chronic disease management - act healthhealth.act.gov.au/sites/default/files/oms service...

CHRONIC DISEASE MANAGEMENT123 Carruthers Street, Curtin ACT 2605

Phone: (02) 6207 6833

OBESITY MANAGEMENT SERVICE MODELAND IMPLEMENTATION PLAN

Paul Dugdale, Geetha Isaac-Toua, Jennie Yaxley

2014

Version 2

Contents

Executive Summary ------------------------------------------------------------------- 3

Document Information --------------------------------------------------------------- 6Acknowledgements 6

Classification of Body Mass index 6

Abbreviations 7

1: Background ------------------------------------------------------------- 8

1.1 Background 8

2: Service Overview ------------------------------------------------------- 9

2.1 Governance 9

2.2 Location 10

2.3 Deliverables 10

2.4 Close Coordination with Other Services 10

2.5 Delivery Personnel 11

2.6 Consumer Engagement 11

2.7 Information Management 11

2.8 Evaluation and Quality Improvement 12

2.9 Communication Strategy 12

3: Clinical Service Outline --------------------------------------------- 13

3.1 Our approach 13

3.2 Target Patient Population 13

3.3 Clinical Services Components 14

3.4 Service Pathway 15

3.5 Interdisciplinary Collaboration and Liaison 17

4: Other Service Activities --------------------------------------------- 18

4.1 Facilitate the ACT Obesity Network 18

4.2 Community Development 18

4.3 Education, Professional Development and Training 18

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4.5 Policy Development and Quality Improvement 19

4.6 Alignment with ACT Government Healthy Weight Initiative 19

5: Implementation --------------------------------------------------------- 20

5.1 Operational Procedures 20

5.2 Key milestones and implementation activities 21

5.3 Implementation Activities 22

6: Engagement Strategy ------------------------------------------------------ 23

6.1 Canberra Hospital and Health Services 23

6.2 Primary Care and Other Service Providers 23

6.3 Community Engagement 24

6.4 Communication strategy 24

7. References---------------------------------------------------------------------------------- 25

Appendices --------------------------------------------------------------------------------

A. Obesity Management Service Working Group Terms of Reference. 27

B. OSRP Performance Indicators 29

C. Patient Service Pathway 30

D. Glossary 31

E. Related Government Policies and Strategies 33

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Executive Summary

Canberra Hospital and Health Services (CHHS) has been tasked with the establishment and implementation of a tertiary Obesity Management Service (OMS) to commence in early 2014. The service will target people with class III obesity1 which is defined as a Body Mass Index (BMI) equal to or greater than 40kg/m2. This level of obesity is associated with a severe risk of co-morbidity18. Preparations for the new service commenced in July 2011 when an Obesity Service Redesign Project was commenced to review available evidence and data and to hold discussions with health professionals and patients in order to redesign the care of obese patients18 . In 2012-13, the ACT Obesity Interest Network was established, bringing together stakeholders with a shared interest in improving the health outcomes for people with obesity through improved clinical data collection about obesity and the improvement of existing services. The network supported a successful funding proposal for an adult obesity management service19 with a focus on enhanced clinical services for adults with class III obesity. The Obesity Management Service integrates with the ACT Whole of Government, Towards Zero Growth - Healthy Weight Initiative which targets the entire ACT population and seeks to achieve zero growth in overweight and obesity levels.

The OMS will use an interdisciplinary approach to improve the health and well being of adult patients with class III obesity. Class III obesity has been chosen because these patients have a much higher risk of co–morbidities and need for complex care. The service is based on the chronic disease management principles of patient centred care, goal orientated care planning, supported self management including peer support, interdisciplinary team work and close collaboration with other services in order to provide an integrated continuum of care. The OMS will be governed and delivered by the Division of Medicine CHHS as one of the Chronic Disease Management group of services. Service management will be provided by a Senior Medical Specialist supported by a clinical manager. A working group of relevant stakeholders will provide advice to support service implementation and linkages to other services.

The OMS will be staffed by a multidisciplinary team and will operate out of the new Belconnen Community Health Centre (BCHC). BCHC is one of two new extended care community centres in the ACT that incorporate some tertiary health care services. The OMS will provide individual clinical care focusing on lifestyle modification, group education and activities and collaborative community development. The service will also champion the improvement of health outcomes for this often disadvantaged patient group by providing support for policy development, research and professional education.

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The main criteria to be eligible to enter into the service are: Be aged 18yrs and over BMI greater than or equal to 40kg/m2 A degree of co-morbidity Be psycho-socially able to participate in the program.

The OMS will work with patients to achieve a healthier lifestyle and reduced risk factor profile. This will be achieved through:

Multidisciplinary and case management Nutrition education Physical activity programs Addressing barriers to social and emotional wellbeing Supporting long term self-management

and where appropriate: Care Coordination for patients with complex co-morbidity Referrals to other specialities Arrangements for bariatric surgery.

Patients will receive an initial assessment by a nurse and a medical practitioner, followed by allied health assessments as appropriate. A case manager will be assigned and work with the patient to develop a personalised obesity management plan including diet, physical activity and wellbeing related actions. The case manager will be responsible for regularly reviewing the obesity management plan with the patient and their other service providers including the patient’s general practitioner and other specialists. The OMS will also provide education and physical activity groups for patients and where appropriate their carers and family. In general, the service will provide a minimum six month support. The service will not focus on weight loss. Instead the focus is to improve health status and outcomes for morbidly obese people and in doing this improve their risk profile. The service will not take over the primary care of patients from general practice, or provide specialist care for specific conditions other than obesity.

Evidence shows that patients with class III obesity are one of the social groups who routinely face negative attitudes from service providers. Non judgemental service provision focusing on obesity as a chronic condition and not as a condition of personal failing will be fundamental to improving our patients’ care and health outcomes. The OMS will collaborate with community organisations to provide suitable community based activities that welcome larger adults, for example gym and sports programs. The OMS will also coordinate and further develop the ACT Obesity Interest Network and support other health services interested in improving the care of morbidly obese patients. This will involve policy development, quality improvement, and collaborative research to enhance services and outcomes for people with class III obesity. The OMS will also have a role in public education, professional development, student placements and specialist training.

