SKILLS & LEARNING
MULTIDISCIPLINARY TEAM WORK IN THE COMMUNITY SETTING A multidisciplinary team (MDT) is found to be an increasingly effective resource in clinical practice, involving a variety of professionals using their knowledge, skills and best practice across service provider boundaries.
Karen Voas Community Dietitian Betsi Cadwaladr NHS Trust Karen has been on community rotation for about six months and more recently commenced a new prescribing support role. She has an interest in nutritional support and enteral feeding and is also involved in the North Wales North West BDA Branch as Event’s Organiser.
REFERENCES Please visit the Subscriber zone at NHDmag.com
36
Each professional involved in an MDT shows different and unique skills, which, combined, can be useful for the priorities and clinical needs of patients. The team is then better able to make decisions on the care and social situations for patients.1 Patient cases are ever more complex, not only for dietitians, but for other members involved with the patient. No patient case is in isolation. MDT relationships in healthcare are now more vital than ever. They have been increasing and are more diverse and more dynamic, with a wider variety of professionals aiding a team in the complex decisions that are involved with patient cases and health and social care pathways. An MDT in healthcare includes professionals who are involved in the single patient health journey (see Figure 1), such as dietitians, speech and language therapists and social workers. The differing professions with their different areas of expertise meet regularly to discuss their work. This ensures that each patient in the community setting has an effective care plan suited to their needs at that time. This may include decisions to withdraw care, or to commence funding for nursing home placement. As outlined in the NHS Five Year View, the model of care we should be giving patients is to provide the right care at the right time for the right reasons. This relates nicely to MDT working, bringing a variety of disciplines and knowledge together in order to provide the correct treatment.2 The competence and skill set can be different from one MDT to another,
www.NHDmag.com March 2019 - Issue 142
with each individual bringing different ideas, attitudes, experiences and values to the team, which in turn can impact on the team’s knowledge, behaviour and skill set. It has been shown that this has positive effects on the dynamics of an MDT and on how effectively they function together.3 The key to successful MDT working has been shown to be good communication along, of course, with good team work. Regular meetings, discussions and written communication is, therefore, vital. Meetings don’t need to be weekly, but certainly should be on a regular basis, so that all team members can come together to discuss patient cases and find out more about the priorities of the differing professionals.4 Meetings can provide an opportunity to develop a rapport and build relationships with other professionals who are involved in the patient care. Evidence is strong to suggest that effective MDT working can improve the overall care and experience of the patient and can provide better outcomes in cancer patients, dementia patients, in paediatrics and with eating disorders.5,6 A systematic review of MDTs in cancer services has found that there are improved outcomes, increased rates of survival and patient satisfaction when there is an established MDT.7 Within my role, I am involved in a community MDT, which includes occupational therapy, physiotherapy, nurse practitioner and me as the dietitian. Overleaf is an example of a community patient case study, where all these disciplines have been involved in the patient care.
Figure 1: Members of a dietetic multidisciplinary team
Table 1: Benefits of MDT working Reduction in hospital admissions
Cost effective care
Improved patient care
Clear safe plan for ‘high risk’, vulnerable and unwell patients in the community
Better communication between professionals
Better relationships between primary and secondary care (GPs)
Smoother transition from acute to community settings
Inter-professional working
Table 2: Key factors for an MDT approach NICE guidance (2016) suggests that there are key factors needed for a successful MDT approach • Patient-centred care • Shared goal, objectives and agenda • Shared information, technology and patient data, which all can access • Co-location, geographical interaction between everyone • Target for a high-risk population • Physician integration
www.NHDmag.com March 2019 - Issue 142
37
SKILLS & LEARNING COMMUNITY MDT CASE STUDY 62-year-old Male Diagnosis: Idiopathic Pulmonary Fibrosis, prostrate issues, anaemia, shortness of breath on exertion. Social history: Lives in a bungalow. Wife suffers with Multiple Sclerosis (MS). On home oxygen. Unable to walk long distances. Taking a variety of ONS which a locum GP had prescribed on referral to dietitian. District nurse and ANP visit fortnightly to weigh and check oxygen. Weight: on referral: 66.2kg Height: 1.71m BMI: 22.7kg/m2 Usual weight: 70kg – 5.5% weight loss in six months; significant weight loss Locum GP had commenced him on a variety of ONS, including powdered and shot variety, prior to an outpatient appointment with the dietitian. He had already been given food-first advice and, where possible, was trying to implement this into his diet, including regular snacking on higher calorie foods and also adding food fortification methods into his foods. ASSESSMENT On initial assessment, it appeared that he was not keen on the supplements given to him by the GP. He described some taste fatigue and feeling of fullness, which was impacting his own intake at mealtimes. He disliked milk to drink on its own, but was happy to have it mixed in with the supplements. He agreed to have some of the ONS cancelled. The main dietetic issue was the fact that he was a carer for his wife who was suffering with MS. By the time he had cooked their meal, he seemed to come to the dining table where he had lost his appetite and became breathless due to the exertion to the dining room. REVIEW On review, he was really struggling with his appetite and, as part of the MDT working collaboratively, his weight was regularly monitored on a fortnightly/monthly basis by the district nurses and advanced nurse practitioners and it continued to drop. He was admitted into the acute setting, where he was quite poorly and I was contacted by the MDT team consultant who was keen for urgent dietetic review in order to establish if he was appropriate for enteral feeding. On review, he had a change in medication as the MDT aimed together to try get him meals on wheels. Other ways of increasing his intake were discussed by the team, including using different style supplements, eg, juice style, to try and optimise his nutritional status. When he had changed his medication, his appetite increased dramatically and he was able to gain the weight he had lost without the need for enteral feeding. This was a truly successful outcome and shows how working together with all members of the MDT optimises patient care. CONCLUSION
Within the community setting, as part of my current role, I am always liaising and working with the MDT. I have consistently found that when working and communicating regularly with the whole team, a full holistic approach can be taken for each patient. Understanding each MDT discipline can have a huge impact on the overall care of the patient during their health journey. Specialist nurses, or nutritional support nurses and advanced nurse practitioners can be useful healthcare professionals to encourage patients and discuss action plans, to weigh patients and provide further information 38
www.NHDmag.com March 2019 - Issue 142
for referrals. They can be seen as vital in the management of malnutrition, as well as being an important point of contact. I feel that I have a brilliant professional relationship with the MDT. We meet on a weekly basis in order to discuss patients, discuss future plans of effective working and chat through the priorities of the differing disciplines at that time, for example: mobility for physiotherapists, hydration for dietetics, etc. The benefits of MDT working for both patients and professionals are paramount in my opinion, to both patientcentred working and building professional relationships.