Download One System, One Team: Hospital Transitions Pathways Project

Hospital Transitions Pathways Project
One system, One team
FINAL REPORT
Prepared for Metro North Brisbane – Partners in Recovery
August 2015
Metro North Brisbane PIR - Hospital Transition Pathways
August 2015
Disclaimer
Inherent Limitations
This report has been prepared as outlined in the Introduction section. The report is solely
for the purpose and use of the Partners 4 Health Ltd (ABN 55 150 102 257), trading as
Brisbane North Primary Health Network.
The report has been prepared through a consultancy process using specific methods
outlined in the Methodology section of this report. ConNetica has relied upon the
information obtained through the consultancy as being accurate and ConNetica has not
undertaken any auditing or other forms of testing to verify accuracy, completeness or
reasonableness of the information provided or obtained. Accordingly, ConNetica can
accept no responsibility for any errors or omissions in the information provided shown in
this report based upon information provided.
Suggested Citation
Mendoza J, Harvey S & Wands M, 2015. One System, One Team: Hospital Transitions
Pathways Project – Final Report. Prepared for the Brisbane North Primary Health Network,
Partners in Recovery Program. Caloundra, Qld. ConNetica
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Table of Contents
TABLE OF CONTENTS ........................................................................................................................ 3 FIGURES AND TABLES ....................................................................................................................... 5 ABBREVIATIONS ................................................................................................................................. 6 CONSULTING TEAM ............................................................................................................................ 7 ACKNOWLEDGEMENTS ..................................................................................................................... 8 EXECUTIVE SUMMARY ..................................................................................................................... 10 INTRODUCTION ................................................................................................................................. 12 METHODOLOGY ................................................................................................................................ 14 General Methodology ........................................................................................................................ 14 Specific Methodology........................................................................................................................ 15 CONTEXT AND EVIDENCE REVIEW ................................................................................................ 16 Current National Context .................................................................................................................. 16 Regional Context - Metro North HHS ............................................................................................... 17 The Partners in Recovery Initiative .................................................................................................. 18 Other National Initiatives/Programs................................................................................................. 26 REVIEW OF EVIDENCE ..................................................................................................................... 27 Care Coordination and Integrated Care .......................................................................................... 27 A whole-of-systems approach.......................................................................................................... 35 OVERVIEW OF TRANSITIONAL PATHWAYS AND SYSTEM .......................................................... 38 Benefits of conceptual overview ..................................................................................................... 38 The “As Is” Model .............................................................................................................................. 38 The “To Be” Model ............................................................................................................................ 44 Care Pathways for People with Specific Needs ............................................................................... 44 ConNetica
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DISCUSSION ...................................................................................................................................... 46 Overview of data and evaluation of evidence ................................................................................. 46 CONCLUSION ..................................................................................................................................... 57 Recommendations and Action Steps .............................................................................................. 59 REFERENCES AND BIBLIOGRAPHY ............................................................................................... 66 APPENDIX 1 – FEEDBACK FROM INTERVIEWS WITH NGOS AND OTHER STAKEHOLDERS .. 73 APPENDIX 2 – FEEDBACK FROM WORKSHOPS AND FORUMS .................................................. 79 APPENDIX 3 - PCEML PIR, PROCESS FLOWS ............................................................................... 83 APPENDIX 4 – A SUMMARY OF ALTERNATIVES TO ED ............................................................... 88 APPENDIX 5 – AN EXAMPLE OF A SHARED CARE PROTOCOL .................................................. 89 ConNetica
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Figures and Tables
Page
Figure: 1 – Action Research in Healthcare
14
Figure 2: PIR Support Facilitation – A Continuum
19
Figure 3: West Moreton-Oxley Region – System Reform Environment
20
Figure 4: Process for care and Discharge of Patients with Suicide Risk for
Emergency Departments
33
Figure 5: WHO – System Building Blocks
37
Figure 6a & 6b: Overview of Transitional Pathways and System – “As Is”
41
Figure 7: Overview of Transitional Pathways and System – “To Be”
42
Figure 8: Optimal Treatment for Borderline Personality Disorder
43
Figures 9.1-9.4. Client Intake & assessment process flows, PCEM PIR
118
Figure 10: Pre and Post Prison Release Process, PCEM PIR
122
Table 1: Principles, System Changes & Program Changes for Housing First
24
Table 2: A Guiding Framework for Shared Care Protocols, Improved Outcomes
for People with Severe Mental Illness and Stable Housing Solutions, MICAH
Projects
25
Table 3: Principles of Care Coordination
28
Table 4: Common Elements in Effective Care Coordination
29
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Abbreviations
ACT
Acute Care Treatment (Note: not Assertive Community Treatment)
AGPN
Australian General Practice Network
ATAPS
Access to Applied Psychology Services
CMMH
Community-managed mental health (PDRSS – see below)
COAG
Council of Australian Governments
DHS
Victorian Department of Human Services
DoH
Victorian Department of Health
DoHA
Federal Department of Health and Ageing
D2DL
Day to Day Living Program
EPPIC
Early Psychosis Prevention and Intervention Centre model
FaHCSIA
Dept of Families & Housing, Community Services & Indigenous Affairs
GP
General Practitioner
GPQ
General Practice Queensland
GPV
General Practice Victoria
HF
Housing First
ICM
Intensive Case Management
LGAs
Local Government Areas
LHNs
Local Hospital Networks
MNHHS
Metro North Health and Hospital Service
MHNIP
Mental Health Nurse Incentive Program
NGO
Non-Government Organisation (or community service provider)
NHHN
National Health and Hospitals Network
NHHRC
National Health and Hospitals Reform Commission
NPA
National Partnership Agreement
PARC
Prevention and Recovery Care
PDRSS
Psychiatric Disability Rehabilitation Support Services
PCPs
Primary Care Partnerships
PHaMs
Personal Helpers and Mentors program
PHN
Primary Health Networks
PRG
Project Reference Group – established to oversee this consultancy
RBWH
Royal Brisbane and Women’s Hospital
Red/Cab
Redcliffe-Caboolture Hospital
TAU
Treatment As Usual
TPCH
The Prince Charles Hospital
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Consulting Team
ConNetica Consulting Pty Ltd
Director
John Mendoza
ConNetica Consulting Pty Ltd
Chief Executive & Director
Marion Wands
Harvey Risk Management Pty Ltd
Harvey Risk Management Pty Ltd
Director
Stephen Harvey
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Acknowledgements
We wish to thank the Metro Brisbane North staff for their assistance in the conduct of this
project, particularly Paul Martin (System Reform Lead, PIR), Pauline Coffey (Manager, PIR),
Shirley Anastasi (Manager Clinical Governance, Metro North Mental Health Services) and
all the members of the NB PIR Consortium Management Committee.
