Important factors for establishing a team-based approach to the assessment and management
of feeding, swallowing, and nutrition disorders in pediatric
populations
Technical presentation
Julie Carey, M.S., CF-SLP
November 21, 2008
Outline
• Background and rationale• Purpose• Methods• Results & Discussion• Conclusions & Future directions• Questions
Background
• Multidisciplinary & interdisciplinary teams– Preferred practice for health care delivery to complex
populations (Mullins et al., 1997; McCallin, 2001; Williams et
al., 2006)
• Although team approach is preferred …– Factors for establishing such teams are relatively
unknown• Pediatric feeding, swallowing, and nutrition
Background
• Occurrence of feeding, swallowing, & nutrition (FSN) disorders in children in the US (Graham, 1985; Sullivan et al., 2000; Rogers &
Arvedson, 2005):– All children: 10 to over 25%– Premature: 40-70%– Significant medical problems and/or
developmental delays: 70-90%
Background
• Inadequate nutrition during first 3 years of life:– Short-term consequences
• critical window of development
– Long-term impact
Rationale
• Nature of feeding, swallowing, & nutrition (FSN) disorders in pediatric populations– TIME SENSITIVE– Requires efficient management– Interdisciplinary approach meets these needs
• Not well-established nationally for FSN– Salient factors for the establishment of such teams are
not yet known
Purpose
• Primary research questions:1) What are the salient factors predictive of successful establishment of the role model interdisciplinary team addressing the evaluation and management of pediatric feeding, swallowing, and nutrition disorders? 2) What are the salient factors predictive of continued operation and successful functioning of such a team?
Methods: Participants
• Core members of the role model FSN interdisciplinary team (n=18)– Included: speech-language pathologists, dieticians,
clinical psychologists, nurses, and gastroenterologists • Located at a University Children’s Hospital• 8 team members consented; 6 completed
focused interviews• All disciplines represented except
gastroenterology
Methods: Procedures
• Focused interviews
• Transcribed and coded
• Content analysis(Graneheim & Lundman, 2003; Lemieux-Charles & McGuire, 2006; Kvarnstom, 2008 )
– Qualitative analysis– Quantitative analysis
Methods: Data analysis
SchematicTheme Subtheme Subtheme
unit
Admin support
Financial support
Billing & Collection
Funding for clinical
materials
FTEs
Dept support
Admin personnel
Allocated personnel
“And again, just administrative buy-in, you need the blessing of the hospital to make it happen.”
“There’s going to be billing questions that come up, you know – why does a patient need to billed by separate services at the same appointment, for example”
Methods: Data analysis
Frequency Unit:Unit of meaning captured in one or more coded statements
Example: “In order to have adequate evaluation, and then optimal management recommendations with these children with complex feeding and swallowing issues, which is why they get to us, it takes multiple disciplines in order to do that because the inter-related factors are so great”
Methods: Data analysis
• Salient (primary) factors:– A minimum of 1 frequency unit across all 6
participants
• Secondary factors:– 1 frequency unit was identified across 4-5 participants
• Tertiary factors:– 1 frequency unit was identified across 3 or fewer
participants
RESULTS AND DISCUSSION
ADMINISTRATIVESUPPORT
FACILITY FACTORS
Billing and collection
Financial Location
ALLOCATED PERSONNEL
PERSONNEL
SUCCESSFUL ESTABLISHMENT
CORE DISCIPLINEPERSONNEL
ADMINISTRATIVEPERSONNEL
DEPARTMENTALSUPPORT
Consultants
PHILOSOPHYAND MISSION
Designated space
Access to medicalResources
System-wide communication
Funding for clinical materials
FTEs
STATE & REGIONALSUPPORT
= salient
= secondary
= tertiary
LEGEND
Results & Discussion: Salient factors
• Predictive of successful establishment:– Location (32 freq units)
“Oh yeah, I think you physically need to all be in the same place when you’re seeing these patients, and when you’re staffing, and all that kind of stuff. Definitely, yes.”
