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HRT0812 – Health Roundtable MHBG 2008. P E D A T. Paediatric Eating Disorders Advisory Team Demeter Child & Youth Mental Health Service. The Demeter Context. Demeter– growing population of 500 000 Projected population over next 5 years = 574 000) 0 – 19 years = 100 000

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  1. HRT0812 – Health Roundtable MHBG 2008 P E D A T Paediatric Eating Disorders Advisory Team Demeter Child & Youth Mental Health Service

  2. The Demeter Context • Demeter– growing population of 500 000 • Projected population over next 5 years = 574 000) • 0 – 19 years = 100 000 • Projected over next 5 years = 109 500) • Education facilities : • 51 state primary schools • 15 state high schools • 3 special schools • 20 private primary and secondary schools

  3. Our work context • 34 bed Paediatric Ward – • Paediatric Outpatient Department • 8 bed Child and Youth Mental Health Unit – • 3 community CYMHS teams – • CYMHS Consultation Liaison service

  4. An identified need…

  5. The problem… • Eating disorders - remain the most difficult and dangerous of psychiatric conditions to understand and treat • Treatment of eating disorders requires a coordinated, multidisciplinary, physical, psychological and other service interventions in, and across, a number of different health settings. (RANZCP, 2004; NICE, 2004) • “There is general consensus that a multiskilled and multidisciplinary approach is optimal…. (RANZP, 2004) • The numbers of presentations of eating disorders within the District was increasing • The age of presentations with eating disorders was decreasing

  6. The problem… • A typical young person’s journey : • Can begin with GP or private practitioner • Referred to paediatric and/or psychiatric outpatient care (often both) • Move to paediatric and/or psychiatric inpatient care (often both) and • Return to both paediatric and psychiatric outpatient care

  7. The problem… • These multiple treatment sites and their interfaces provide significant difficulty with: • Continuity of care • Holistic treatment planning • Fragmentation of service delivery • Poor skill level – low levels of clinician competence and confidence • Desire to reduce rates of re-admission (to both paediatric and psychiatric wards) • Early treatment drop-out • Lengthy episodes of care within the health system

  8. Solution found ? • No additional funding/resources were available • Initiative to develop a specialist advisory team rather than a specialist treating team to: • Provide expert consultation and advice • Facilitate sharing of knowledge and skills between treating clinicians and members of the advisory team • Facilitate the development of skills across clinical settings (paediatrics, cymhs and private practitioners) • Based on a collaborative approach between the departments of Paediatrics and Child & Youth Mental Health Services

  9. Advisory team members A group of expert health care professionals who utilised the best available evidence in assisting clinicians to plan and provide high quality care for those with eating disorders • Consultant Psychiatrist • Paediatrician • Dietician • Psychologist

  10. PEDAT was born… • Key objectives of the PEDAT – • provide expert assessment • advise on the identification, treatment, and management of the eating disorders Anorexia Nervosa, Bulimia Nevosa, Eating Disorders not otherwise specified, and related conditions • Provide specialist multidisciplinary care with an emphasis on improving and highlighting the importance of the ‘experience of care’ for young people and their carers

  11. Other PEDAT roles: • Provide input as requested to case conferences across both community and inpatient settings • Liaise with other service providers in the primary care and private care sector • Educate, advise and support GP’s and schools • Advocate for resources/services for young persons with eating disorders

  12. Maintain continuity of care with the treating team • Ensure ongoing monitoring, at various levels of intensity, of all children and adolescents experiencing eating disorders in our service • Provide coordinated care that was previously provided by paediatric outpatients

  13. The Process. . .

  14. The process. . . • The key method of provision is a monthly half day ‘clinic’ • Components: • direct consultation to young person and/or family and carer (as needed) - Paediatric review - Dietetic review - Psychiatric review • Case consultation to case manager (without f-f client contact) • Supervision and support of therapy • Option to provide all components, or some of

  15. The process. . . • Advice and recommendations for the bio-psycho-social management of the young person are provided • The core treatment remains with the case manager and the respective CYMHS Consultant Psychiatrist • Recommendations made to the clinical team - must be fed back through the treating teams clinical case conference via the case manager

  16. The process. . . An example • Example of a consultation session: • Case presentation – history; symptoms; formulation; areas of concern or questions for the advisory team • Collaboration in determination of priorities and care plan ie. what components/format would best meet the identified needs of young person • Implementation of plan • Team re-group and discuss findings and recommendations with case manager, family and client; answer questions; and clinical documentation