Our thanks are also extended to the staff of the various NGOs and other stakeholders who
have participated in our interviews and who have taken the time to make written
submissions.
Our consulting team also wishes to acknowledge and thank all 126 participants in the
workshops, particularly the consumers and carers whose personal contributions have
been invaluable for the project.
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“Everybody talks about the weather but no one does anything about it”
Mark Twain
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Executive Summary
In March 2015 Metro North Brisbane Medicare Local PIR engaged ConNetica to examine
existing transition pathways to and from hospital and the community with a view to
improving the “patient experience” and quality of transitions. As a part of the consultancy
ConNetica agreed to engage key stakeholders, including consumers and carers with
experience of the process; articulate key roles, responsibilities and requirements and
make recommendations for improvements as well as outline a number of specific
pathways for particular conditions.
ConNetica adopted an action research and positive enquiry methodology with a focus on
a whole-of-systems approach to the structure of the transitional pathways to and from
hospital and the community. A brief review of the literature informed both our analysis
and critique of the current structure and practice of the mental health system within the
Metro Brisbane North region. At the same time we have given careful consideration to
feedback from stakeholders and consumers who have direct experience within the
current system.
Key findings from the interviews with NGOs and other key stakeholders together with the
feedback from the workshops indicate a wide range of significant shortcomings and
inconsistencies across the three catchment areas (Royal Brisbane and Women’s Hospital,
The Prince Charles Hospital and Redcliffe-Caboolture Hospital) and the four hospitals.
Several systemic failures have been identified that represent a reputational risk to each
hospital as well as to the patients with mental illness/es.
The reforms currently underway within the Metro North Health and Hospital Service
(MNHSS) and the differences in work practices, transitional arrangements and use of
referrals to NGOs at the four hospitals has made the preparation of an accurate overview
of the “As Is” transitional pathways and system much more problematic than originally
anticipated. Accordingly, our focus has been primarily directed toward the articulation of
an overview of the “To Be” modal as this will provide the foundational structure for a more
sustainable, consistent and higher quality system performance with improved “patient
experience” in the future.
A working paper was presented to the NBPIR Consortium Management Committee in late
July 2015. In that paper, a number of key strategic opportunities that could lead to
systemic improvements in the “patient experience” and quality of the transition to and
from hospital were outlined. The Working Paper made nine recommendations to facilitate
a whole-of-systems approach to improved performance which were agreed to and
developed further with the input of the CMC.
The ten recommendations, inclusive of the CMC input are, in brief:
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1. That there be a heads of organisation agreement – based upon agreed key
principles, shared policy and procedures, defined roles, responsibilities and
accountabilities.
2. That a specific engagement strategy be developed and implemented to ensure
both senior clinician and community sector staff actively participate in the change
management process.
3. That experienced members of the community sector workforce be embedded on
a trial basis within two of the four hospital Emergency Departments and participate
in the Triage assessment for all patients who present with mental health needs.
4. That joint training and professional development programs are provided for both
hospital clinicians, community MHS staff and the community sector.
5. That hospital discharge planning be undertaken at least 48 hours prior to
discharge. That the content of the discharge pack be standardised across all four
hospitals in MNHHS.
6. That a comprehensive evaluation system be implemented to ensure accurate
system performance, measurement and continuous improvement.
7. That easily accessible shared “consumer” centric individual care plan software is
provided to facilitate access to all relevant information about the client by the
treatment/ support team.
8. That a funding mechanism be developed to assist and encourage NGO service
integration, alliance-building and rationalisation.
9. That longer term funding mechanisms and partnerships be explored with NGOs.
10. That a strategy to reduce the number of ED presentations across the region be
developed by the CMC in collaboration with the MN HHS.
Through implementing these recommendations together with a number of other
suggested improvements, the stakeholders in the Metro North Brisbane region have the
best opportunity of meeting the stated objectives of this project – to improve the “patient
experience” and quality of the transition to and from hospital and the community – and an
opportunity to make a ‘step change’ in the quality of care provided to mental health
clients in the region.
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Introduction
ConNetica was engaged by Metro North Brisbane Medicare Local PIR (MNB PIR) in
February 2015 to undertake an analysis of the current mental health system for the region
by focusing specifically on improving hospital transition pathways. This project has been
identified as one of a suite of four priority projects by MNB PIR to improve the current
response to needs by building future capacity within the region.
The other three projects focus on the mapping of existing services and the identification
of gaps within those services; the development of a comprehensive web based directory
navigation tool for mental health in the region, and a project to improve the effectiveness
of NGO in-reach within the four catchment areas.
The overall aim of this project is to improve the “patient
experience” and quality of the transition to and from
hospital and the community by developing whole-of-sector
transition pathways ……
The overall aim of this project is to improve the “patient experience” and quality of the
transition to and from hospital and the community by developing whole-of-sector
transition pathways that clearly articulate the roles, responsibilities and timelines of
relevant parts of the service system (e.g. hospital, primary care, NGOs). A whole-ofsystems approach has been taken to the evaluation of services delivery. The report
explores the:
•
Transition pathways, including roles, responsibilities and the primary drivers for the
provision of a coherent and effective system.
•
The consumers and the family/carers experience of transitions to and from
hospital, together with an examination of the information, services and supports
they need.
•
The opportunity for increased collaboration among service providers in planning
and implementing the transition of people to and from hospital.
We have adopted the definition of the Integrated Care Pathway from the Scottish NHS
best practice model as an exemplar of the type of approach which ConNetica believes
MNB PIR should guide the development of ‘one system, one team‘ in mental health
services across the region.
