Mental Health Eating Disorders Nurse Practitioner Candidate Service Model

1. Mental Health Eating Disorders Nurse Practitioner Candidate Service Model Southern Health Alyson Wheelhouse

2. Presentation Outline • 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

3. Background • 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

4. Background • 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

5. Steering committee • 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

6. Service Drivers • 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

7. Current Eating Disorder Service • 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

8. Service gaps 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

9. Service Gaps • 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

10. Key ED NP Principles • 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!!)

11. SH key strategies and how they align with the NP Role • 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

12. 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

13. Enhance operational capabilities • Implement training • Enhance professional development and learning • Develop and embed research into practice • Redesign processes so that data is embedded

14. Current SH Mental Health Eating Disorder NP Model of care 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

15. Current SH Mental Health Eating Disorder NP Model of care 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

16. Current SH Mental Health Eating Disorder NP Model of care Transition: • general practice, private, community health centres, and generic case management

17. Advanced Scope of Practice • 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

18. New Service Model (where the NP role may sit within the newly developed whole of life eating Disorder Unit) 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.

19. Case Examples • 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

20. 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

21. Case example • 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

22. 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.

23. 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

24. And on discharge – client was transferred again OOA with the view that she would initiate engagement with the eating disorder services in that area