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Continuing evaluation of the OMS has been integral to its planning and development, and will intensify once the service is initiated. It includes:

Reviewing the context of the obesity epidemic and obesity services around the world. Reviewing inputs to the OMS including referrals, staffing and other resources. Evaluation of processes of care including standard operating procedure, intake, case

management, discharge, communication and team function. Monitoring impact including measures of clinical effectiveness, patient life style changes,

and the impact of education and community development activities.

The OMS will open in early 2014. There will be a staggered approach to services implemented. A communications strategy starting with the Obesity Interest Network and the CHHS Division of Medicine, broadening to other divisions, general practices and Calvary Hospital will be instigated to generate referrals to the service. A formal public launch will be arranged once patient care is underway.

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Document Information

This document describes the Chronic Disease Management Obesity Service (OMS) model and the activities and timeframes associated with establishing the OMS to commence in early 2014. The service will initially target people with class III obesity which is defined as a Body Mass Index (BMI) of 40 or more. Class III obesity has been chosen because these patients have a very severe risk of co–morbidities and require significant complex care2.

Acknowledgements

The Authors’ would like to thank the following people for their support in developing this service model:

Dr Nic Kormas, Professor John Dixon, Professor Joseph Proietto and Associate Professor Tania Markovic and their associated teams, for there valued advice.

University of Canberra’s Health Faculty students for their project work. Shane Cumberland Program Director - Innovation and Redesign ACT Health. Members of the ACT Obesity Interest Network Chronic Disease Management Unit staff.

Classification of Body Mass Index2

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BMI (Kg/m2) Classification Risk of co-morbidities

Less than 18.5 Underweight

18-5–24.9 Healthy weight Average

25.0–29.9 Pre-obese Increased

30.0–34.9 Class I Obesity Moderate

35.0-39.9 Class II Obesity Severe

Greater than 40 Class III Obesit Very severe

Abbreviations

ACT Australian Capital Territory AHS Australian Health SurveyANU Australian National University ANZOS Australian and New Zealand Obesity SocietyBMI Body Mass IndexASO3 Administration Service Office, Grade 3CCP Chronic Care ProgramCDM Chronic Disease Management CDMN Chronic Disease Management Network CDMU Chronic Disease Management Unit OMS Obesity Management ServiceCDMR Chronic Disease Management RegisterCIT Canberra Institute of Technology CHHS Canberra Hospital and Health ServicesCHI Community Health IntakeCVD Cardiovascular DiseaseESSO Edmonton Staging System for Obesity FTE Full Time EquivalentGP General PractitionerHP Health Professional ID Interdisciplinary MDT Multidisciplinary TeamOSRP Obesity Service Redesign Project PA Physical ActivityPre-op Pre Operative RN Registered Nurse SMS Senior Medical SpecialistSOP Standard Operating Procedure Sx Surgery TCH or CH The Canberra Hospital or Canberra Hospital YMCA Young Men’s Christian Association

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1: Background

1.1 BackgroundObesity is best considered as a chronic condition which has a direct negative impact on wellbeing and is also amenable to specific treatments1, 4. The management of obese patients requires a clinical approach. Results from the 2011-12 Australian Health Survey show that 25.5% of adults aged 18 years and over living in the ACT are obese. General Practice (GP) supported by other primary health care services can provide care for the majority of obese adults. There is however a need for an intensive interdisciplinary approach for people with class III obesity. In July 2011 an Obesity Service Redesign Project (OSRP) was established for Canberra Hospital and Health Services (CHHS). The project was lead by the Division of Medicine and supported by an expert advisory group with representation from CHHS Divisions, ACT Medicare Local, University of Canberra and the Health Care Consumer Association. The aim was to review available evidence and data, and hold discussions with health professionals and patients in order to redesign the care of obese patients. The project report outlined how services could be improved for people with class III obesity in the OSRP Service Proposal Paper 20123, summarised in Figure 1. The project continued in 2012-13 with the aim to improve clinical data collection about obesity by clinicians; build the ACT Obesity Interest Network; improve existing services and develop a funding proposal for an Adult Obesity Management Service.

Figure 1: Obesity Service Proposal

In August 2013 recurrent funding was provided by the ACT Government to the Division of Medicine to develop and implement an interdisciplinary adult obesity management program. The program will be referred to as the Obesity Management Service (OMS)

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2: Service Overview

The Obesity Management Service will be an interdisciplinary service focussed on improving the health of adults with class III obesity. The Service will be led by a medical director and will focus on improving the risk profile of morbidly obese patients through secondary prevention and better coordination of services. The service will focus on supporting the management of morbid obesity but will not take over the primary care or management of the patient’s co-morbidities. For this purpose an interdisciplinary approach will be of paramount importance.

The Service will operate through the following activities:

1. Individual clinical care services including medical assessment, allied health and nursing intervention including care coordination, all with a focus on lifestyle modification.

2. Group education and activities lead by health professionals.

3. Support for community development focussed on people with class III obesity, their families, carers, service providers and other people who support them.

4. Liaison with CHHS service including within the Division of Medicine (especially Endocrinology/Diabetes ACT, Cardiology, Respiratory /Sleep Clinic), other Divisions and other patient/client services outside of CHHS.

5. Facilitation of the ACT Obesity Interest Network.

6. Support for and undertaking of policy development, research and education.

Evidence shows that patients with class III obesity are one of the social groups who routinely face negative attitudes from service providers. Non judgemental service provision focusing on obesity as a chronic condition and not as a condition of personal failing will be fundamental to improving our patients’ care and health outcomes.

Funding for the OMS has been appropriated in the 2013/14 budget, with the OMS to commence operations in early 2014. Recurrent funding has been provided in the 2013 -14 budget over four years and allows for an OMS without bariatric surgery. As the service develops allowance should be made for additional funding for bariatric surgery as an additional evidence based intervention.

2.1 Governance

The OMS will be governed and delivered under the auspices of the Division of Medicine CHHS within Chronic Disease Management, as the responsibility of the Director of Chronic Disease Management.

