1. Brindha Dhandapani Ros Swift Lewisham Healthcare NHS Trust
Multidisciplinary feeding clinic Integrated service for children with complex feeding difficulties
Brindha Dhandapani
Ros Swift
Lewisham Healthcare NHS Trust

2. Background
Innovative proposals for service redesign across community and acute services following integration of University Hospital Lewisham and Community Health Services in April 2010
To deliver excellent service building on the strengths in both organisations
Lack of coordination of hospital and community services, duplication of services and lack of continuity of care  
I would like to thank BACCH for giving us the opportunity to present our feeding clinic pilot. In Lewisham, previous attempts at establishing a feeding service had been unsuccessful
due to various barriers, mainly that of hospital and community teams being under different organisations. Lack of coordination of hospital and community services, duplication of services and lack of continuity of care and support for
 parents were identified as barriers to providing a comprehensive service. The opportunity to build on the strengths of both teams arose when services were redesigned following integration of hospital and community teams in 2010.

3. UHL Pathway Referral received Gastro clinic (Gastro/dietician)
Joint Gastro clinic
(Paed/surg/diet)
Assessment
Investigation
Management
S&LT
Existing pathways highlighted duplication of services, same group of professionals needed to support both pathways. We felt that we could make the service more efficient and more acceptable for parents and carers if we joined forces. increased number of appointments, time spent in liaising with professionals, delay in implementing treatment plans increasing clinical risk and resulting in parent/carer dissatisfaction and professional frustration.
Referral/Liaison
HEN
Community Paediatrics
Review
Discharge

4. CHS Pathway Referral S< Assessment Comm Paed Assessment Hosp Paed
Dietician
HEN
Tertiary

5. Case example-AA
8year old with Cerebral palsy, gastrostomy fed, vomiting, poor weight gain,
Multiple hospital & community appointments
Multiple DNAs
Community staff not able to attend appointments in the hospital
No response to change in treatment plan
Unable to co-ordinate services to implement plan
Just to give an example of a child who was seen in the feeding clinic; AA is an 8year old with CP, who had ongoing problems with vomiting and poor weight gain. He has been seen several times in hospital and community settings. Parental engagement was hit and miss. There was little response despite optimising treatment and changing feed regime. Community and hospital teams were frustrated with the lack of response to interventions. We had huge problems difficulties implementing treatment plan in the community-home/school. There was a lot of time spent liaising with professionals. It was felt that this child would benefit from a coordinated approach to resolving some of these issues resulting in improved parental engagement.

6. Aims and Objectives
To provide a co-ordinated approach, through collaborative working between community and hospital services
Improved parent/carer satisfaction
Reduce referrals to tertiary feeding service
Reduce number of hospital appointments
Providing detailed care plans with clarity of input
The main objective was to offer a co-ordinated approach through joint working. We aimed to reduce the number of appointments a child had to attend, prevent delay in implementing treatment plans by devising clear care plans with clarity of who is providing what, all of this resulting in improved parent/carer / professional satisfaction. We also felt that by providing a multidisciplinary service we would be able to reduce to the tertiary feeding service.

7. Multi-disciplinary feeding service- Pilot
A multi-disciplinary feeding service for children with neuro- disability, ASD, learning difficulties with complex feeding difficulties
To complement existing hospital based Joint Gastro- enterology clinic and improve collaborative working
Core team - Dietician, Speech and Language Therapist, Paediatrician (Community /Acute)
Extended team - Specialist Nurse, Occupational Therapist, Physiotherapist, Care- coordinator, (Clinical Psychologist)
The proposal was to set up service for children with complex feeding difficulties with underlying complex disabilities including Cerebral palsy, ASD and learning difficulties. The core team included hospital and community dieticians, speech and language therapist and paediatricians, both from hospital and community. Support was sought from the extended team including physiotherapist and occupational therapist and care –coordinators and community/ school nurses.

8. Referral criteria Children resident in Lewisham requiring;
Multidisciplinary input
Poor response to initial advice
Extreme parental stress
Complex ethical issues
We agreed on the following criteria; some of these complex children need multidisciplinary approach to their feeding problems, children who had poor response to initial advice from individual professionals. As we know feeding is such an emotive subject. extreme parental stress which warrants joint working to alleviate parental anxieties and help build trust. We felt this would a good forum to address complex issues such as decision around gastrostomy feeding.

