clinic

TBI speech therapy

Splints

Botox clinic (with EMG)

Feeding Clinic

NMES (neuromuscular electrical stimulation)

PMR (Physical Medical Rehabilitation)

Pool therapy Observation with CCTV projection of hydrotherapy

Complex movement Clinic Jointly seen by Rehabilitation medicine physician,

neurologist and neurosurgeon

For decision of medical treatment for complicated cases

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Feeding Clinic Jointly assessed by OT, ST & Dietitian

OT: oral-motor skills and sensory based issues,

feeding skills of care giver; meal preparation,

ST: swallowing skills and VFSS; vital stimulation

Dietitian: nutritional issue, concerning intake, supplement, ? Knowledge of gastrotomy

=> generate a new/ optimal schedule of meal time and use of supplement; best posture, mehtod and support during swallowing

Respiratory Therapist >30 RT shared between Regions hospital, and Gillette Childrens

Consultation by referral

For all pulmonary and respiratory problems for paediatric and adult cases

Care giver and nurses education, suction, change of trache, titration of oxygen; recommendation of ventilator and mode of use and other accessories for resp problems

Just for in-patients, ensure patient can return to home with optimum level of support

? IDSP program model for tele-medical consultation by nurses

Then cases will be follow up in OPD by physician

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Advocacy of Family support

Family Voices of Minnesota ~ keeping families at the center of health care

Parent to parent

Do you know a child who could benefit from a medical grant?

Kids live better at home

Pacer Center~ champions for children with disabilities

Pediatric services : providing exceptional care for children at home

Helping more families find strength in numbers begins with 1

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Family service Recreation therapy

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AAC Jointly assessed by SLP and OT and provide treatment

To get the cognitive level/ response level of clients

Try out different kind of switches

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Seating Evaluation Jointly seen by OT, PT, ASD

and vendor

Provide instant assessment and make decision at once,

Anticipate to wait around 3 months time the 1st fitting

On loan by vendor for trial of 1 week at home and wherever need to go

ASD will be responsible for the tailor-made device, including AAC mounting

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Lifetime Clinic Cater for cases transition from paediatric to adult

Out-patient base

? All Gillette case will be entertain in Lifetime Clinic?

CP

Epileptic

Spinal bifida

Neuromuscular

poliomyelitis

Provide continuum care

Tackle multiple problems in adult life including sex counselling

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Lifetime Clinic

Efficient One-stop service as patients live far away

Self-finance => fund raising projects

Patient & family-centred service model

Brachial Plexus Service Clinic, seen by orthopaedic surgeon

Pre-clinic Hand function assessment (Active Movement Scale, Modified Mallet Assessment) with recommendation for home programme

Hand splint;

Scar management

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Hand Clinic Evaluate by hand surgeon

Expect OT will fix the condition upon referral on the same day

Spasticity evaluation PT

OT

Rehabilitation Physical medicine

Neurosurgeon

Ortho physician

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Advanced clinics Complex movement disorder clinic

(physician, neuro-surgeon, nurse, neurologist)

Spasticity Evaluation clinic (physician, ortho surgeon, neurologisst)

Therapist’s role: pre-clinic assessment and video taking

Armeo demo Provide environment for gravity assistive training

(not robotic)

Benefit those cases with acute phases

TBI

Young stroke

SCI

Brachial plexus injury

? Hemiplegia

3 sessions x6weeks or 2 sessions x9 weeks

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Gait analysis

4 PT & 5 engineer/technician, 1 PTA

15 gait analysis, make recommendation

For diagnostic purpose, pre-surgery assessment, then follow up one year, one-stop-service

Energy consumption as outcome indicator of treatment

Dynamic EMG for both LE & UE with instant video

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Courage Centre Out-patient rehabilitation, 40 in-patient beds waiting for foster-family

Pool & gym are program based, open to public PH as recreational facilities

ABLE program 3sessionsx5daysx12weeks

Activitiy-Based-Locomotor-Exercise, run by fitness specialists

For SCI & neuromuscular condition (11 to 60)

Wellness and fitness of clients

Vocational rehabilitation (4 weeks job-readiness training) Assessing and training of ability, skills, behaviour

AT introduced by staff who is severely handicapped

SPORTS & recreation

Clinic

Multiple purpose Rm: AAC & Tele-medical consultation

Paediatric & adolescent service

Thera-suit method

Healing garden

Dr. pet visit daily

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Patient management / Service model**

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Inpatient Rehabilitation Round Coordinated by Rehabilitation coordinator, lead by paediatrician Weekly round for setting goal of rehabilitation plan, Priority for

the week ahead (how to support goal for d/c) Case information Medical update Goal for discharge, with discharge date (will be changed according

to patient’s progress) Community re-entry Family education Equipment Positioning/mobility Cognition Medical Selfcare Transition (to out-patient)

family dynamic Strength Barriers

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Inpatient Rehabilitation Round Protocols/ treatment guidelines of specific disease

such as SDR

Role delineation among OT, PT, CP & ST

Role of OTA

Who is responsible for training of PCA?