The OMS will be managed by a Senior Medical Specialist (SMS). The SMS will be responsible for overseeing the clinical care and high level administration of the service. The SMS will be supported by the Service Coordinator who will be responsible for the day to day coordination of the staff and services. A working group of relevant stakeholders will provide advice to support the implementation, function and evaluation of the service. The working group will be chaired by the Director of Chronic Disease Management. Please see Appendix A for the Terms of Reference for the working group.

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2.2 Location

The new interdisciplinary OMS service will initially operate out of Belconnen Community Health Centre (corner Lathlain and Wales Streets, Belconnen, ACT 2617). The centre has been designed to cater for people with class III obesity. The centre provides bariatric furniture and equipment and rooms with doors wide enough to provide safe entrance and egress of bariatric wheelchairs and chairs.

2.3 Deliverables

The OMS will deliver an interdisciplinary service that will support key service deliverables, service outputs and outcomes. Clinical and other outcomes will be assessed by using a selection of performance indicators. Significant weight loss will not be a main focus of the service. The key deliverables will be:

Commence OMS service January 2014. OMS fully operational by July 2014. Sustainable student placement plan established. The continuation of ACT Obesity Interest Network.

2.3.1 Service Outputs Service outputs will measure the following productivity and quality markers:

Number of referrals to the service Number of patients with an Obesity Management Plan that includes self management

strategies. Number of occasions of service.

2.3.2 Other Activity Outcomes The following non clinical services outcomes will be measured:

Evidence of patient community integration Patient support group established and running by Jan 2015 Evidence of education activities Involvement in quality improvement including research Evidence of facilitation of the ACT Obesity Interest Network

2.4 Close Coordination with Other Services

Patients accessing CHHS expect services to be delivered in a coordinated way. To provide integrated patient centred care, the interdisciplinary OMS service will work closely with multiple providers, including:

CHHS Division of Medicine services (especially Endocrinology, Diabetes, Respiratory and Cardiology services),

other CHHS Divisions, bariatric surgery providers,

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primary healthcare including general practice, other community health service providers.

Close coordination with other services will allow the program to provide patient centred care and avoid service duplication. The service will not take over the primary care of patients from general practice nor provide specialist care for specific conditions other than obesity.

2.5 Delivery Personnel

The OMS will consist of a multidisciplinary team of health professionals dedicated to improving the health of adults with class III obesity.

Staffing will include a senior medical specialist, service coordinator, registered nurses and allied health clinical positions.

All clinical staff will be responsible for providing clinical and patient education services. Staff will be also involved in community development, professional education, policy development and quality improvement/research.

2.6 Consumer Engagement

Consumer engagement to improve the service will be addressed through ACT Health’s consumer feedback as part of the ongoing evaluation of the service and consumer representation on the working group. Consumer engagement will be augmented through shared care planning. Once the program has been established and there is a reasonable number of patients who have been through the service, some ‘ex-patients’ will be invited to undertake chronic disease group leader training in order to co-lead the introduction groups and have an active role in support groups.

2.7 Information Management

The service will utilise ACTPAS to record individual and group patient activities, referrals, discharges and waiting lists. Patient information will be recorded in CHHS medical record files. Privacy and confidentiality of the patients’ information will be maintained in accordance with relevant CHHS policies and legislation including the Human Rights Act 2004 and the ACT Health Records (Privacy and Access) Act 1997 (Health Records Act). In 2014 the patient clinical files will become electronically based as the CHHS patient e-record system is developed as part of the ACT Health Clinical Repository. In the longer term this repository will provide an environment that allows the service to organise, report, and audit data, communicate with other services and patients. It will also provide patients with greater access to their information and appointments.

Time spent providing staff education, supporting policy development, facilitating the ACT Obesity Interest Network and undertaking community development activities will be reported through the CDM quarterly reports.

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2.8 Evaluation, Quality Improvement and Research

The service will report quarterly through the CDM and Division of Medicine quarterly reports on services provided, milestones achieved and current outlook. The service will undergo a major evaluation review after twelve months of operation in the second half of 2015. This will include:

Context evaluation of the service against national guidelines and other obesity services (national and international).

Input evaluation reviewing the program structure, referrals, staffing and resources. Process evaluation including policy, standard operating procedure, eligibility, referrals,

intake, case management, discharge, communication, team function and client satisfaction with the process.

Impact evaluation including measures of clinical effectiveness, patient and other customer satisfaction, patient life style changes, and the impact of policy, education and community development activities.

Ongoing evaluation of the activities of the ACT Obesity Interest Network

The service will also engage in continuous quality improvement both internally and in line with CHHS quality and safety activities.

Evaluation and quality improvement activities will draw on proposed performance measures for improving services for people across CHHS outlined in the CHHS OSRP Service Paper 3. These measures are outlined in Appendix B.

The establishment of the OMS provides an excellent opportunity for research and quality improvement in chronic disease management, service design and translation of evidence into practice. The service will be involved in research by working in collaboration with the CDM’s ANU academic unit ‘Centre for Health Stewardship’, other researchers and programs with a similar interest. Staff and students involved in the service will be encouraged to participate in quality improvement and research.

2.9 Communication Strategy

The OMS communication strategy will be developed to describe the communications strategy required to increase the awareness of the Obesity Management Service amongst potential referrers and to seek their involvement in the ongoing service development.

For patients and carers communication strategies will include face-to-face contact, telephone and email contact, flyers, information brochures and written care plans. Communication with other health care providers will be achieved through face-to-face contact, contact by telephone, fax or letters, electronic health records, and conventional health records. Service details and referral pathways will also be distributed to service providers.

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3: Clinical Service Outline

The Obesity Management Service (OMS) will work to improve the health and well being of adult patients with class III obesity (BMI ≥ 40kg/m2).

3.1 Our approach

The service will provide people centred care, interdisciplinary team work, care planning and group work where appropriate. We will work in close collaboration and communication with other services.