– Administrative support (30 freq units)“And again, just administrative buy-in, you need the blessing of the
hospital to make it happen.”– Administrative personnel (23 freq units)
“You need a clinic coordinator, just because of the number of providers that are there.”
“And then that our medical director also made sure we had the administrative support from the hospital to make it fly, and that was really critical to getting it off the ground;”
– Core discipline personnel (16 freq units)• Speech-language pathology, nutrition,
psychology, and nursing.
INTERDISCIPLINARYTEAM
DYNAMICS
PATIENT CAREISSUES
CONTINUED OPERATION / SUCCESSFUL FUNCTION
*RULES OF CONDUCTAND OPERATION
PROS
CONS
NEUTRAL
PROS
CONS
NEUTRAL
PROS
CONS
NEUTRAL
Clinical Research
Clinical Algorithm
•Professional support•Intellectual gain•Interpersonal interactions•Service delivery method
•Scope of practice•Discipline floor time•Interpersonal & prof. trust issues•Personality conflicts•Conflicting patient care opinions
•Prior team experience or training•Comparison of interdisciplinary vs individual service•Defining roles of team members•Communication structure
•Standard of care•Interdisciplinary care efficacy•Rewarding family interactions•Efficient delivery of care•Ongoing education in pt care
•Balance need with productivitydemand•Principles of care•Population demographics•Pt communication methods
•Increased demand for services•Maintaining communicationb/t team and family•Conflicting Tx recommend
*See next page
TEAM FUNCTION FACTORS
RULES OF CONDUCTAND OPERATION
PROS
CONS
NEUTRAL
Clinical Research
Clinical Algorithm
•Benefits of specialized training•Strengths of interdisciplinary model•Experience and interest level ofteam members•Good team reputation•Weekly team staffing adv
•Scheduling and coordination issues
•Working with medically complex children without strong medical background•Balancing pt care with indirect careresponsibilities•Accommodating growing pt base demands
•Scheduling procedure descriptions•Prior and ongoing professional training•Team organization and protocol descriptors•Roles and responsibilities of team members
CONTINUED OPERATION / SUCCESSFUL FUNCTION
Conclusions
• The outcomes of this study successfully identified salient factors for each overarching theme of interest
Conclusions
• Outcomes– Salient factors identified for establishing the
team relate to significant institutional support• Administrative• Location & existence of core disciplines
Conclusions
• Outcomes– Those identified for continued existence
• Interdisciplinary team dynamics• Patient Care Issues• Rules of Conduct and Operation
Future Research
• Determine how representative the outcomes from this role model team are of other such teams across the country– Regional differences– Urban and rural differences– Core discipline representation– Clinical operations– Medical centers v private practice or corporate
groups
Acknowledgements
• Dr. Julie Barkmeier-Kraemer
• Dr. Joan Arvedson
• ASHA – SPARC committee
• Members of the pediatric dysphagia research group at the University of AZ
References
Cashman, S.B., Reidy, P., Cody, K., & Lemay, C.A. (2004). Developing and measuring progress toward collaborative, integrated, interdisciplinary health care teams.
Graham, G.G. (1985). Poverty, hunger, malnutrition, prematurity, and infant mortality in the United States. Pediatrics, 75, 117-125.
McCallin, A. (2001). Interdisciplinary practice – A matter of teamwork: An integrated literature review. Journal of Clinical Nursing, 10, 419-428.
Mullins, L.L., Balderson, B.H.K., Sanders, N., Chancy, J.M., & Whatley, P.R. (1997). Therapists’ perceptions of team functioning in rehabilitation contexts. International Journal of Rehabilitation and Health, 3(4), 281-288.
Rerkasem, K., Kosachunhanun, N., Tongprasert, S., Khwanngern, K., Matanasarawoot, A., Thongchai, C., Chimplee, K., Buranapin, S., Chaisrisawadisuk, S., & Manklabruks, A. (2007). The development and application of diabetic foot protocol in Chiang Main University Hospital with an aim to reduce lower extremity amputation in Thai population: A preliminary communication. The International Journal of Lower Extremity Wounds, 6 (18), 18-21.
