Multidisciplinary Team Working with Patients with Heart Failure

1
Multi-disciplinary Team Working with Patients
with Heart Failure

• Tracey Rumfitt.
• Team Manager/Lead Specialist Occupational
  Therapist in Heart Failure

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Who makes up the Team ?
Specialist Nurse
Psychologist
Pharmacist
G.P.
Social worker
District Nurse
Consultant (Cardiologist or COE)
Patient
Practice Nurse
Occupational Therapist
Physiotherapist
Dietician
Exercise Physiologist
Exercise Professional
Palliative Care Team
C
Community Matron
3
Teams work best when made up of a combination of.

• Parallel team members autonomous professionals
  working within their own specialist area
  linking with other team members when necessary.
• Collaborative team members individuals who know
  one another well and work together closely on
  projects.

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The aim of the team

• To deliver high quality services and seamless
  care for people with Heart Failure, in order to
  control symptoms, provide support and information
  whilst improving the quality of life of the
  individual.

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NICE Guidelines for Heart Failure

• Heart Failure care should be delivered by a MDT
  with an integrated approach across the healthcare
  community.
• multi-disciplinary care programmes improve
  patients quality of life, satisfaction with care
  and the risk of unplanned hospitalisation for
  Heart Failure compared with conventional care.

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What constitutes good teamwork ?

• Open communication
• Working toward a joint goal or purpose
• Care centred on patients
• Professionals with unique skills
• Collaboration/role blurring
• Shared knowledge and learning
• Awareness of colleagues interests and specialist
  skills

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What do Occupational Therapists contribute to a
team ?

• The analysis of, and use of activity and
  occupation as a treatment medium.
• Assessment of the environment.
• Expert knowledge of equipment and adaptations.
• Assessment of Activities of Daily Living.
• Problem Solving.
• Pacing and goal setting.
• Energy conservation.
• Relaxation techniques.

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Development of the OT specialist role in
Sunderland.

• Developed in 2002 following the publication of
  the NSF for Coronary Heart Disease.
• Areas of work
• Heart Failure Post Discharge Service.
• Heart Failure Clinic.
• Heart Failure Rehabilitation Group.
• Referral from others

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OT Role

• Less involvement in traditional OT role
• eg equipment, adaptations, referrals to others.
• Additional interventions
• Provide advice and education on the condition,
  including discussion on prognosis when
  appropriate .
• Identify risk factors and discuss lifestyle.
• Provide individualised and group rehabilitation.
• Relaxation techniques.

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Future plans

• More involvement in palliative care/day services.
• Improving support for relatives/carers.
• Expanding Rehabilitation group to patients who
  are NYHA III/IIII
• Supplementary prescribing diuretics.

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Final Message

• From my experience dont try to be Wonder
  Woman and do everything yourself.
• Find out what resources are out there.
• Find out about interests and specialist skills of
  colleagues.
• Use the voluntary sector.
• Delegate work to others.
• Save yourself and your specialist skills for the
  patients who really need you.

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References

• Blue, L (2004) Improving Outcomes in Chronic
  Heart Failure London, BMJ Publishing.
• CHD Collaborative (2004) Supportive and
  Palliative Care for Heart Failure London, NHS
  Modernisation Agency.
• Hutchings, S Hall, J Loveday, B (2003)
  Teamwork A guide to Successful Collaboration in
  Health and Social Care Oxon, Speechmark
  Publishing.
• Royal College of Physicians (2003) NICE
  Guidelines No5 Chronic Heart Failure -
  National Clinical Guideline for Diagnosis and
  management in Primary and Secondary Care London,
  Royal College of Physicians.