The service will:3.1.1 Work to achieve a healthy lifestyle and reduce the risk factor profile for adults with Class III

obesity. This will be achieved through a case management approach involving: Interdisciplinary assessment Development of an Obesity Management Plan Nutrition education Physical activity Addressing barriers to social and emotional wellbeing Supporting long term self-managementAnd where appropriate provide: Care Coordination for patients with multi-morbidity Referrals to other specialities Arrangements for bariatric surgery

3.1.2 The OMS clinical service will integrate into the community and work closely with Canberra Hospital and Health Services (CHHS), primary care and general practice and other services to ensure a continuum of care for the patients.

3.2 Target Patient Population

The patient population consists of adults (over the age of 18yrs) with a BMI greater than 40. The program will not treat pregnant women, noting that there is separate clinic for obese pregnant women.

Patients will be suitable for the service if they meet the following three evidence based criteria. Criteria 1: Age

People aged 18yrs or above.

Criteria 2: Degree of obesity and co-morbidity. Adults with a BMI≥ 40 and with a degree of or increased risk of co-morbidities

Criteria 3: Psycho-social appropriateness. The service will be available for: People with a willingness to improve their lifestyle. People living in the community.

The service will not be appropriate for: 13


People who have severe current psychiatric symptomotology or severe cognitive impairment.

People who are housebound.

3.3 Clinical Service Components

The OMS will be a multi component assessment and intervention service for adults.

Multidisciplinary obesity management clinic

The following health professionals will provide a multidisciplinary clinic at Belconnen Community Health Centre (BCHC):

Medical Practitioner Nurse Dietitian Psychologist Physiotherapist and/or Exercise Physiologist

The clinic will provide an initial assessment by a medical practitioner, an Obesity Management Plan by a nurse or allied health practitioner and individual nutritional, physical activity and psychological advice. Clinic staff can also undertake home visits if appropriate.

Patients may be referred by the clinic to other services. These could include services that are part of the Obesity Management Service including obesity management groups and care coordination; and services provided by CHHS, other agencies and the private sector.

Obesity management groupsThe OMS will provide groups for nutritional and lifestyle education, and for physical activity.Groups will focus on self management strategies and provide a supportive environment to improve patient confidence, knowledge and ability.

Care coordination service Care coordination is for patients with multiple co-morbidities and frequent tertiary health service users. This service will be provided by the existing CHHS Care Coordination Service, who are expanding their indications to include class III obesity. Care coordinators will provide individually tailored support including coordination of tertiary care (hospital and community based), self management strategies, advance care planning and facilitation of other support services.

Bariatric surgery serviceBariatric surgery has been shown to be a successful intervention for patients with a BMI equal or greater than 40.1, 13 It can significantly improve a person’s health and changes lifestyle habits forever.6, 7, 8 Patients need to make significant life style adjustments to ensure that bariatric surgery outcomes are sustainable. Careful selection of the patients, timing of surgery and surgical procedure combined with the skill level of the surgeon will minimise the number of poor surgical outcomes.13, 14

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The OMS will support a model of care for bariatric surgery based on the approach taken at Concord Hospital NSW15. In collaboration with the patient, their general practitioners and other involved medical specialist, the OMS will:

Identify potential patients, Provide pre-surgery interventions to improve the patient’s overall health and prepare

them for the significant life style adjustments that are required to ensure that bariatric surgery succeeds,

Refer potentially suitable patients for surgery, Work with the surgical service to minimise the risks of surgery , Provide multi-disciplinary ongoing support post surgery.

3.4 Service Pathway

This section describes the clinical service pathway of the OMS. A pathway flow chart is outlined in Appendix C.

3.4.1 Referral and Intake ProcessReferrals will be initially accepted from:

General Practitioners. Specialists (e.g. Diabetes/endocrinology, respiratory, cardiology, surgery and surgical

services). Chronic Care Program

Referral to the new service can be made directly to the service, through the Community Health Intake (CHI) or via the ACT Health electronic referral system (E-referral/Concerto). Referrers will be provided with an assessment criteria checklist to assist with the identification of suitable patients.

Each patient referred into the service will be contacted by an OMS staff member and given a clinic appointment.

The patient population will be diverse and the service will be sensitive to the needs all patients. The following populations have higher prevalence of obesity and are at an increased risk of developing obesity related life threatening conditions:

Socioeconomically disadvantaged People with chronic disease and or disability People who are from Aboriginal and Torres Straight islanders’ background

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3.4.2 Medical Review

At the initial clinic appointment the patient will receive a review of their medical history and a medical assessment to determine the key issues impacting on the patient’s obesity. This assessment will include:

A detailed history of the patient’s obesity journey and their efforts to manage it. A review of current patient issues related to their obesity as well as other influencing

factors such as co-morbidities and social circumstances. A review of CHHS clinical records to determine what other services are being accessed. A general baseline physical examination.

The outcome of the medical review will be a summary of issues and a plan of action which may include referral to other medical services if appropriate. A summary letter will be sent to the referrer and copied to other relevant clinicians. Following the review the patient may be returned to the original referrer or continue with the OMS. Continuing patients will be allocated a case manager who will commence the process of developing the obesity management plan, based on the initial medical review.

3.4.3 Obesity Management Plan

Clinical interventions will be in accordance with the NHMRC recommendations for Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults1.

Development of the Obesity Management Plan The obesity management plan (OMP) will address:

Issues identified in the plan of action arising from the medical review. Biomedical factors with a focus on prevention and management of risk factors including

weight gain and other conditions Self-care and lifestyle management. Psychosocial care.

This plan will include: Patient demographic and clinical background information Physical activity , nutrition and psychological recommendations Patient life goals Change parameters that will be monitored by the patient and the treating team. Involvement of other clinical services as appropriate.

Care planning will be undertaken in collaboration with the patient, and with the patient’s permission their carers, general practitioner and other members of their treating team. A copy of the OMP and appropriate correspondence will be provided to the patient, general practitioner and referrer.

Implementation of the Obesity Management PlanThe intensity and complexity of the OMS clinic interventions and other follow up outlined in the OMP will depend on the individual need of the patients. Obesity like other chronic diseases is a complex and progressive condition with patients often having a large number of co–morbidities. There will be a moderate intensity of service provision in the initial stages of care for example

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individual treatment sessions, group physical activity and education classes. The case manager will be responsible for reviewing the Obesity Management Plan regularly with the patient, family and other service providers including OMS staff.