Integrated care pathway (ICP)
“An explicit agreement by a local group of staff and workers, both multidisciplinary and
multi- agency, to provide a comprehensive service to a clinical or care group on the basis
of current views of good practice and any available evidence or guideline. It is important
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that the group agree on communication, record keeping and audit. There should be a
mechanism to pick up when a patient has not received any care input specified by the
pathway so that the omission can be remedied. The local group should be committed to
continuous improvement of the integrated care pathway on the basis of new evidence of
service developments or of problems in implementation.” (Scottish NHS, 2007)
Embedded in the above definition of integrated care pathway there are a number of
criteria which any system is required to include if it is to be internally coherent and
consistent with the above best practice model. Such a system would need to include:
•
An overarching explicit agreement
•
Defined multidisciplinary and multi-agency agreements
•
Defined roles, responsibilities and accountabilities of key stakeholders and their
staff engaged to provide services within the system
•
Adherence to “good practice” and evidence based guidelines
•
Agreed communication, reporting, record keeping and audit procedures
•
Quality control mechanisms
•
Establishment and measurement of objective evaluation criteria and system KPIs
•
Commitment to continuous improvement
•
Maintenance of up to date knowledge base
Whilst the “As Is” transitional pathways model does not poses all of these characteristics
the “To Be” model has been specifically designed from a systems performance
perspective and is intended to meet all of the above criteria.
Following a brief discussion of the methodology, the current national and regional
context is discussed and the evidence on care co-ordination and integrated care is briefly
summarised. A whole-of-systems approach is taken to ensure a full analysis of the current
context.
This paper focuses on a detailed examination of the transitional pathways into and from
hospitals in the region and two models the “As Is” and the “To Be”. There is then a
detailed discussion of the evidence arising from the consultations and stakeholder
engagement processes. Consideration is given to a number of key issues identified by
participants during the consultation process. This is followed by a brief conclusion and
action plan. Details of community sector consultations and feedback from the workshops
are provided in Appendix 2.
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Methodology
General Methodology
ConNetica’s preferred methodology when undertaking this type of project is to utilise the
elements of the action research and positive enquiry approach incorporating the
elements of action learning research, sometimes called participatory action research.
Action research is often described as an iterative process that incorporates collaborative
processes with key stakeholders to continually review and share learnings to identify areas
for improvement and inform knowledge, recommendations and future action. Action
research’s strength lies in its focus on generating solutions to practical problems and its
ability to empower practitioners, by getting them to engage with research and the
subsequent development or implementation activities.
F IGURE: 1 - A CTION R ESEARCH IN H EALTHCARE (A FTER O’ ’L EARY ’ S C YCLE OF R ESEARCH M ODEL)
1
Within this Action Research framework, ConNetica has utilised elements of Appreciative
Enquiry to identify the “As Is” and the “To Be” hospital transition pathways. Specific
process strategies have included story boarding to record current experiences,
compilation of service pathway maps and nominal group processes to prioritise actions to
achieve the desired “To Be” model. ConNetica has used these strategies in order to
1 Koshy E, Koshy V & Waterman E (2011). Action Research in Healthcare. Sage Publications. London
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maximise the input from a wide range of key stakeholders during the consultation
process.
“when people are active in decisions affecting them, they
are more likely to adopt new ways” Kurt Lewin
We believe that the effective involvement and collaboration with key stakeholders has
provided a true and accurate understanding of existing pathways and the issues
impacting the “As Is” hospital transition pathways. This understanding, along with effective
and ongoing stakeholder engagement, has helped maximise stakeholder commitment to
the resulting “To Be model” as planned. By working closely “with” people throughout this
project rather than “on” people we have started the process of facilitating the necessary
commitment towards the achievement of a more integrated and sustainable mental
health system for the Metro North Brisbane region.
Throughout the project a whole-of-systems approach was adopted which viewed the
transitional pathways within the specific regional context of the system to further ensure
the relevance of our recommendations.
Specific Methodology
During the consultancy process the following specific methods were utilised within the
general methodological framework outlined above to procure the wide range of data that
has informed the discussion and recommendations within this report.
•
Face to face interviews were conducted with Key NGO’s and other stakeholders
prior to the workshops
•
Telephone interviews with other key stakeholders has also been completed
•
Five workshops were undertaken for RBWH, TPCH and Red/Cab catchments for
service providers including staff and managers from community sector services,
community mental health services (MNHHS), HHS hospital and private hospitals
(N=97) plus consumers and carers at Brisbane and Moreton (N=29)
•
Literature review
•
Other research included a review of best practice models
•
Liaison with other PIRs
•
Desk top audit of AQuA MNMH documentation and HHS “internal discharge”
processes
•
Evaluation of range of other correspondence from interested parties, consumers,
carers and other participants.
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Context and Evidence Review
Current National Context
From this review, the consultations, and an analysis of the current operating environment,
several key issues emerge:
•
The national mental health reform agenda remains unclear. The National Mental
Health Commission completed an exhaustive review of mental health services for
the Federal Government in November 2014. The Federal Government released
the full report in April 2015 and then announced an “Expert Reference Group” in
mid-June 2015 to report back by late October on (broadly speaking) an
implementation plan. It is expected that the NMHC Report and the ERG process
will lead to further changes but these are difficult to predict both in terms of
directions and timing at this time.
However, it would be surprising if the Commission’s emphasis on regional
planning and funding to improve service integration and consumer outcomes was
not endorsed and followed through by the Government given the establishment of
Primary Healthcare Networks. The PHNs, along with state LHD/HHS authorities are
the ready-made governance structures for commissioning models of service
delivery. Commissioning models have show promise in terms of improvements in
care coordination (Willging et al 2007; MacArthur Foundation 2007; Begley et al
2008; Miller et al 2013)
•
The Partners in Recovery program commenced operations across 48 Medicare
Local regions in July 2013 and is funded until 30 June 2016. Like all
Commonwealth funded mental health programs, there is no clarity as to the future
funding for this program.
•
Funding for community sector organisations remains unclear. In April the Federal
Government announced, after months of conjecture, that funding for some 300
community sector organisations operating across 160 Commonwealth funded
programs would be extended another year to 30 June 2016. This was the second
one-year funding extension by the Abbott Government and has created significant
uncertainty for most community mental health sector organisations and their staff.