9. Pilot 3 all day clinics Feb, April and June 2011 12 children
6 children with Cerebral palsy
3 children with Autism
1 child with Chromosomal disorder
1 with Learning difficulties
1 child with congenital infection

10. Outcome All the children had detailed care plans
Six (50%) children had fewer appointments in the hospital
Six (50%) children were discharged from the hospital clinic to avoid duplication of services
Reduced referral to tertiary feeding services by(7/12) 60%

11. Parent/carer satisfaction
Ten parents/carers (83%) completed satisfaction questionnaires
Administration of clinic was thought to be Excellent-Good by majority of the parents
70% thought the appointment length was just right, 30% thought it was too long
All 10 (100%) said their questions and concerns were addressed
90% said it was useful having health professionals together for the appointment
60% thought the advice given was useful and practical but 40% said it was not
Parents and carers were asked to complete satisfaction questionnaires, which was a standardized form used widely in our trust. This was modified to suit this service.

12. Parent feedback
“So nice to have all professionals in one room, bringing information together and leaving as a parent with a plan”
“great having the discussion and plan written and given to me to take away”
“Would welcome more multi team appts”
“Good to review matters and to be able to monitor changes”
These were some of the comments; they welcomed the multidisciplinary approach, support with monitoring, appreciated having a care plan given to them at the end of the clinic.

13. Parent feedback “Wanted more practical advice”
“More advice and information instead of going over things we already knew”
“no new information or advice”
These were the comments we learned from, we felt we would have benefitted from psychology input to the clinic. We needed to build our expertise on managing sensory behavioural feeding issues.

14. Professional feedback
Seven professionals completed questionnaires
All 7 felt the length of appointment was just right
“Co-ordinated approach – most useful”
“Saved time liaising with other professionals”
“Works best when the right people are present- i.e. child’s therapist”

15. Pre-clinic food diary/information gathering
Joint Pathway
Referrals received
Triage referrals
Pre-clinic food diary/information gathering
Multidisciplinary feeding clinic
S&LT
Hosp dietician/
Home Enteral Nutritionist
Hosp Paediatrician/
Comm Paediatrician
Referral are accepted from hospital or the community teams who identified suitable children meeting the referral criteria. The referrals were triaged by the core team. These children would be known to two or more of the teams . The admin team will then embark on the info gathering exercise which involves chasing reports from professionals, information from necessaries and schools. Parents are invited to the clinic and asked to complete a food diary. Appointments are 90 minutes long. This will involve history taking-detailed feeding and dietary , assessment- growth measurement. Feeding and drinking assessment are not carried out in the clinic, this would be arranged prior to the clinic and the result fed back to the team or will be carried out after the clinic.
The team then has a discussion and formulate the plan. The plan is then fed back to parents and their views sought. A key worker will be identified who will follow up and oversee implementation.
Care Plan
Discharge
Review
Support wider team

16. Strengths Improved understanding of roles and services offered
Improved links with hospital and community services

17. Weaknesses
Specialist investigations not available in the trust e.g. videofluoroscopy
Lack of Psychology input
Different processes across hospital and community services
Tariffs, ref criteria

18. Opportunities
To develop the knowledge base and expertise of the feeding team
To improve the overall management of feeding issues in the community/hospital
Potential to expand the service

19. Threats
Increased referrals might result in increased waiting times and less efficient service
Extra funding and resources
Duplication of assessments if services are not sufficiently well co-ordinated- Admin support
Funding for doctor and therapists time
Admin support
Key workers

20. Case example-AA
8year old with Cerebral palsy, gastrostomy fed, vomiting, poor weight gain
Care plan with clear responsibilities
Medication administered at school, new feed regime, equipment sorted
Reduced hospital appointments
Key worker to liaise with parents and professionals with guidance from the service
Parents and professionals satisfied with outcome
Showing the difference it made to individual children and families, efficient use of professional time, saving money by capitalising on the expertise of the local team and reducing referrals to tertiary services helped us in our discussions with managers to establish this service following the successful pilot.

21. Next steps Negotiate Psychology input for the service
Resources for parents and professionals
Training of wider teams
Video-fluoroscopy service
If we are to sustain the success of implementing care plans which is what made the biggest impact, we will need to train wider teams to support parents and monitor.
Continue to negotiate with CAMHS