Chronic disease management and obesity research has shown that for lifestyle changes to be sustained support needs to be provided over a long period of time1.Program intensity will decrease in the maintenance phase of the OMP. The patients will be supported during this time through intermittent case management reviews and community integration including support programs. The support group program will also support those who have had or are considering bariatric surgery.

Given the chronic and complex nature of obesity it is envisaged that patients will move back into and out of the intervention stage in the early maintenance period. A burst of moderate intensity service provision before and following bariatric surgery especially from the dietetics service may be required.

The intensity and length of time spent in the service will have an accumulative impact on service capacity overtime. To mitigate this risk, group programs will be used and include out sourced and supported community programs. , improved anthropometric markers, decreased risk and improved eating patter3.4.4. Discharge

Discharge from the service can occur at various stages of the patient’s journey. When patients are discharged from the service, where ever possible their ongoing case management for obesity will be transferred back to their general practitioner or if required, other primary care service. For each discharged patient the service will provide a discharge summary and an ongoing Obesity Management Plan that includes a self management plan.

3.5 Interdisciplinary Collaboration and Liaison

The OMS in consultation with the patient and their general practitioner may refer patients to other services such as home tele-monitoring; telephone coaching; community groups; specialist medical services and bariatric surgeons. A close working relationship will be required with other services to improve the management of the patient’s obesity related co-morbidities, such as diabetes, chronic pain and arthritis, cardiac disease, cancer, depression, sleep apnoea and chronic obstructive pulmonary disease. There may be potential for various medical specialities to review these patients at BCHC. The service will work with the CHHS GP Liaison Unit and the ACT Medicare Local to facilitate co-ordination with general practitioners and local primary health care providers.

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4: Other Service Activities

The OMS team will have a role in supporting other health services and the wider ACT community in improving care and support for morbidly obese patients. This will include community development, quality improvement, research and policy work to enhance services outcomes for people with class III obesity. This section details these activities.

4.1 Facilitate the ACT Obesity Interest Network.

The OMS will coordinate and further develop the ACT Obesity Interest Network which is currently supported by the Chronic Disease Management Unit. This network brings together local researchers, clinicians, policy makers and government and non government stakeholders with a shared interest in improving the health outcomes for people with obesity. The aim of the network is multi-factorial including continuing education, problem solving, advocacy and networking. The network can assist in the evaluation of projects and in the development of new projects.

4.2 Community Development Community development will be an important function of the OMS and will focus on patients and the people who support them. In order to provide accessible and sustained activity and supports for patients with class III obesity it will be important for the program to engage closely with its consumers and wider community. The program will work collaboratively to assist in the development and support of suitable community based activities that welcome larger adults, for example gym and sports programs.

Community development will also include the facilitation of:

Community based physical activity programs and physical activity options for patients and other obese people. This process will include the training of suitably qualified fitness leaders and personal trainers.

A long term support group especially for patients who have undergone bariatric surgery. Simular support groups already operate in NSW and Victoria.

Ongoing community engagement. This will be a two way street, it will not just be the service outreaching into the community to improve the community response to obesity, but it will also provide a vehicle for community to input into how we run the service.

4.3 Education, Professional Development and Training

The OMS multidisciplinary team with the support of the ACT Obesity Interest Network will have a significant role in the education of others. This will include:

Public education programs and resources. Provide placements for physician training. Input into the vocational sector, undergraduate and graduate training programs.

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Support for the professional development of other health professionals and students in developing experience and skills in managing obesity as a risk factor for chronic conditions

Supervising student projects and clinical placement, providing a positive interdisciplinary learning environment.

The OMS will be the first public obesity management service to be established in the ACT therefore a professional development program will be required for the multi-disciplinary team. OMS staff will be expected to establish a network of support both locally and interstate.

4.4 Policy Development and Quality Improvement

The service will be involved in relevant policy development support and input. This will be supported by the use of quality improvement strategies including:

Providing support to improve the care of severely obese patients admitted to the Canberra Hospital. This could be achieved through continued support of the Bariatric Equipment Working Group, consultation, education and network forums.

Providing expert input into policy review in relation to the severely obese patient. The service will support the enhancement of other services through advocacy and policy development. This will be achieved by raising awareness of the need for sensitive active management of people with class III obesity.

4.5 Alignment with ACT Government Healthy Weight Initiative

While the OMS is a clinical service targeting those with class III obesity, the aim of reducing levels of obesity and the associated rates of chronic disease is strongly aligned to the ACT Government Healthy Weight Initiative. The Healthy Weight Initiative targets the entire ACT population (including those with class III obesity), and seeks to achieve zero growth in overweight and obesity levels in the near future. The Healthy Weight Action Plan describes the various actions that will be undertaken across ACT Government Directorates and within the non-government sector (Refer to Appendix E for more information).

Given that the target populations of the OMS and the Healthy Weight Initiative overlap, it is essential that communication with the public and other key professional stakeholder organisations is efficient and effective. To that end, the OMS executive and the Population Health Division will collaborate to ensure public messaging and engagement efforts are clear and unambiguous.

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5: Implementation

The OMS will open in early 2014. There will be a staggered approach to the service’s implementation. The implementation process will be informed by the continuation of the engagement strategy (Section 6) and continuous quality improvement. A communication strategy starting within the Division of Medicine and broadening to other divisions, general practices and Calvary Hospital will be instigated to generate referrals to the service. A formal public launch will be arranged once patient care is underway.

5.1 Operational Procedures

Operational procedures for the OMS will be outlined in standard operational procedures (SOPs) based on the best available evidence and advice provided from similar interstate, overseas programs and key stakeholders. These SOPs will reflect the operational requirements of CHHS, the Division of Medicine and Chronic Disease Management. The SOPs will be finalised after six months of operation and then reviewed regularly in accordance with ACT Health policy.

Initially there will be two SOPs drafted as follows:

1. OMS Patient Care SOP

To include an outline of the initial assessments and how the Obesity Management Plan is to be developed, implemented and reviewed. This SOP will also include allied health assessment and intervention protocols.