  17. An important part of the process… for us

  18. Paediatrician • Medical assessment • BP, PR, Temp • Ht, Wt. • General physical • Decide • Medically stable • Inpatient admission vs outpatient care • Designated bad guy

  19. The bearer of bad news • Diagnosis • You/Your child has an eating disorder • You/ your child might die • Treatment • Admission to GCH • NGT, blood tests, IV

  20. Dietitian • Detailed diet history • How detailed? • Physical activity • How much • What type • Purging & binging • Food behaviours & interests • Quasi – scientific knowledge

  21. Food Myths • Can’t eat after 7pm • Allergic to meat/dairy etc • Fat = fat • Fat from the shower/water/washing up • I have a fast metabolism • I come from a skinny family

  22. Food Myths • Vegetarians • “The poor animals” • Portion sizes • Misinterpretation of what ED is • Misinterpretation of what is normal eating

  23. PEDAT as a team • Treatment of eating disorders extremely difficult in isolation • Pressure off treating therapist • Talking about food & medical • Extreme end of bell curve • early intervention of children & adolescents disordered eating

  24. Sequence • PEDAT GCH Robina PEDAT • GCH • Paediatrician on-call • Dietitian on-call • CL Team

  25. Common scenarios in GCH • Once medically ‘out of danger’ • “Mum the <insert clinician> is being mean to me, I want to go home” • Denial – ‘I wasn’t really sick in the first place’ • Attempt to force parents to choose • Child and their love/affection • Rx of ED • Soln: parents choose not to choose • Warn parents in advance

  26. Recovery of Normal Function • Initial • Sometimes physically impossible to eat enough • NGT often only option • Role of TBK • Lean body mass • ED Vs Leukaemia • Long term • 90% of weight for height • Maintain for > 6 months

  27. Outcomes • Acceptance by clinicians • Acceptance by Paediatricians and Psychiatrists • Direct clinical supervision for paediatric monitoring and dietetic services • Communication of consultation advice back to the treating clinical team • Improved supervision and confidence for case manager clinicians • Improved continuity of care • Improved consumer/carer experience (“one-stop shop”) • Continuity of care within the advisory team • Maintenance of a holistic approach to care

  28. Challenges • Referrals of clients from outside the service • Triage criteria – when demand exceeds available appointment times • Acute versus early intervention

  29. Evaluation . . .

  30. A helpful reflection from another. . ..

  31. Prof Susan Sawyer (Royal Children’s Healthy Eating Clinic) “I started the healthy eating clinic with the whole idea of it being an early intervention service, trying to be a site that young people and their families could come to before all of the severity of anorexia nervosa in its full hand came into being. I think it is really ironic that we spent the first six years of running this service absolutely at the hard end – we only ever saw the most extreme cases of anorexia nervosa. Now that we are so well known for the service that we run, the really good news now is that in the last few years we have started to see much more exactly the sorts of cases that I had established the clinic to see. We still see the hard end, but in addition we see a number of young people at really the right time to be seeing them.” (VicHealth, 2004)

  32. In summary . . . • The formation of the PEDAT arose out of a need to better meet the needs of young people presenting to the health service with eating disorders • In the absence of resources to provide an appropriate (minimum) standard of care, it is our attempt to provide a multiskilled and multidisciplinary approach to children and adolescents experiencing the devastating effects of eating disorders

  33. In summary . . . • We have learnt an enormous amount, including : • the importance of expert case management; • of communication; • of holding the anxiety within the family; • and within the other health professionals; • the value of integration between inpatient and outpatient services • the delicate and complex nature of finding a balance between the medical, the nutritional, the psychological, the social …. • And the list could go on . . . . . .

  34. PEDAT’s future • Service enhancement – additional two specialist eating disorders clinicians • PEDAT provides a solid platform (specialist collaboration and team work ) for further service expansion • Estimated that 70% of clients will be managed through the Maudsley Model/CBT- E • Ongoing role of PEDAT for initial assessment by multidisciplinary team and ongoing monitoring of an estimated 30% of clients with eating disorders • Move towards balance between acute illness and early intervention • Increase capacity to assist with education and training • Merge with the state-wide initiatives • Further formal evaluation of service

  35. Acknowledgements This initiative has been developed through the leadership, commitment and dedication of : Dr Doug Shelton, Paediatrician, Director of Child Community Health Dr Nigel Collings, Psychiatrist, Director of Child & Youth Mental Health Services Ms Jodie Watkins, Assistant Director of Psychology, Child & Youth Mental Health Services Ms Lyza Norton, Senior Paediatric Dietician

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