Strategic planning and operations have been placed in an extended holding
pattern in effect.
•
In addition, changes arising from the Hovarth Review of Medicare Locals (2014)
have seen the recent transition from Medicare Locals to the successful tenders for
Primary Health Networks (PHN) from 1 July 2015. The changes to funding,
governance structures and systems and stakeholder relationships are now being
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addressed by PHNs, but these are nascent organisations with all the usual start up
challenges.
•
The National Disability Insurance Scheme is creating further uncertainties for the
community mental health sector generally. The results of the trials in other
jurisdictions have revealed serious challenges for service providers and the
appropriateness of the NDIS model for psychiatric disability has been a point of
conversation. The future of the Partners in Recovery initiative and the relationship
to the NDIS, remains unclear.
In essence, the national context for PIR and indeed the
entire mental health sector is one of strategic and
operational uncertainty …
In essence, the national context for PIR and indeed the entire mental health sector is one
of strategic and operational uncertainty which presents difficulties for local leadership in
gaining stakeholder commitment to reform.
Regional Context - Metro North HHS
Context
There is also a high level of change across the Queensland Hospital and Health Service
(HHS) in Metro North and more generally across Queensland as a range of broader
streaming changes are being introduced with changes to existing documentation and the
introduction of/and rationalisation of policy and procedures. Mental Health is now one of
nine streams across MN HHS and reports to Asso. Professor Brett Emmerson. Transitional
Housing and Transcultural Mental Health, while providing services in MN HHS, are both
based in the Metro South and report to Asso. Professor David Compton.
Document Review
Based upon a detailed review of the documentation provided by Shirley Anastasi,
(Manager Clinical Governance MH MHS), interviews and feedback from the project
workshops and forums, there are clearly significant differences between the various
hospitals and the operating environments within each catchment.
At the same time there are a number of initiatives which have already been identified as a
part of the review which either have not been fully implemented or are at different stages
of implementation at different hospitals. These initiatives stem from the ‘AQuA’ Project
commenced in 2013 and documented in the MNMHS Review of Implementation (Sept
2014). These differences have made it difficult to articulate the “As Is” model.
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The Partners in Recovery Initiative
ConNetica and our partner in the Metro North Brisbane Mental Health Atlas Mapping
project, the Mental Health Policy Unit at the Brain and Mind Research Institute are
currently working with 13 Partners in Recovery projects across three jurisdictions.
PIR was initiated by the Gillard Government in 2012 to address the gaps in services for
people with “severe and persistent mental illness with complex needs”. The target
audience was those who had a significant level of unmet needs, rather than those who
were not accessing any services. PIR also aimed to improve the experience of care for
those with severe and persistent mental illnesses through providing a stronger emphasis
on recovery and integrated care.
PIR was not so much a model of care but an initiative that allowed service provider
collectives to develop appropriate service linkages, improve the capacity of agencies to
work with the target group.
It most closely aligned with service navigation models
developed in some jurisdictions overseas (Bowler 2006; Corrigan et al 2014; Plant 2013;
Raleigh et al 2014). As such it is more ‘remedial’2 than a true structural change initiative.
The degree of structural change is dependent on local factors (bottom-up) rather than any
national strategy or initiative to restructure mental health care (top down).3
Given the lack of prescription in the PIR initiative, there is a great deal of viability and
innovation in how individual regions have gone about implementing the initiative.
Figure 2 is one, high level representation of the PIR service model (developed by Brisbane
North PIR) and the role of the key personnel, namely the Support Facilitators. Typically,
over time as the project matures, SFs spend less time with PIR clients on activities at the
left hand end of the continuum and more time on activities at the right hand end.
While PIR was slow to get some momentum in most regions, it has now gained greater
momentum and regard among the community mental health sector and increasingly by
community mental health services and hospital-based clinicians. However, the funding for
the PIR program is currently due to conclude on 30 June 2016.
This is creating
uncertainty with respect to future service delivery options within the mental health sector.
At the same time the NDIS has not been fully articulated or rolled out and the relationship
between PIR and NDIS remains unclear. This uncertainty may have a negative impact
upon service provision options in the near future and some consideration of contingency
planning is recommended.
F IGURE 2: PIR - S UPPORT F ACILITATION – A CONTINUUM
Remedial is so far that PIR acknowledges the complexity of the mental health care services system and provides the bulk of
the available resources to one-on-one intensive support to consumers to facilitate and enable their access to services.
3
This is an important point of difference with the NDIS which is fundamentally a top-down, re-commissioning model of service
and change for the disability sector.
2
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F IGURE 3: W EST M ORETON -O XLEY R EGION – S YSTEM R EFORM E NVIRONMENT
System'Reform'Environment'
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Perth Central East Metro Partners in Recovery
This Medicare Local (now WA Primary Health Alliance and 360 Health and Community)
has developed a range of innovative, highly effective and comprehensive medical, mental
health support and psychiatric treatment programs, including suicide prevention,
Aboriginal and Torres Strait Islander Health and Closing the Gap program, extensive inreach to the prison and justice system, palliative care and targeting rough sleepers. A
number of these initiatives have linked to service integration and broader system reforms
through the PIR initiative.
In-reach by the PCEM Partners in Recovery (PIR) into acute hospitals has been
opportunistic rather than systematic. The PIR team have established a presence at two of
the three hospitals in the region. PIR staff regularly visit and meet with clinical staff but
generally in response to a PIR client referral where it is evident that the individual has a
high number of hospital/ED presentations.
A “Collaborative Model of Shared Care Planning” following discharge from acute care
involving two public hospital MHSs, GPs and NGOs with a private psychiatrist has
struggled to gain traction. One of the hospitals has disengaged from the project.
PCEM PIR program have awarded a number of small and larger Innovation and
Collaboration Grants to NGOs to deliver programs and strengthen partnerships with
organisations across the catchment area. PIR funded the development and piloting of a
care coordination training program (3-day) for all services. The state mental health
association now delivers the program.
PCEM PIR has extended the scope of the existing innovative outreach services.