2. OMS Clinical Administration SOP

This document will outline the clinical roles and responsibilities and clinical administrative processes, including referral processes.

The OMS will operate within the broader polices and procedures of CHHS and ACT Health and the statutory requirements of the ACT and the Commonwealth.

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5.2 Key Milestones

The key milestones and target dates to set up and commence the OMS are outlined in Table 1.

Table 1 Key Milestones to Establish the OMS

Key Milestone Target Date

Development Phase

Develop and implement an engagement strategy September 2013

Finalise Obesity Management Service Model February 2014

Establish Governance Structures: clinical and operational December 2013

Receive approved budget for 2013/14 September 2013

Recruit management staff September –Dec 2013

Recruit other staff on 2013/14 budget* October –Feb 2014

Finalise Service Communication and Marketing Strategy February 2014

Pilot Phase

Commence OMS service - receiving referrals (internal initially) January 2014

OMS clinics commence February 2014

OMS patient group education session commence March/April 2014

Expand the service to full capacity April-July 2014Consolidation

OMS fully operational July 2014

Formal evaluation of the first 12 months of full service. August –Oct 2015

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5.3 Implementation Activities

Activities prior to commencement Activities on commencement of service

Activities post commencement

Site visit, other states and lit search Develop draft referral protocols and processes in consultation with other services

Education packages and resources

Establish governance structures Develop relevant documentation care plans and other clinical forms and pilot

Education framework

Receive funding Establish and pilot clinic business rules

Finalise 2014-15 QI & Research plan

Establish a workforce structure Develop and pilot operational clinical procedures

2014-15 Community development plan

Location finalised Develop and pilot group procedures Finalise procedures based on pilot

Staff duty statements completed Information and data management plan

Finalise service capacity based on pilot

Commence move to location Establish safety framework including security

Finalise an evaluation framework for the next 18months.

Equipment identified Protocols for infection control, storage, waste, stores

Start up equipment purchased

BECHC & service specific

Communication and marketing strategy and information brochures

Communication strategy approved Establish operational performance management framework

Working group established Develop any service agreements with other stakeholders throughout the pilot stage.

Consultation with key stakeholders Evaluation plan for pilot

Draft model of care finished

Recruitment

Training of staff

Model of service finalised

Map clinical service pathways

Map of relationships service providers/ service integration

Negotiate service relationships

Initial service capacity established

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6: Engagement Strategy

Preparations for the OMS commenced in July 2011 when an Obesity Service Redesign Project was commenced to review available evidence and data, and hold discussions with health professionals, community groups and patients and carers in order to redesign the care of obese patients2.In order to provide successful outcomes for this group of patients it is imperative that this engagement continues. The community development work of the service will allow for community input into how we run the service.

Adults with class III obese patients are seen by general practice, all CHHS Divisions and many external services. In order to work closely with these services and others, a strategic engagement strategy will be implemented. The strategy involves the following key actions:

Establish an OMS working group. Outline the service model to stakeholders. Discuss what support the service will provide to our key stakeholders. Ensure the program supports the progression of the ‘ACT Chronic Conditions Strategy

2013-2018’16.

A lot of this work will be augmented through the establishment of the Obesity Management Service working group and the co-opting of others as required by the group. Refer to Section 1 page 8 and Appendix A for more information regarding the working group.

6.1 Canberra Hospital and Health ServicesThe CHHS engagement will involve initial consultation with the Division of Medicine Executive and Clinical Units especially Respiratory, Diabetes Services and Cardiology. In the years 2008- 2012, 45% of all patients coded for obesity were admitted under the Division of Medicine and of these patients almost half were admitted to Respiratory speciality areas. Refer to figure 2. The engagement strategy will also include other CHHS services areas including Rehabilitation, Aged and Community Care; Women, Youth and Children and the Division of Surgery. The service will also have representation on the OMS Working Group, Chronic Disease Network, and the Bariatric Equipment Working Group.

6.2 Primary Care and Other Service Providers Engagement with external stakeholders will be initiated prior to the commencement of the OMS and will continue through the implementation of the program. This will include building on the relations established through the Expert Advisory Group for the Obesity Redesign Project in 2011-2012; the ACT Obesity Network, site visits to interstate programs and membership of national interest groups, for example, the Australian & New Zealand Obesity Society.

Key external stakeholders will be primary care and Calvary Public Hospital operated by Calvary Health Care ACT. Engagement with primary care will be facilitated though consultations with representative bodies including ACT Medicare Local and Winnunga Nimmityjah Aboriginal Health Services.

23


Other services that will be included are the ACT Ambulance Service, Community Care services, Diabetes Australia ACT and physical activity providers such as the YMCA, Heart Foundation, Canberra Institute of Technology and University of Canberra student lead programs.

Figure 2 .CH Divisions where Patients Coded with Obesity were Admitted (1 July 08 -30 June 2012).

45%

23%

2%

8%

20%

2%1%

Med Surg

Crit Care RACC

WYC CRCS

Mental H

6.3 Community Engagement

The Obesity Service Redesign Project conducted consultations with community groups. The OMS development team continues this engagement with key stakeholders and other community groups including the NSW Obesity Support Council. The Obesity Support Council is an incorporated association run by people with obesity who provide peer support to others and lobby for improved services and more research.

The OMS will continue to develop this community engagement by: Community development activities and education. Working closely with patient support groups including the Obesity Support Council. Working to improve the service through actively seeking feedback from our patients, refers

and other stakeholders.

6.4 Communication Strategy

A communication strategy has been developed for use in the early phase of the service. This will include information for patients, information for clinicians and frequently asked questions. A formal launch of the service will be held once it is fully operational.

24


7.References

1. NHMRC— Clinical Practice Guidelines for the Management of Overweight and Obesity

in Adults, Adolescents and Children in Australia (2013). ISBN: 1864965908

http://www.nhmrc.gov.au/guidelines/publications/n57

2. World Health Organisation. Obesity: preventing and managing the global epidemic.

Report to WHO Technical Report Series 2000; 894(3):i-xi, 1-253 Retrieved 27 October

2009 http://whqlibdoc.who.int/trs/WHO_TRS_894.pdf

3. CHHS Obesity Service Redesign Project Service Report J Yaxley and P Dugdale 2012.

4. Sharma AM and Kushner RF Int J Obesity (2009) A proposed clinical staging system for

obesity, International Journal of Obesity 33, 289–295; doi:10.1038/ijo.2009.2.