Licensing of home visit

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Integrated Rehabilitation Plan

In addition to rehabilitation round, discharge goal

Treatment goals and progress will be recorded right after treatment;

Record in the EDM system

All disciplines can share the progress of the case

WeeFim will be filled by different disciplines

Rehabilitation plan will match with the discharge goal set in Rehab round

Discharge summary that indicate difference between initial in-take and pre-discharge status

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Neuro-palliative care round Weekly round

Team members included:

Physician

Social worker

Chaplian

Nurse

Pharmicist

No fixed ward for palliative, but referral based,

Prepare parents for planning of “end-of-life” service

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Discharge process Patient-family service

More community based, social worker will due with the community service; ? Need for financial support, home helper, home modification

CP will liaise with school for additional help to school, personal assistant in school

Biweekly family conference, whoever involved in the treatment of the case will sit

Checklist according to discharge plan

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Nurse round

Facilities

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Healing Garden Donated by a family that has benefited from Gillette, the

family involved in design => design from user’s perspective

Different texture of floor

Ramp and stairs

Multisensory

Musical instrument

Shaded area: mail box for ventilate joys or sorrows

Different plants

Playground facilities, for climbing and crawling,

Limited entry, for Rx purpose

Playhouse

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Healing Garden in Gillette

Ronald McDonald House Build inside the hospital

Daily operated by volunteer

Home like atmosphere

Support 3 families

Free for food, laundry service

For transition

For parents’ overnight

Provides respite, comfort, convenience to a New Community of Familities

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Laundry service by parents

Family resource centre

Double bed room and single bed room vs isolated bed

Bathing facilities

Fund donation

Printing material of individual needs

d/c from hospital => school with IEP,

Service government subsidy vs private insurance

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Patient Resource Centre

Gait Lab

Assistive Technology Dept Seating device

Cranio-cap

Prosthetic & orthosis: Brace for correction of

scoliosis

Lower limb multi-level hinged brace

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Assistive Technology Dept Efficient

Brace in 1-2 days

Participated in seating evaluation, tailor-made seating device, with commercially available frame from vender

Clear role delineation of technician and clinical staff

Attend Rehab Round

Colourful material with client’s preference

Material are more advanced => enhance efficiency

Use of CAD

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Information from patients’ perspective Educational material for self management

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Educational pamphlets

Epilepsy life stages ~ preteens and early teens

Brachial plexus injuries

Juvenile rheumatoid arthritis

Neuromuscular conditions

Center for Cerebral Palsy

Managing Spasticity~ our family-focused approach to treatment

Cerebral palsy Road map: what to expect as your child grows

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Educational pamphlets for parent

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• Mobility

• Musculoskeletal

• Communication and cognition

• Feeding and Nutrition

• Social/ Emotional Development

and Behaviour

• Self-Care and Daily Living Skills

• Sensory Functions

• Recreation & Fitness

Assessment and Intervention

Key providers in Care Team

Educational package

After your injury ~ information and resources about neurotrauma

Working together: your guide to Brain injury rehabilitation at Gillette

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Package encourage self-management

All About me

At a glance: my health information, medical needs and relevant documents

Make your move! A transition guide for teens

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Tube feeding for love educational workshop for parents and care givers Information from expert (Marsha Dunn Klein)

Sharing among parents

Introduction of the web-site “meal time notions”

Offer information for parents Tube feeding with potential to change into oral feeding

Keep interact with babies during the tube feeding process

Workshop runs after office hour to facilitate working parents to participate

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Staff development

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In-service training Psychiatric Management of child & adolescent with concussion Culturally related due to high volume of sports injury

among kids and adolescent, considered as Neuropsychiatric disorder, will last for 6/12

6-35% mild TBI result in post-concussion syndrome

Collaboration of medical, rehabilitation and psychiatric for follow up the case and family