StreetDoctor is a mobile, easily accessible, confidential and non-discriminatory bulkbilling primary health care service that aims to improve patient health and reduce
hospitalisation for marginalised people of all ages. The fully mobile clinic regularly
attends key locations (psychiatric hostels, crisis accommodation services and mobile
kitchens) across the central Perth and eastern suburbs providing all of the services a
conventional clinic would provide. The services are now highly integrated with psychosocial supports with a strong focus on recovery.
ConNetica assisted PCEM PIR to process map client intake and prison release. The
mapping has supported stakeholder engagement through establishing clear roles,
responsibilities and relationships and ensured that every referral to the PIR program
receives assessment and transition to appropriate care. In effect every PIR referral is
‘triaged’ to appropriate care across the region. (See Appendix 3)
The prison in-reach and post-release support provided by PIR is now subject to a separate
evaluation over the latter half of 2015.
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While the senior leadership of Metro North Perth Mental Health Services are strongly
engaged with the PIR project, the engagement of individual acute care units varies and is
generally ‘relationship’ based rather than systemic (i.e. where the PIR staff have
established a good rapport and working relationship with an individual clinician or group
of clinicians).
West Moreton Oxley Partners in Recovery
The WMO PIR central team have undertaken extensive research to inform their approach
to integrated service delivery and operating frameworks. This region has incorporated
much of the People Powered Health model (NESTA, UK 2013) into their system reform
activities. This approach recognises the significant pressure upon health budgets and the
need to provide better and more outcomes with the same or less funding. It is largely built
on the premise that patients do better when they are involved in developing and
delivering their own care – that is described as ‘co-production’.
The People Powered Health approach involves five areas of practice: more than medicine
(new services), people helping people (peer support), redefining consultations, networks
and partnerships, and user co-design and co-delivery. The supporters of this approach to
service delivery, assert that the costs of managing clients with long term health conditions
could be reduced by 20%.
The UK national mental health strategy – No Health Without Mental Health – has a guiding
principle that people with mental health problems must be involved in planning and
decision making by professional staff. Peer support was identified as one way in which the
UK Government’s priorities for mental health will be delivered. It was reported in one
study that one program that included 49 peer support packages saved 300 hospital bed
days. Another program that is adopting the People Powered Health Approach in
Stockport, expects that the new mental health pathway will reduce referrals to secondary
care by 65%, discharge rates by 25% and re–presentation by 60%. This will lead to a net
savings of over £500 per patient reducing the cost per patient from £1,880 to £1,320.
(http://www.nesta.org.uk/sites/default/files/the_business_case_for_people_powered_heal
th.pdf)
The People Powered Health approach creates significant organisational challenges and
therefore requires the drivers of such change to:
•
Address how patients and professionals will interact
•
Invest in changing organisations, which at times is difficult as these organisations
are often already over–stretched and or have failed at large scale change
previously
•
Convince relevant stakeholders that this new approach will facilitate achievable
health benefits and is not simply a cost cutting exercise.
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WMO has developed a comprehensive schema (Figure 3) to illustrate the transition of
people with complex mental health needs throughout their recovery journey. This
involves the referral of patients to and from hospital, corrections, police, housing services
and Department of Communities and includes the following phases/elements of
interventions:
•
Complex crisis and acute services provided by hospitals/ambulances
•
Rehabilitation services, including therapeutic treatment and support groups,
access to GPs, utilisation of NGO services, peer support
•
Prevention and Living Well services including – volunteers and interns/students
who provide mentoring support, navigation to and from services, neighbourhood
centres that have staff trained in mental health and providing a place for people to
meet socially and or access relevant services, training programs to boost self
esteem, self efficacy and social engagement
Underpinning WMOs referral pathways work has been considerable focus on:
•
Workforce development initiatives in particular the development of the Aftercare
Provisional Intern Program, the Student Hub and the Volunteer Concierge
Program. The individuals participating in these initiatives are supervised by
qualified staff and are cost effectively filling the gaps that often arise in service
provision.
•
Consultation with relevant stakeholders involved throughout the referral pathways
including practitioners, consumers and service providers to identify service gaps,
needs, expectations and improved service practices.
Metro South Brisbane PIR
In March 2015 ConNetica was engaged by Micah Projects to facilitate the engagement of
key regional stakeholders in developing shared solutions for providing better housing
outcomes for those with severe and persistent mental illness. As a part of that process
ConNetica and Micah undertook literature reviews to identify models of housing and
services delivery that best meet the needs of the target group in preparation for
consultative workshops. ConNetica also undertook a roundtable discussion as a part of
the co-design process and agreed to co-design protocol templates for common
conditions that have difficulties attaining and retaining housing.
The outcome of this project concluded that the Housing First approach represents a
substantive and qualitative improvement in harm minimisation; health outcomes; material
benefits; social inclusiveness and psychological wellbeing of those lucky enough to be
provided with permanent housing as compared to other models. Nonetheless,
stakeholders recognise that the macro policy conditions in the region and Australia more
generally, are not aligned to the Housing First principles (see Table 1). Therefore service
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level reforms will be undertaken to provide improved housing and health outcomes for
people with complex mental health needs. The development of shared care protocols
among key stakeholders has now commenced based on the framework shown in Table 2.
The outcomes of the Micah Projects work have assisted with the preparation of this report.