Rogers, B. & Arvedson, J. (2005). Assessment of infant oral sensorimotor and swallowing function. Mental Retardation and Developmental Disabilities Research Reviews, 11, 74-82.
Rudolph, C.D. & Link, D.T. (2002). Feeding disorders in infants and children. Pediatric gastroenterology and nutrition, 49(1), 97-112.
Scott, J.C., Conner, D.A., Venohr, I., Gade, G., McKenzie, M., Kramer, A.M., Bryant, L., & Beck, A. (2004). Effectiveness of a group outpatient visit model for chronically ill older health maintenance organization members: A 2-year randomized trial of the cooperative health care clinic. Journal of the American Geriatric Society, 52, 1463-1470.
Sullivan, P.B., Lambert, B., Rose, M., Ford-Adams, M., Johnson, A., Griffiths, P. (2000). Prevalence and severity of feeding and nutritional problems in children with neurological impairment: Oxford feeding study. Developmental Medicine and Child Neurology, 42, 674-680.
Williams, S., Witherspoon, K., Kavsac, P., Patterson, C., & McBlain, J. (2006). Pediatric feeding and swallowing problems: An interdisciplinary team approach. Canadian Journal of Dietetic Practice and Research, 67 (4), 185-190.
Questions
Additional information (not covered in presentation)
Methods: Data analysis
Preliminary schematic
Revised schematic
Theme Subtheme
Administrative support
Financial support
Departmental support
Administrative personnel
Allocated personnel
Theme Subtheme Subtheme unit
Admin support
Financial support
Billing & Collection
Funding for clinical
materials
FTEs
Dept support
Admin personnel
Allocated personnel
Methods: Data analysis
Individual StatementsUnit of meaning captured in
just one coded statement
Example: i6s73q11
“We have staffing once a week which really leaves it open for people to bring up topics, issues, problems, concerns.”
Linked Statements2+ statements that create 1
meaningful unit
Example:i1s61q6 “We just had our big feeding
conference…”i1s62q6“…obviously our institution
was supportive of showcasing what we do here.”
FREQUENCY UNIT ANALYSIS
Methods: Reliability
• Intra-rater reliability– 20% of interview contents randomly
selected for repeat analysis by same rater 3-5 days after final analysis
– % exact agreement within each rater
• Inter-rater reliability– Same 20% analyzed by different rater– % exact agreement between raters
Results: Reliability
[Minimum criterion for reliability = 70%]
• Intra-rater reliability– Exact agreement = 83%
– If accept semantically-related assignments, adjusted reliability = 97%
• Inter-rater reliability– Exact agreement = 75%– Semantically-related assignments result in
adjusted reliability = 96%
Results & Discussion : Salient factors
• Predictive of continued operation and successful functioning:– Interdisciplinary team dynamics
• PROS: (frequency units = 22)– e.g. intellectual gain, interpersonal interactions…
• NEUTRAL: (frequency units = 23)– These are descriptive of team dynamics without being
positive or negative
• CONS: (frequency units = 41)– e.g., scope of practice issues, differing opinions regarding
patient care by different disciplines
Results & Discussion : Salient factors
• Predictive of continued operation and successful functioning:– Patient care issues
• PROS: (frequency units = 31)– Frequently stated that this model offers the best
possible care for this population
• NEUTRAL: (frequency units = 18)– e.g. Description of team and family communication
Results & Discussion : Salient factors
• Predictive of continued operation and successful functioning:– Rules of conduct and operation
• PROS: (frequency units = 45)– e.g. perceived benefits associated with interdisciplinary
versus multidisciplinary team structure and function • NEUTRAL: (frequency units = 67)
– Descriptions of team organization and logistics• CONS: (frequency units = 35)
– e.g., “…and just trying to coordinate all of those services into one appointment, which is the ideal way of providing care can be, I think, a logistical nightmare especially for our coordinator.”