5. Best Weight- A practical guide to office –based obesity management. Y Freedhoff and

AM Sharma, 2010 Published Canadian Obesity Network.

6. Schauer, P., Kashyap, S., Wolski, K., Brethauer, S., Kirwan, J.P., Pothier, C.E., Thomas,

S., Abood, B., Nissen, S.E & Bhatt, D.L. 92012). Bariatric Surgery versus Intensive

Medical Therapy in Obese Patients with Diabetes. N Eng J Med. 366 (17): 1567-76

7. Mingrone, G., Panunzi, S., De Gaetano, A., Guidone, C., Laconelli, A., Leccesi, L., Nanni,

G., Pomp, A., Castagneto, M., Ghirlanda, G. & Rubino, F. (2012). Bariatric Surgery

versus Conventional Medical Therapy for Type 2 Diabetes. N Engl J Med. 366(17):

1577-85.

8. Jill L Colquitt , Joanna Picot , Emma Loveman and Andrew J Clegg 2009 Surgery for

obesity (Review) The Cochrane Library Issue 4

9. Karmali S, et al (2010) Bariatric Surgery A primer Clinical Review, Canadian Family

Physician. 56; 873-9.

10. Bond D, Wolfe P, Evans R, Meador J, Kellum J , Maher J and Wing R (2009) "Becoming

Physically Active After Bariatric surgery is Associated With Improved Weight loss and

Health-related Quality of Life ", Obesity, 17(1):228-231

11. Whitney S, Mada K, Raymond J, Coday M & Tichansky D (2008), 'Support group

meeting attendance is associated with better weight loss', Obesity Surgery, 18:391-4

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http://www.nhmrc.gov.au/guidelines/publications/n57

12. Colles S, Dixon J &. O’Brien P (2008) "Hunger control and regular physical activity

facilitate weight loss after laparoscopic adjustable gastric banding", Obesity Surgery,

18(7):833-40

13. NICE 2006, Obesity guidance on the prevention, identification, assessment and

management of overweight and obesity in adults and children.

http://guidance.nice.org.uk/CG43.

14. NICE Commissioning a bariatric surgical service for the treatment of people with

severe obesity,

http://www.nice.org.uk/usingguidance/commissioningguides/bariatric/

CommissioningABariatricSurgicalService.jsp

15. Concord Metabolic Rehabilitation Clinic

http://www.sswahs.nsw.gov.au/concord/endo/department_dia_om.html

16. ACT Health (2013) ACT Chronic Condition Strategy – Improving Care and Support

2013-2014. http://www.health.act.gov.au/c/health?a=dlpubpoldoc&document=2825

17. ACT Health Interprofessional Learning, Education and Practice CED08-049,

http://inhealth/PPR/Policy%20and%20Plans%20Register/Interprofessional

%20Learning,%20Education%20and%20Practice.pdf

18. Yaxley J. & Dugdale P. Canberra Hospital and Health Services Obesity Service Redesign

Issues Paper. ACT Health, Canberra 2011.

19. Yaxley J. Dugdale P. & the Canberra Hospital and Health Services Obesity Service

Redesign Expert Advisory Group. Obesity Service Redesign Project Services Proposal.

ACT Health, Canberra 2012.

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http://inhealth/PPR/Policy%20and%20Plans%20Register/Interprofessional%20Learning,%20Education%20and%20Practice.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Interprofessional%20Learning,%20Education%20and%20Practice.pdf

http://www.health.act.gov.au/c/health?a=dlpubpoldoc&document=2825

http://www.sswahs.nsw.gov.au/concord/endo/department_dia_om.html

http://www.nice.org.uk/usingguidance/commissioningguides/bariatric/CommissioningABariatricSurgicalService.jsp

http://www.nice.org.uk/usingguidance/commissioningguides/bariatric/CommissioningABariatricSurgicalService.jsp

http://guidance.nice.org.uk/CG43

Appendix A:

OBESITY MANAGEMENT SERVICE WORKING GROUP TERMS OF REFERENCE

RoleThe Obesity Management Service (OMS) working group has been established by Chronic Disease Management in the Division of Medicine to improve services for the management of adults with class III obesity by supporting the development of an Obesity Management Service and through collaboration with relevant services. This is an operational group to concentrate on service implementation and stake holder coordination.

Tasks Collaborate, inform and discuss any processes or issues relevant to the development

implementation and continuous improvement of an Obesity Management Service. Provide guidance on evidence based practice and the delivery of services within existing

guidelines. Coordinate the input and represent the views of their respective areas. Facilitate the implementation of new pathways within their respective areas To participate in a meeting that operates under the principles of transparency, leadership,

integrity and commitment, demonstrating accountability and an integrative approach. Collaborate with key stakeholders including liaising with the:

o ACT Diabetes Service Reference Group regarding obesity,o Population Health regarding preventive issueso ACT Surgical taskforce regarding surgical issues o the ACT Obesity Interest Networko CHHS the Bariatric Equipment Working Groupo And others as required

Determine appropriate key performance indicators relevant to service descriptors. Understand and promote the groups objectives. Enable research and education opportunities.

Meeting Schedule & Process Meeting will occur eight weekly or as requested by the chair. Where necessary the committee may choose to make out-of-session determinations and

decision via electronic means such as e-mail or teleconferences. Information will be discussed and debated openly and transparently, and with respect for

other committee members’ opinions and points of view. An agenda, including all relevant attachments will be distributed to all committee members

at least one week prior to the scheduled meeting. Minutes and action items will be distributed within two weeks of the scheduled meeting to

ensure action items can be completed in a timely manner. Minutes and action items will be managed by the CDMU.

