CHRONIC DISEASE MANAGEMENT
123 Carruthers Street, Curtin ACT 2605
Phone: (02) 6207 6833
OBESITY MANAGEMENT SERVICE MODEL
AND
IMPLEMENTATION PLAN
Paul Dugdale, Geetha Isaac-Toua, Jennie Yaxley
2014
Version 2
Contents
Executive Summary -------------------------------------------------------------------
3
Document Information ---------------------------------------------------------------
6
Acknowledgements
6
Classification of Body Mass index
6
Abbreviations
7
1: Background ------------------------------------------------------------1.1 Background
2: Service Overview -------------------------------------------------------
8
8
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.
33
Related Government Policies and Strategies
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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
BMI (Kg/m2)
Classification
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
Risk of comorbidities
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Abbreviations
ACT
Australian Capital Territory
AHS
Australian Health Survey
ANU
Australian National University
ANZOS
Australian and New Zealand Obesity Society
BMI
Body Mass Index
ASO3
Administration Service Office, Grade 3
CCP
Chronic Care Program
CDM
Chronic Disease Management
CDMN
Chronic Disease Management Network
CDMU
Chronic Disease Management Unit
OMS
Obesity Management Service
CDMR
Chronic Disease Management Register
CIT
Canberra Institute of Technology
CHHS
Canberra Hospital and Health Services
CHI
Community Health Intake
CVD
Cardiovascular Disease
ESSO
Edmonton Staging System for Obesity
FTE
Full Time Equivalent
GP
General Practitioner
HP
Health Professional
ID
Interdisciplinary
MDT
Multidisciplinary Team
OSRP
Obesity Service Redesign Project
PA
Physical Activity
Pre-op
Pre Operative
RN
Registered Nurse
SMS
Senior Medical Specialist
SOP
Sx
TCH or CH
YMCA
Standard Operating Procedure
Surgery
The Canberra Hospital or Canberra Hospital
Young Men’s Christian Association
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1: Background
1.1 Background
Obesity 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,
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


bariatric surgery providers,
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-management
And 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.
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The service will not be appropriate for:


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 groups
The 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 service
Bariatric 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 Process
Referrals 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 Adults 1.
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 Plan
The 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.
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There will be a moderate intensity of service provision in the initial stages of care for example
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 patter
3.4.4. 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
Pilot Phase
Consolid
ation
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
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 2014
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
Communication and marketing
strategy and information brochures
BECHC & service specific
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 Services
The 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 20112012; 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.
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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).
2% 1%
Med
20%
Surg
45%
Crit Care
RACC
8%
WYC
CRCS
2%
Mental H
22%
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.
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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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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/Commissionin
gABariatricSurgicalService.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%20Learnin
g,%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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Appendix A:
OBESITY MANAGEMENT SERVICE WORKING GROUP
TERMS OF REFERENCE
Role
The 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 issues
o ACT Surgical taskforce regarding surgical issues
o the ACT Obesity Interest Network
o CHHS the Bariatric Equipment Working Group
o 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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Quorum
5 members including the Chair or their delegate
Term
The group’s TOR and membership will be reviewed after 18months
Chair
Director of CDM
Secretariat
Provided by the OMS
Membership
Position Title
Director of CDM (Chair)
Obesity Management Service Coordinator (Secretariat)
Medicare Local
Population Health Division
Respiratory services
Chronic Care Program
Cardiology
Consumer
General Practice Advisor
Community Care
Bariatric Surgery
Diabetes ACT
Incumbent (February 2014)
Paul Dugdale
Jennie Yaxley
Jenny Permezel
Paul Kelly
Mark Hurwitz
Jan Ironside
Leonard Arnolda
Fiona Tito Wheatland
Marianne Bookallil
Ana O’Rourke
Andrew Mitchell
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.
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.
2
Improve people with obesity and their carers’ Satisfaction surveys.
satisfaction with the care they receive.
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
- 30 -
Appendix D:
Glossary
bariatric surgery
behavioural
intervention
body mass index
gastro-oesophageal
reflux disease (GORD)
healthy diet
healthy weight
hepatomegaly
hyperinsulinaemia
hyperlipidaemia
hypertension
metabolic syndrome
Interprofessional
practice
multicomponent or
multi factorial
intervention
obesity
OSRP
Prader-Willi syndrome
prediabetes
sleep apnoea
type 2 diabetes
- 31 -
Surgery on the stomach and/or intestines to help a person with severe
obesity lose weight.1
Use of the common components of behavioural treatment—selfmonitoring, goal setting and stimulus control1.
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.
A condition in which the stomach contents (food or liquid) reflux from the
stomach into the oesophagus, causing heartburn and other symptoms1.
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.
A body mass index (BMI) of 18.5 to 24.91.
The condition of having an enlarged liver1.
Higher levels of insulin circulating in the blood than would be expected by
the level of glucose1.
Abnormally elevated levels of any or all lipids and/or lipoproteins in the
blood1.
Elevated systemic arterial blood pressure1.
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.
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
An intervention that aims to address a range of factors that may influence
the outcome measure of interest1.
Excessive fat accumulation that may impair health, classified when the
BMI is ≥ 30 kg/m21.
Obesity Service Redesign Project
A genetic condition characterised by neurological impairments that cause
an altered pattern of growth and development with associated
hyperphagia (overeating) 1.
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.
A sleep disorder characterised by abnormal pauses in breathing or
instances of abnormally low breathing during sleep1.
A metabolic disorder that is characterised by high blood glucose in the
context of insulin resistance and relative insulin deficiency1.
very low-energy diet
Wellbeing
A diet that generally provides between 1675 and 3350 kilojoules per day1
“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/wellbei
ng?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/healthservices/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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