ADHD symptoms, depression, anxiety, irritability

Functionally include poor sleep quality

Rx methodology: CBT, behavior intervention for sleep

Grief as kids may not be able to return to previous sports

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OT Advance leadership workshop OT competency

Evidence based

outcome

Pros & cons of specialization,

? Wise therapy investment

What to do in the next 5 years

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The Center for Pediatric Rehabilitation The inpatient rehabilitation programs and services include:

Acquired Brain Injury Program (BI)

Cerebral Palsy Program-Selective Dorsal Rhizotomy Service (SDR)

Other Comprehensive Inpatient Medical Rehabilitation (CMR)

Spinal Cord Injury Program (SCI)

Rehabilitation post Complex Orthopedic Surgery –Single event multilevel surgery (SEMLS) Service

There are 18 in-patient beds in Gillette’s rehabilitation units.

In general, the patient’s length of stay is 3 to 6 months. On average, the number of admission is 105 per year.

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Manpower There are many part-time staff in Gillette and their working

hours are very various. This flexibility in working hours results

in low turn-over rate. In September 2013, the overall full-time

equivalents (FTE) manpower is 1111.

Case observation PT with Locomat

School for Mathematics

OT for electrical stimulation

ST

2xsessions PT, 2xsessions OT, 2xsessions School 2xsessions ST 1x music therapy 1x recreation therapy

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People we met in


FEEDING COURSE Marsha Dunn Klein, M.Ed., O.T.R./L.

Tonya (OT)

Advance Technology Department

Lifetime Clinic

Hand Clinic w/

Dr. Ann Van Heest

Whole team dine with Janey (PT), Tonya (OT) & Candace Vegta (SLP, course coordinator)

Dr. M Gormley Paediatric Rehab

Medical Physician

Team life in Twin Cities

Objectives 1. Compare and contrast the service organization and

care delivery model between overseas and Hong Kong

• PCA service facilitate return to home (over-night, or 24 hr PCA can be parents, but hired by rehabilitation agent)

• Level 1 trauma centre, supported by rehabilitation service • Cases referred by other hospitals, follow through the rehabilitation,

• Screen by Rehabilitation Coordinator, endorsed by rehabilitation physician, then further assessed by nurse; and team evaluation

• No NICU, but situated in Region Hospital • Neurosurgeon will support other hospitals • Ronald McDonald Family Home => transition home to facilitate return to

home programme • No step down service • Emphasize on education of care taker, PCA, • Rehabilitation Garden

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Objectives

2. Explore the feasibility of adopting new service model / protocols/ guidelines in Hong Kong

• Pre-surgery thorough assessment and planning for SDR cases (same in HK)

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Objectives

3. Acquire an understanding of the disease / condition management

• Parent-to-parent volunteer service as peer support

• Complex movement clinic

• Spasticity evaluation clinic (same in HK)

• Hand clinic (same in HK)

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Objectives

4. Appreciate the collaboration of the

multi-disciplinary team in related care service

• Early discharge plan

• Mini-round (everyday), each case with a mail box, include nurses, physician and therapists

• Multidisciplinary weekly round, coordinated by rehabilitation coordinator,

• Task specific, with a separate team for planning of rehabilitation schedule, with automatic system for pottering of patient that saved professional time; patient and relative can refer to the schedule and empower self-management

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Objectives 4. Appreciate the collaboration of the

multi-disciplinary team in related care service

• Social work, CP & rehabilitation coordinator

• Chaplain

• OT, PT, ST

• Physician, case surgeon,

• Handover time include not only nurse but also assistants

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Objectives 5. Gain an understanding on the inter-facility

communication and coordination to ensure continuity of care

• Partner with other hospitals and set up satellite clinics

for regional population

• Burnsville Clinic in Fairview Pediatric Rehabilitation

• Courage Center in Golden Valley

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Objectives 6. Identify the areas where training needs to be improved

and able to set up associated training curriculum for service development

• 3 levels of training

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Objectives 7. Evaluate the effectiveness of related services through

Allied Health quality framework Services being observed include inpatient acute rehabilitation,

out-patient services for both pediatric and transition to adult clinic, Feeding Clinic, Seating evaluation, Brain Injury Program, Brachial Plexus Clinic.

Centers of Excellence included Center for Cerebral Palsy, Center for Pediatric Neurosciences, and Center for Pediatric Rehabilitation.