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Quorum5 members including the Chair or their delegateTerm The group’s TOR and membership will be reviewed after 18months ChairDirector of CDM

SecretariatProvided by the OMSMembership

Position Title Incumbent (February 2014)Director of CDM (Chair) Paul DugdaleObesity Management Service Coordinator (Secretariat) Jennie YaxleyMedicare Local Jenny PermezelPopulation Health Division Paul KellyRespiratory services Mark HurwitzChronic Care Program Jan IronsideCardiology Leonard ArnoldaConsumer Fiona Tito WheatlandGeneral Practice Advisor Marianne BookallilCommunity Care Ana O’RourkeBariatric Surgery Andrew MitchellDiabetes ACT Chris Nolan

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Appendix B:

Key Improvement and Performance Indicators suggested for the OSRP Key Improvements from OSR Project Performance indicators

1 Increase CH coded separations for obesity. Number of ICD 10 Obesity separations.

Improve the recording of obesity as a problem for non inpatients.

Number of E-records that record obesity as a health problem.

2 Document inpatient care pathways for obese patients in relevant clinical areas.

Number of inpatient pathways that included “obesity”.

Update existing care pathways to include proper management of obese patients within these pathways.

Number of documents in the policy and procedures register that include the words; obese, obesity, BMI or bariatric.

3 Increase availability and outline appropriate use of bariatric equipment and facilities across CHHS.

Audit the amount of bariatric equipment available in CHHS for general use.

4 Improve access to health services for people with obesity.

Obesity Management Service case load and occasions of service.

Improve people with obesity and their carers’ satisfaction with the care they receive.

Satisfaction surveys.

5 Create and sustain a network of people who are interested in improving the health of people with obesity.

Network activities.

6 Selected obese patients share their stories and identify issues about their recent interactions with CHHS.

Patient interview data.

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Appendix C: Patient Service Pathway

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Liaise with relevant care providers (e.g. GPs,

Community services etc.)

DischargeReferral received Obesity Management Plan

Initial medical assessment.

Referral - to a more appropriate service(s)

and Discharged

Extra information obtained prior to appointment e.g.

pathology results

Group programs

Medical review as required

OMP Implementation with case manager

Allied Health treatment and review

Assessment

Case manager appointed

Bariatric surgery or medication if required

Liaison with GP /specialist(s)/other as

required

When client's health and psychosocial situation is

stable discharge planning commenced with

GP/specialist /other

Discharge to GP/specialist /other

Individual further assessment

by AOMS Allied Health

Initial medical clinic appointment

Base line measurements Bp, Height , waist etc

Team review of assessment Information

Obesity Management Plan (OMP) drafted with the

patient and treating team

Additional information collected

(questionnaires, diaries, etc)

OMP reviewed regularly with patient and treating team

Integrate into community groups and support group

Community groups and support group

Program and care plan reviewed with patient and

team for discharge

External referrals if required -for management of co

morbidities, equipment etc

Care coordination if required

Clinic appointment arranged with patient

Appendix D:

Glossary

bariatric surgery Surgery on the stomach and/or intestines to help a person with severe obesity lose weight.1

behavioural intervention Use of the common components of behavioural treatment—self-monitoring, goal setting and stimulus control1.

body mass index An index of weight for height that is commonly used to classify underweight, overweight and obesity in adults. It is defined as the weight in kilograms divided by the square of the height in metres (kg/m2) 1.

gastro-oesophageal reflux disease (GORD)

A condition in which the stomach contents (food or liquid) reflux from the stomach into the oesophagus, causing heartburn and other symptoms1.

healthy diet A diet that contains plenty of fruit and vegetables; is based on starchy foods such as wholegrain bread, pasta and rice; and is low in fat (especially saturated fat), salt and sugar1.

healthy weight A body mass index (BMI) of 18.5 to 24.91.hepatomegaly The condition of having an enlarged liver1.hyperinsulinaemia Higher levels of insulin circulating in the blood than would be expected by the level of

glucose1.hyperlipidaemia Abnormally elevated levels of any or all lipids and/or lipoproteins in the blood1.hypertension Elevated systemic arterial blood pressure1.metabolic syndrome A combination of medical disorders (including high blood pressure, obesity, high

cholesterol and insulin resistance) that, when they occur together, increase the risk of developing cardiovascular disease and type 2 diabetes1.

Interprofessional practice Occurs when all members of the health service delivery team participate in the team’s activities and rely on one another to accomplish common goals and improve health care delivery, thus improving the patient’s experience and quality of care.17

multicomponent or multi factorial intervention

An intervention that aims to address a range of factors that may influence the outcome measure of interest1.

obesity Excessive fat accumulation that may impair health, classified when the BMI is ≥ 30 kg/m21.

OSRP Obesity Service Redesign ProjectPrader-Willi syndrome A genetic condition characterised by neurological impairments that cause an altered

pattern of growth and development with associated hyperphagia (overeating) 1.prediabetes A condition in which blood glucose levels are higher than normal, but not high enough to

be diagnosed as type 2 diabetes; includes impaired fasting glucose and impaired glucose tolerance1.

sleep apnoea A sleep disorder characterised by abnormal pauses in breathing or instances of abnormally low breathing during sleep1.

type 2 diabetes A metabolic disorder that is characterised by high blood glucose in the context of insulin resistance and relative insulin deficiency1.

very low-energy diet A diet that generally provides between 1675 and 3350 kilojoules per day1

Wellbeing “Wellbeing is not just the absence of disease or illness. It is a complex combination of a person's physical, mental, emotional and social health factors. Wellbeing is strongly linked to happiness and life satisfaction. In short, wellbeing could be described as how you feel about yourself and your life” Better Health Channel- Vic Health http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/wellbeing?open

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Appendix E

Related ACT Government Policies and Documents

Towards Zero Growth Healthy Weight Action Plan (available at http://health.act.gov.au/health-services/population-health/population-health)

Population Health Division Strategic Framework 2013-2015 © Australian Capital Territory, Canberra, July 2013 available at www.health.act.gov.au | www.act.gov.au

ACT Chronic Conditions Strategy — Improving Care and Support 2013-2018 Australian Capital Territory, Canberra, May 2013 available at www.health.act.gov.au | www.act.gov.au

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http://health.act.gov.au/health-services/population-health/population-health

http://health.act.gov.au/health-services/population-health/population-health

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