T ABLE 1: P RINCIPLES , S YSTEM C HANGES & P ROGRAM C HANGES FOR H OUSING F IRST
Principles
Systems Changes
Program Changes
Planning immediate access to
housing for people chronically or
episodically
homeless;
coordinating housing & support
sectors with funding sources;
inclusion of housing procurement
specialists
&
clinical
serviceproviders with distinct roles in
housing & service systems planning
& provision
Clinical or support services
are provided by individuals or
teams that are separate from
the consumer’s housing
Consumer-choice & selfdetermination
Strong
emphasis
on
the
participation of people with lived
experience in housing & service
systems planning
No requirement to participate
in clinical services; choice over
intensity & types of services in
(inc. ACT, ICM, etc); serviceproviders do not work in the
consumer’s housing
Individual, recoveryoriented, & client-driven
services
Service systems planning focuses
on the dev’t of or collaboration with
existing services that are oriented
towards consumers’ strengths; dev’t
of peer support & self-help
Rather
than
focus
on
consumer
deficits
or
problems, focus of services is
on promotion of recovery;
inclusion of peer support
Harm reduction
Planning focuses on new services
designed to reduce harm rather
than cure addictions
Clinical & support services
take
a
harm
reduction
approach with consumers
Social & community
integration
Housing & service systems planning
focuses on how to provide access
to normal market housing, rather
than the building or appropriation
of congregate housing in which
formerly homeless people live
together with on-site support
services
Consumers have access to
housing subsidies to enable
them to live in normal, rental
market housing, if that is their
choice; the focus is on
scattered site housing & the
promotion of integration into
typical community settings &
networks of support
Immediate access to
housing with no housing
readiness requirements
NO BARRIERS
Source: Housing First Toolkit , Mental Health Commission of Canada, 2014
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T ABLE 2: A G UIDING F RAMEWORK FOR S HARED C ARE P ROTOCOLS , I MPROVED O UTCOMES FOR P EOPLE
S EVERE M ENTAL I LLNESS AND S TABLE H OUSING S OLUTIONS , MICAH P ROJECTS
WITH
Therapeutic alliance
What we know about the
client group …
What can we agree we are
ALL trying to achieve …
Agreed & shared
PRINCIPLES of care
management
These may be generic or specific to the primary condition
of the consumer (e.g. Borderline Personality Disorder)
Roles & responsibilities of
core providers
WHO does WHAT
WHEN
Multi-agency care
management goals
What are you own agency’s
care management goals?
Are they explicit?
What can we agree on?
Governance
What structure/s are needed to implement, monitor &
continuously improve?
Reference
Standards/Guidelines
National or Professional
Shared …
Organisational
(Developed from the Scottish ICPs)
Other Partners in Recovery Programs and Initiatives
Liaison with other ConNetica PIR partners and contacts in Central Queensland, Wide Bay,
Inner West Sydney and Illawarra-Shoalhaven has informed the transitional models
outlined in this project. Similar concerns have been identified across the PIR projects
however most efforts on system reform have focussed on either case coordination (for PIR
clients) or community care coordination between mental health NGOs, public sector
community MHS, and NGO service providers and government agencies in employment,
housing and general community care. ConNetica is not aware of any other PIR group
systematically examining the transitions from hospital to community and designing and
implementing responses.
A common finding in the evaluations being undertaken by ConNetica across these PIR
projects, has been the difficulty in engaging hospitals (acute care units) and the clinicians
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working there – particularly the senior psychiatric and nursing clinicians. This point is
addressed in the ‘Discussion’ section in this report.
Other National Initiatives/Programs
South Homeless Outreach Psychiatric Service (SHOPS) VIC
This service has operated in Melbourne for 20 years. Currently operating out of the Alfred
Hospital in St Kilda, the multi-disciplinary team includes a nurse, OT, social worker and
psychiatrist. They adopt an assertive case management model, engaging clients on their
own terms with frequent meetings and building supportive relationships. Typically this is
undertaken in close partnership with NGOs such as the Sacred Heart Mission and the
Prahran Mission to address immediate concerns i.e. treatment, food and housing. This
represents an excellent example of good integrated services between a tertiary health
care provider and a large community service provider.
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Review of Evidence
Care Coordination and Integrated Care
Improved care coordination and integration of services within the health care sector, and
across health, social care and other public services, is a 21st Century priority for the
governments of most developed economies. The expectation is that integrated care will
lead to more person-centred, coordinated care, improve outcomes for individuals, deliver
more effective care and support and provide better value from public spending. Partners
in Recovery is one of a number of efforts to coordinate care and integrate services in
Australia and is possibly the largest in terms of scale and cost.
A systematic review of the literature on integrated care or hospital transitions for people
with mental illness was beyond the scope of this project. However, ConNetica has almost
continually reviewed the literature on care coordination and integrated care over the past
five years. For this project, we specifically examined additional literature on Emergency
Department presentations, hospital transitions and discharge and community/NGO inreach for patients with mental health problems.
A wide range of international, national and local literature and documentation was
reviewed to identify the most effective transitional pathways and models which have
informed the development of the pathways and models presented in this paper.
There is now a considerable body of literature surrounding the development, elements
and efficacy of care coordination and service integration. This is not confined to mental
health services but extends to other areas of health care, particularly for chronic and/or
complex care, and social services such as employment and housing.
The Tables 3 and 4 summarise the common principles and elements associated with care
coordination. 4
The terms care coordination and service integration tend to used interchangeably in the literature. In this report we define
care coordination as the processes associated with coordinating care for an individual or group of individuals based on their
expressed or known needs. Service integration occurs in response to care coordination and is a systems or structural response
to care coordination.
4
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T ABLE 3: P RINCIPLES OF C ARE C OORDINATION © C ON N ETICA
Principle
Meaning
Person Orientation
The service focuses on the individual first & foremost as an
individual with strengths, talents, interests as well as limitations,
rather than focusing on the person as a “case”, exhibiting
particular indicators of disease or a diagnosis.
Person Involvement
The service focuses on the person’s rights to full partnership in all
aspects of their care, including partnership in designing,
planning, implementing & evaluating the service that supports
their needs
Self-Determination
Choice
/
The service focuses on the person’s right to make individual
decisions or choices about all aspects of their own care process,
including areas such as the desired goals and outcomes,
preferred service use to achieve the outcome, preferred moment
to engage or disengage in service
Growth
Orientation
Potential
/
The service focuses on the inherent capacity of any individual to
recover regardless of whether, at the moment he or she is
overwhelmed by the disability, struggling, living with or living
beyond their disability
Valuing engagement
The key starting point is engagement not an assessment against
narrow inclusive/admission criteria.
The belief that engagement in work, social activities & education
all help individuals in terms of their physical, emotional and
mental wellbeing. This is particularly true for individuals
recovering from serious mental illnesses
Insight
with
Low/No
stigma or judgment
The services assist the individual in developing insight into their
circumstances/condition/illness and assist them in developing
mastery over their lives. A focus on empowerment & optimism
Family/carer
Engagement
Respect for & recognition of the client’s family, carer &/or
“advocate’s” role in decision-making. Recognition of family
needs
Support
&
Flexibility
The services must be relevant – right service at the right time and
in the right place
Valuing Outcomes
The services value outcomes more highly than process. Values
data that shows progress, impact & outcomes above inputs &
activities
Cultural appropriate
The services should be provided in a culturally appropriate &
safe manner, respectful of cultural sensitivities, interpretations &
expectations of behaviour, family & community involvements.
