A Coordinated Local Approach to Disordered Eating Services

Summary

This project improved care delivered to people with eating disorders in Broken Hill and surrounding areas in Far West Local Health District (FWLHD). It focused on increasing clinicians’ skill and confidence by providing education sessions, improving access to resources and increasing opportunities for professional networking.

Aim

To increase the skills and confidence of local clinicians in identifying, diagnosing and treating eating disorders by 50 per cent, by January 2017.

Benefits

• Improves the skills and confidence of local clinicians in identifying, diagnosing and treating eating disorders.
• Improves standards of care for eating disorder clients and their families or carers.
• Increases awareness of eating disorders across a range of clinical areas and the community.
• Improves the management of referrals to eating disorder services.
• Enhances collaboration among clinicians that offer eating disorder services to the community.
• Increases awareness of local resources and helps doctors access them quickly and easily.

Background

Eating disorders are complex conditions that require a multidisciplinary approach to care and treatment. In 2013, NSW Health released its Service Plan for People with Eating Disorders. It states that local health districts “need to provide leadership in service development strategies that enhance the assessment and treatment of people with eating disorders at all levels of need and link care across sub-specialities, across public and private providers, across age groups and across clinical settings”¹.

A report commissioned by the Butterfly Foundation in 2012 suggests that around four per cent of the Australian population are affected by eating disorders to clinically significant levels¹. In Broken Hill, this would be approximately 780 people. However, prior to the project, referrals for eating disorders were less than five per year and mental health services reported low levels of diagnoses for these conditions. This suggested a significant unmet need for services targeting people with eating disorders and those yet to be diagnosed.

In March 2014, the National Eating Disorders Collaboration held a forum in Broken Hill that was well attended by health service clinicians and community service providers. It was agreed that eating disorders were more common in Broken Hill than referral data suggested. There was also confusion over what services were available and how they could be accessed. This confusion was confounded by a lack of confidence in many doctors to provide treatment to those with eating disorders, as it was seen as an area that requires specialist advice.

Dietitians and staff from the Child and Adolescent Mental Health Service (CAMHS) noted the number of clients with eating disorders or significantly disordered eating patterns had increased in recent years, further increasing the need for improved coordination and level of care in Broken Hill. However, no significant changes or interventions had been made since the forum in 2014. In addition, many local health positions were being filled by recent graduates who were new to the role and the local area, resulting in a lack of professional links between and within organisations.

Implementation

1. Online survey

An online survey was sent to relevant stakeholders, including FWLHD departments, local doctors, allied health staff, high school teachers, social services workers and the Far West Primary Health Network. This measured their level of skill and confidence in identifying, diagnosing and treating eating disorders. The survey consisted of 17 questions, as follows:

• three questions seeking demographic information
• two questions that gauged the level of contact with eating disorder clients
• eight questions about confidence in diagnosing and treating eating disorders
• three questions about knowledge of available resources
• one open question for comments or suggestions.

2. Service analysis

A service gap analysis and planning meeting was held with all FWLHD departments, general practitioner (GP) practices and non-government organisations in Broken Hill. A driver diagram was developed to identify the root causes of eating disorder service issues. Results from the survey were combined with the driver analysis to identify interventions that would address the key issues. These were:

• an electronic resource compendium (ERC)
• in-service education on eating disorders
• a community of practice network
• a local referral and treatment pathway.

3. Electronic resource compendium

An ERC was developed to increase awareness of local resources and make sure clinicians could access them quickly and easily. It contains electronic versions of screening tools, assessment plans, medical management guidelines and patient and carer brochures. It also contains a collection of links to useful websites for clinicians, patients and carers. A version was also created for local high schools, with tailored teacher and school-based resources and student brochures.

Brightly coloured USBs with large colour-matching tags were used to share the ERC with GP practices, high schools and relevant FWLHD health services including dietetics, mental health, emergency care and paediatrics. This made sure they wouldn’t get lost on busy wards or in staff rooms. A face-to-face orientation was also provided, to highlight the most useful resources for individual roles or wards, as well as what information can be found through the website links.

4. Staff education

In-service education sessions on eating disorders were held with each department and service in Broken Hill. Sessions included information on eating disorder categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the standard classification of mental disorders used by mental health professionals. Presenting features and risk factors for different types of eating disorders were also discussed.

5. Community of practice network

A professional networking group was established in September 2016. It has been set up as a community of practice, open to any clinician working with people who have or are at risk of eating disorders. The following terms of reference were developed as the responsibilities and functions of the group:

• to raise the profile of eating disorders within local health services and ensure they are considered part of all relevant health initiatives and plans
• to serve as a forum for local health clinicians, teachers and other relevant service providers to discuss, plan and evaluate local eating disorder issues and services
• to ensure regular professional development and education on eating disorders is openly available to local communities
• to generate and apply new ideas and innovations in eating disorder care, staying up to date on what is new and sharing with a wider audience as appropriate.

The community of practice meets every two months and will review the terms of reference on an annual basis, to ensure it continues to meet member and community needs.

6. Local referral pathway

The initial survey identified that many people felt the need for a more organised and planned approach to eating disorder referrals. A local care pathway was seen as vital to standardising care for all clients and improving care coordination. A referral pathway is currently in development and will outline the referral process in detail, with local options and pathways for treatment. It will be a valuable tool for clinicians to use in an effort to improve care and reduce confusion for new staff, who may not know where or how to refer clients to appropriate eating disorder services.

Project status

Sustained – The project has been implemented and is sustained in standard business.

Key dates

March 2016 – March 2017

Implementation sites

• Broken Hill Hospital (Dietetics, Mental Health, CAMHS, Paediatric and Emergency Departments)
• Broken Hill GP Super Clinic
• Maari Ma Aboriginal Health Service
• Royal Flying Doctor Service
• Broken Hill High School
• Willyama High School

Partnerships

Clinical Excellence Commission Clinical Leadership Program

Results

A post-implementation survey conducted in January and February 2017 showed:

• the confidence of clinicians in making a diagnosis increased by 115 per cent
• the confidence and skills of clinicians to identify, diagnose and treat eating disorders increased by 121 per cent, exceeding the aim of 50 per cent
• the ability of clinicians to work effectively with eating disorder clients increased by 232 per cent
• awareness of online resources increased by 71 per cent among clinicians
• knowledge of tertiary centres that offer eating disorder services increased by 53 per cent among clinicians.

Lessons learnt

• Low referral numbers does not necessarily mean low levels of need. The issue may be poor rates of diagnosis due to clinicians not knowing how or when to diagnose clients.
• Once awareness campaigns and education are provided on a particular condition, it is important that clinicians are prepared for the subsequent increase in referrals.
• It is important to allow plenty of time to arrange meetings with groups external to the local health district, such as schools and GP practices, as this process can take longer than expected.
• Try to find a champion in each clinical area to support the project on the ground, such as a nurse in a paediatric ward, a GP in a practice, or a CAMHS worker. It may not be possible to get everyone involved, but having support from someone in each area will keep the project moving.

References

1. NSW Ministry of Health. NSW Service Plan for People with Eating Disorders 2013-2018. North Sydney: NSW Health; 2013.
2. Deloitte Access Economics. Paying the Price: the economic and social impact of eating disorders in Australia. Crows Nest, NSW: Butterfly Foundation; 2012

Further reading

• Centre for Eating and Dieting Disorders. Resources for Health Professionals

Contact

Heidi Drenkhahn
Community Dietitian
Far West Local Health District
Phone: 08 8080 1397
heidi.drenkhahn@health.nsw.gov.au