Reflections on a UK model of a regional flexible multidisciplinary team

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Reflections on a UK model of a regional
flexible multidisciplinary team

• Peter Martin
• Clinical Director, Palliative Care
• St. Vs Melbourne, EH, EPC

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Accident or Design?

• Initial motivation for integrated palliative care
  service came about due to posts in SE Melbourne
• Mainstreamed Palliative care Unit in MMC
• Community VMO for SEPC
• Mixed Urban / Rural service
• Consultative Service MMC DGH
• Hon Monash Uni esp. re med UG placements
• MIPH as informatics research scholar

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Patient Carer Impact

• Frequent powerful comments about
• Continuity of care
• Lack of duplication of assessment interventions
  
• Rapid access to inpatient facilities
• Early intervention by psycho-social team
• Crisis response
• Communication with patient carers
• Overall a sense that somebody in system knew
  them
• Ability to plan UG placements integrate research

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Missing the UK- New Post
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Under One Roof

• Dedicated reception staff
• Co-located with volunteer run info resource
• Also regional pall care central access pt, profs
  pts
• Chemo day unit
• Outpatient centre
• Day hospice
• Integrated in-patient
• Haematology, oncology pall care

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The Early journeyProfs perspective

• Breast Cancer MDT
• All cases private public (mandated audited)
• Whole team
• BC Nurses, Radiographers, Clinical trials Nurses,
  CNC Chemo DU, Med Onc, Rad Onc, Pall Care (Met
  disease 1st or last), HistoPath, Radiologist,
  Breast Surgeon
• Case presented by BC Nurse
• Discussion debate, almost all contributed
• Consensus plan documented agreed who would see
  them in clinic
• Clinic immediately afterwards clearly minority
  metastatic disease at presentation but support
  offered in pro-active manner

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A regional way of multi-professional working

• What would make it work?

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The Advanced journeyProfs perspective

• Initially palliative team meeting
• Replaced 7 other meetings!!
• Started week after my arrival
• Core
• Mac Nurses (CNCs) from community and hosp,
  Chaplains, OT (asst who rep Physio), CAST (Equiv
  RDNS liaison), Pall Med Phy, Clin Psychology
  (PhD stud), Social Work, Outpatient Nurse, NUM
  from IP unit designated pall care lead nurse,
  Care team manager from 3 day hospices, Lung CNC

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Floating / Flexible Team

• GPs
• District Nurses
• Often came as group
• Breast care CNCs
• Colo-rectal /Stoma CNCs
• Speech Pathology
• Dietetics
• Physiotherapy
• Social workers from other units
• Clinical trials nurse

• Many brought students as found it useful way of
  understanding the whole pathway for patients
• Clinical Psychology PhD students often helpful
  with supervision from Dept head

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Structure of Meeting

• Held in day hospice
• 845-1030
• Pts _at_ 11 so running over time not an option!
• 3 rotating chairs
• Chair vital to keep focused
• Monthly education
• ¼ ly service planning meeting
• (845-1010-11)
• Annual away day
• Mandated NSF

• Agenda
• Visitors always top priority unless they wished
  to stay for prof development
• Ward staff next
• Then the rest

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Rotating the order for the rest

• Community patients
• Outpatients
• Hospital day Hospice
• Integrated Day Unit
• CDU, Day Hospice
• Tapping House
• Charity funded
• Deaths Discharges

• Consultative service
• CAST
• Community Hospital had some nominated PC beds
• Only inpatients formally presented as such by
  Intern

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What we documented

• Which patients discussed
• Free text of main problems
• Goal of care for each patient
• Key worker
• For complex cases case manager who all
  decisions went through irrespective of
  organisation
• Action and who was responsible for actioning plan
• Most had only 1 or 2 actions

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The next leap forward

• Successful application for 1st ever integrated
  cancer care Intern post
• Linked to new intern training requirements
• Thus shared between pall care, haem onc
• Net result is that Oncology inpatients presented
  at this venue
• Both med onc rad onc medical staff attended as
  well as CDU staff CNC

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Observations

• Initially everyone thought they knew all about
  the patient
• Obvious surprise about how much others knew
• Most surprised how often this cumulative
  knowledge was vital or influenced management
• Also useful to get perspective from those who
  heard whole story but didnt know patient this
  grounded team
• Less duplication as actions designated
• Overall, less us them much more of us
• Frequent people commenting on support and
  educational role of attending meeting

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Challenges

• Some wished to stay in smaller team
• Initially tended not to contribute but gradually
  resolved
• Bereavement service coordinator unable to attend
• Keeping meeting focused
• But allowing all to contribute
• Now making it too bio-medical
• How to not let same pts discussion dominate
  meeting
• Not useful as debriefing forum
• Focus was on those that need specific bereavement
  support
• Chair role challenging

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Reflections

• Felt more patient centred
• Contrast with service centred
• May only be applicable to certain population size
• May be useful in
• Regional advanced tumour streams?
• Sub-regional palliative care approach?
• Useful to address care pathway issues
• Team ethos of education, QA research enhanced

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Discussion

• martinpe_at_svhm.org.au