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T ABLE 4: C OMMON E LEMENTS IN E FFECTIVE C ARE C OORDINATION © C ON N ETICA
Element
Meaning & Application
Robust governance
Clearly articulate roles & responsibilities, terms of reference,
selection of stakeholders & metrics for monitoring performance.
arrangements
Policy frameworks are broad & flexible enough to enable
devolution of service planning & delivery to the local/regional
level
Leadership
Organisational leadership demonstrated through an active
commitment to work in a coordinated & cooperative way with
others; actively breaking down service silos; leading reform efforts
Long-term commitment of
A minimum commitment of 3 years, with preference for 5-7 years
to bring about sustainable changes
resources
Client focus
The experience of service & support of the client is central to
sound policy development & service delivery. Practical application
of the principles of care coordination in operations.
Focus on outcomes
A balance of short & long term results & clear overall outcome
with timely reporting
Shared knowledge
An open, common set of resources & knowledge & sustained
focus on practice development
Communication
Effective, efficient, timely & synchronised communication of
information between practitioners, service providers & policy
makers
Integrated systems &
Planned and cooperatively built integrated networks – in
assessment, planning & reporting, human resources, learning &
development, ICT systems etc.
operating platforms
Integrated & comprehensive assessments of need - holistic health,
social & risk assessments
Single, individual care plans – co-owned by client and shared on
their terms with service providers
Regional/local capacity &
ownership
Engaging the local leaders across sectors (business, community
and government) & providing freedom within limits (outcomes) to
enable contextually relevant responses
Partnership & reciprocity
The recognition that complex social issues require genuine crosssectoral partnerships – within & beyond government & a shared
responsibility in the outcomes
Leverage & augmentation
Policy makers collaborating with service deliverers & the
community sector to leverage investment of resources & augment,
complement & supplement existing programs & services to
deliver the policy objectives
Provision of Incentives
New incentives such as rewards, recognition or autonomy or
funding can all be used to stimulate change/improvement
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Hospital Discharge
‘Hospital
discharge
involves
a
dynamic
network
of
interactions
between
heterogeneous health and social care actors, each characterised by divergent ways of
organising discharge activities; cultures of collaboration and interaction and
understanding of what discharge involves and how it contributes to patient recovery”.
Waring et al 2015
Occupational, professional epistemologies, culture and a range of other organisational
factors have all been identified as barriers to safe hospital transitions to community and
primary care for all patients, not just those with chronic conditions or mental health
problems (Philibert and Barach, 2012; Shepperd et al 2013; Waring et al 2015).
For people with mental health problems, discharge and discharge planning from an acute
care admission has been subject to critical examination by various state and territory
statutory authorities and inquires for more than a decade in Australia (Griffiths, Mendoza
& Carron-Arthur 2015). All too often, readmission to hospital within 28 days and more
serious adverse outcomes for patients and their families have been associated with poor
discharge practices for people with mental health problems. It is estimated that between
20-30% of all suicides recorded in Australia involve patients who have either not been
admitted to care on presentation or following discharge from acute care.5
While the same generic factors identified as barriers to safe hospital discharge are
relevant to mental health patient discharge, there are additional challenges not all of
which are given prominence in generic reviews. Poor continuity of care (King et al 2001)
and inadequate resources both within the hospital to carry out planning and in the
community to support the patient post-discharge are frequently cited as key factors in
unsafe hospital discharge (Pirkola et al 2009). Shorter than optimal length of stay in
inpatient care is also frequently identified with adverse patient outcomes (Hunt et al
2009). Communication and information systems and sharing are also given prominence
(Griffiths et al 2015).
Less frequently cited are issues relating to the nature of recovery from acute episodes of
mental illness and the need for integrated health and social services for potentially
extended or indefinite periods.
Efforts to address the problems associated with hospital discharge for mental health
patients have tended to be local and not sustained over time. However there are
exceptions to this in the US and UK and these are discussed here.
5
There are no reliable data available but discussions with colleagues at AISRAP indicate that this is probably the extent of
suicide associated with non-admission at ED and following discharge from acute psychiatric care within a 3 month period.
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Emergency Departments (ED)
ED is the front door to our hospital system in Australia, and in many developed nations.
Mental health, including substance abuse, related presentations to Australian EDs are
rising (AIHW, 2015). A recent review of presentations to Adelaide EDs shows an annual
average increase in MH & AOD related presentations of between 7-10% across the major
hospitals (Seaview-ConNetica report to SA Health).
The increase in mental health presentations to ED is associated with adverse reports of
long waiting periods for mental health patients, excessive use of force to restrain patients,
disruptive behaviour by patients in the ED, including violence toward ED staff, and a
significant number of patients leaving the ED before assessment. ED staff often lack the
confidence and expertise to assess, interact and provide appropriate or evidence based
care to people presenting with MH problems (Shafiei et al 2011). Mental health patients
also experience longer wait times in ED than non-MH patients.
Numerous studies point to continuing negative attitudes of ED staff toward people with
mental health and substance abuse disorders, particularly those involving intentional selfharm and suicidal behaviour (Chapman & Martin 2014; Milner et al 2013). Presentation at
ED of suicidal patients is considered inconsistent with people trying to get help and
therefore they are too often dismissed and misunderstood (SANE, 2014).
Lee (2006) found that patients, who did not wait in ED for treatment following initial triage,
were most often those with psychiatric problems.
Shafiei and colleagues suggest a number of changes to enhance the ED experience for
MH clients:
•
developing short stay units for intoxicated patients who need observation,
behavioural management or stabilisation before psychiatric assessment
•
to reduce after hours presentations, establishing 24-hour triage phone services
and alternative pathways to care particularly for those with lower-level emotional
distress
•
the provision of mental health nurse practitioners in the ED team.