GCSH has partner with other hospitals and set up satellite clinics for regional population, including Burnsville Clinic in Fairview Pediatric Rehabilitation, Courage Center in Golden Valley. Both facilitate clients with disability transition from adolescent to adulthood.

Training and supervision of professional staff are centralized so that service are aligned and much cost-effective.

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Additional points to learn from GCSH:

Joint a 2 days multidisciplinary certificate course in feeding. Audiences included occupational therapists, speech pathologists, and dietitians. Hence all parties will share similar language for communication.

Appreciate the collaboration of the multi-disciplinary team in related care service

Gain an understanding on the inter-facility communication and coordination to ensure continuity of care

could identify some improved areas for setting up associated curriculum or service guideline

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Care Team ~ Key providers are in bold

Adaptive Equipment Specialist/

Vendor of Medical Equipment

Audiologist

Child Life Specialist

Neurodevelopmental Pediatrician

Neuropsychologist / Psychologist

Nurse/ Nurse Practitioner

Orthotist

Ophthalmologist

Pediatric Neurologist

Pediatric Neurosurgeon

Pediatric Orthopedist

Pediatric Rehabilitation Medicine Physician

Respiratory Therapist

Sleep Health Specialist

Social Worker

Therapeutic Recreation Specialist * (done by OT in HK)

Occupational Therapist

Physical Therapist

Speech and Language Pathologist

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Multi-disciplinary activities

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Future Plan

Multi-disciplinary approach to introduce normal mealtime programme for children dependent on enteral feeding

Plan:

To implement a pilot multidisciplinary normal mealtime programme for children in need of tube-feeding in CMC, DKCH, QEH, TMH and PMH.

Long term goal:

to develop a protocol for encouraging children in need of GT feeding to receive proper treatment without losing feeding ability

Short term goal:

to try a one-year pilot cross-district multidisciplinary project including nurse and OTs in education of family of GT care and oral-feeding training

Common challenges

Action plan in principle and brief schedule Plan/ Item Details Timeframe

Arrange presentation to ask for support from clinical department

Identify inclusive criteria 1. Those just decided to have GT 2. Those kids may consider wean off GT

1Q2014

To develop written education material for parents and introduce to related professions

1. Nurse: in stoma care, NGT care 2. OT: importance of normal meal time

1Q2014

Recruitment of cases

To identify outcome measures for the pilot study And recruitment of cases (3-4 cases x 5 hospitals = 15-20 cases)

2Q2014

To introduce treatment guideline/ protocol to other hospitals

Documentation Preliminary result analysis Final analysis

4Q2014 1Q2015

Detail action plan for pilot project Suggested actions Details

Responsible colleagues

Schedule

Get Clinical support to implement the project in the 5 hospitals

Dr. Bill Chan (UCH), Dr. CK Li (PWH) Dr. CY Lee (CMC), Dr. Kwong L(TMH) Dr. W Tse (QEH), Dr. N Tse (PMH) Dr. SL Lee (QMH/DKCH)

Carol & Sanne

4Q2013

Define Inclusive criteria

1. Children fed by NG/ gastrostomy/gastro-jejunostomy tube, 2. Medically stable and safe oral feeding 3. Caregiver would actively participate in the feeding

training/ treatment

Katrine & Maxica

4Q2013

Suggest and design documentation format of outcome measure

1. Amount of oral intake (frequency, tolerance), pre-post 2. Feeding behavior checklist (still searching Chinese

validated tool) 3. Enjoyment of mealtime satisfaction (subjectively rate by

caregiver)

Template ready by 1Q 2014

Educational pamphlet 1. Feeding material 2. Gastrostomy care 3. NGT care

OT team Nurse team Nurse team

1Q 2014

Implementation of the project

1. start oral feeding training by OT when they are in-patient; 2. Education on tube feeding and care will be provided by

nurse before discharge. 3. Follow up in OPD by OT

Joint disciplines effort

2Q 2014

Data analysis OT team 4Q 2014

Introduce treatment guideline/ protocol to other hospitals +/- NGOs

Joint disciplines effort

1Q 2015

Inspirations / reflections Training of therapists

Invite expert to deliver special topic

Encourage therapists to take up research projects by funding => LR, suggest project, implementation

Manpower

Allow different contract type => for retain staff

Support by volunteers

Fund raising for special projects

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HKCH … a centre of excellence that provide client-centred service

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gillette children’s specialty healthcare · pmr (physical medical ......

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