Service Structure & Triaging - Decision Making in Clinical Settings

Hi Everyone,

Happy New Year! I hope 2015 is a fantastic year for us all.

Since it is the beginning of a new year, today I thought I’d write about designing our clinical service structure, since some of us might be setting up new services, or perhaps rethinking the way we would like to offer services and triage clients.

Service structure, triaging and waiting lists have always been difficult for me, as I have always had such limited hours of work to service a large number of wards/units and patients. Right now I work three days a week and have 115 potential patients across six units. Being a senior clinician, my workload is two days clinical and one day admin/research/leadership duties, so with only 16 hours of time for clinical work, how on earth do I plan my services and choose who has access to music therapy? Also, how do we decide who is in most need of music therapy when there is a waiting list? Unfortunately I have no magical answers for these questions, but can talk about how I have done things in the past, and how I’m thinking of putting together my services for the coming year.

I have always wanted to implement a ‘quality over quantity’ approach to my service structure, but in several workplaces have always been instructed to provide ‘equity of service’ instead – which has meant spreading myself and the services thinly across many units. What this means in practice has been providing one group session per unit per week. This is not optimal for several reasons – 1. patients get only one opportunity for music therapy per week, and no opportunity for in-depth individual treatment, 2. advocating for and educating about music therapy is very difficult, as I would fly in and fly out of units once a week for a session before running off to do the next one – not great for trying to showcase music therapy’s efficacy when it may appear that I’m dashing in to do a ‘singalong’ (dreadful word) and then leaving!, and 3. I never get to feel part of a team, as I’m never in any one unit for long enough to engage with staff members and form professional relationships. I really dislike this type of ‘equity’ as it feels to me that no one is getting a quality service, albeit an equal one! Hang on a minute – surely some music therapy is better than none, right? So the ‘quantity’ approach is sometimes the best we can do under the individual constraints and circumstances of our jobs and roles, and is certainly what I’ve been doing for many years now, while at the same time trying to change the way facilities think about music therapy services provision.

What I’m working towards at the hospital I work at currently is one day of clinical service per unit, so at the moment that would mean that two of the six units would be able to access music therapy. Ideally, this would create a need on the other four units, and would make and ideal opportunity to collaborate on some funding submissions for further music therapy hours. I am acutely aware that this is NOT an equity of service model, but rather a quality service model. It is also a STRATEGIC model. I believe we need to be strategic in our clinical service structures, to encourage others to advocate on our behalf. I could say (and I have!) that we need more music therapy at our hospital until I’m blue in the face, but it means nothing, because I’m a music therapist – OF COURSE I think there should be more music therapy!!! But – if I can create a need, a gap in the service, that inspires others (staff, patients) to ask for more music therapy, then someone – like those holding the money – is more likely to listen.

Another issue here is the use of students to cover clinical work. This is a double edged sword. On one hand it is great to have students for all kinds of reasons, (which I will outline in another post) however, when students are seen to be covering the clinical work, there might be no perception of need, so no reason to support or grant extra funding for positions. This semester I will be taking two music therapy students and one art therapy student for their placements (internships) so will need to think about how best to structure their time in order to get the best clinical experiences for them and the best outcomes for patients AND the music therapy department (and I use the term loosely – haha!). Perhaps time-limited project work like a six week group song writing project or an eight week puppet making project? That way the students can rotate between units to get a wide range of experience, while exposing unit staff and patients to music and art therapy for limited periods of time.

Ok. So we’ve got quality (not quantity) services on two units – perhaps each unit has access to one group and two or three individually referred patients for their day. Let’s assume that the staff are making good quality referrals (also a whole other post!) and you’ve had to institute a waiting list. How do you decide who has a higher need for music therapy? Will anyone really suffer adverse health consequences from NOT receiving music therapy? Perhaps. I feel like for music therapy, triaging is not clear cut. Let’s use an example from speech pathology for clarification. Speech pathologists working in neurological rehab might have two broad areas of practice – eating/swallowing, and communication. For them, it’s pretty clear cut – if someone can’t chew and swallow adequately, they are at risk of gagging, choking and aspirating, which could result in infection, inadequate nutrient intake, and in extreme cases, death. Whereas if someone can’t communicate, it’s pretty upsetting and frustrating, but probably not life threatening, so usually the folks with needs in the area of swallowing will get seen first, as a clear priority. Now how about music therapy? I’ve been thinking about this for a long time, and I can’t come up with any answers. When I worked in neurological rehab, I had referrals for communication, emotional expression, enhancing family relationships, coping in hospital etc. – which of those is more important? Could any of them be life threatening? Maybe. At the moment I work in inpatient mental health, so my referrals are a little different – usually for emotional regulation, mental health education, return to previously enjoyed activities, enjoyment, participation and so on. So again – which is more important? How do I choose? And how can I ethically defend my choices? Possibilities might be a first-come-first-served basis, assessing for depression/suicidality, looking at what other forms of support a patient has, and working with those with the least? Perhaps in other populations, this process is clearer, like in the speech pathology example. Maybe in paediatrics the level of the child’s distress can be used, or kids with out-of-town parents can be seen first? In palliative care, those closer to the end of their lives might be prioritised, or those who are without family? In aged and dementia care are those with higher levels of confusion and agitation seen before those with ‘only’ physical illnesses?

Like I said – I have no magical answers, and I’d love to hear your techniques and resources on this topic. I’ve done a little online researching with no luck. Looking forward to hearing your comments and discussing with you below.


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