Other studies have shown that post-discharge follow up from ED for patients presenting
with suicidal behaviour does reduce suicide risk (Luxton et al 2013) as does local policies
on patients with dual diagnosis (While et al 2012).
Alternatives to ED presentation for mental health patients include mobile crisis resolution
teams, acute day hospitals and crisis or safe houses (Sjoile et al 2010; Johnson, 2013,
Shattell et al 2014). Sonia Johnson and colleagues have undertaken numerous studies
over the past two decades on the efficacy of these models in terms of reducing hospital
admissions and crisis presentations to ED. Suffice it to say, that it is not any one of these
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interventions that result in lower ED presentations, hospital admissions or improved
outcomes for patients, but the combination or suite of alternatives available within the
overall service system in the region. A brief description of these alternatives is provided in
Appendix 4.
Metro North Adelaide Mental Health Services, under the National Partnership Agreement,
established a ‘walk-in’ centre in the suburb of Salisbury to reduce the number of mental
health related presentations at one hospital ED unit. After just 18 months of operation, the
walk-in service was shown to have significantly reduced the number of presentations to
the Lyell McEwen Hospital’s ED. Furthermore, clients and other stakeholders reported
improved client outcomes. Clients were also more likely to have continuing care
connections established following presentation to the walk-in service than those who
presented to the ED (Seaview-ConNetica, 2015).
South Australia has also introduced 24-hour acute crisis teams across metropolitan
Adelaide and a state-wide mental health triage phone service as strategies to improve
patient flow and reduce ED presentations. These are yet to be evaluated but have strong
evidence to support there use in reducing suicide among mental health clients (While et
al 2012).
In addition to the above discussion, the importance of engaging family, friends and other
caregivers in recognizing and treating mental health issues has been recognised as an
important element in good discharge planning for people with mental health problems
(Van Veen et al 2014; Gallan & Shattell, 2015).
It is important to note the literature specifically addressing hospital transitions for mental
health clients are limited by small sample sizes, short follow up periods and a range of
service related variables.
Systems Responses to Mental Health ED Presentations and Hospital
Discharge
In response to the continuing problems associated with both ED presentations and
hospital discharge for people with mental health problems, particularly those with higher
risk of suicide, a number of programmatic or systems responses have developed.
In the US, SAMHSA has described the need for five core services for addressing
‘behavioural health crises: 23-hour crisis observation or stabilisation; short-term, crisis
residential stabilisation; mobile crisis teams; crisis hotlines and web services; and peer
crisis services (SAMSHA, 2014). This continuum of services for addressing the needs of
people in crisis has been informed by reforms in regions such as Butte County California,
Harris County Texas and the state of New Mexico which for more than a decade have
undertaken significant structural reform of their mental health and substance abuse
services (Behar 1986; MacArthur Foundation 2007; Willging 2007).
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Also in the US, a Consensus Guide for Emergency Departments for Caring for Adult
patients with Suicide Risk has been recently published (April 2015). The guide sets out an
end-to-end process (presentation to admission and discharge) for all adults patients with
suicide risk. It includes decision-making tools, comprehensive assessment processes, a
framework for individual care plans and guidance on sharing health care records for
health professionals (see Figure 4).
The ZEROSuicide initiative lead by Michael Allen and David Covington is seen as a best
practice systematic and programmed response to reducing sentinel events for
‘behavioural care’ patients in the US. ZEROSuicide applies many of the principles of
quality management to reduce if not eliminate, the multiple cracks in the fragmented
system of care for people with mental health and substance abuse problems.
ZEROSuicide builds on work done by health care organisations such as the Henry Ford
Health System (HFHS) in Detroit, Michigan where through a sustained whole-of-system
change initiative has seen an 80% reduction in suicide across its nearly 700,000
membership.
F IGURE 4: P ROCESS FOR C ARE AND D ISCHARGE OF P ATIENTS WITH S UICIDE R ISK FOR ED S
In the UK, system-wide initiatives to develop, implement and evaluate integrated care
pathways (ICPs) have been underway for more than a decade in Scotland and Wales and
more recently in England. The Scottish ICPs for mental health include generic pathways
and then pathways for specific client groups. These are client groups where historically
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services have been less able to prevent adverse health and social outcomes and where
clients’ needs are generally more complex.
One of the most significant and robust evaluations of mental health service provision and
the prevention of suicide was undertaken in England and Wales between 1997-2006. This
cross-sectional pre and post analysis of national suicide data in England and Wales
examined the uptake and implementation of key mental health service recommendations
and their association with suicide rates (While et al 2012).
The study clearly showed strong associations between the implementation of several key
service reforms and lower rates of suicide. Those mental health services that implemented
more recommendations had more significant reductions in suicide rates. The key service
reforms were:
•
The provision of 24-hour crisis care – crisis response teams including a single point
of access for people in crisis available 24/7. These teams are intended to promptly
respond to mental health crisis in the community and so prevent inpatient
admission (or ED crisis presentations). They provide only short-term input until
other services are available.
•
Local policies on patients with dual diagnosis – specifically written policy on the
management of patients with dual diagnosis
•
Multi-disciplinary review following suicide – specifically written policy on
multidisciplinary review and information sharing with families after a suicide
•
Assertive outreach – services include an assertive outreach team that provides
intensive support for people with severe mental illness who are more difficult to
engage in more traditional services
•
7-day follow up – written policy on follow-up of patients within 7 days of psychiatric
inpatient discharge
•
Non-compliance – written policy on responses to patients who are non-compliant
with treatment
•
Criminal justice sharing – written policy on sharing of information on risk with
criminal justice agencies
•
Training – front-line clinical staff receive training in the management of suicide risk
at least every 3 years.
The Greater Glasgow and Clyde Mental Health Integrated Care Pathways have been
reviewed by the project team.6 They provide a model of a service wide integrated
approach to assessment, planning, delivery and outcomes for all mental health clients and
then additional components for specific conditions including Borderline Personality
6
For copyright reasons the GGC pathways could not be presented in this report.
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Disorder, Depression, Dementia, Early Intervention (or first psychosis), schizophrenia and
Bipolar Affective Disorder. These pathways, and those in place across the Scottish NHS,
include clearly articulated standards of care based on evidence.
A Note of Caution …
As with all integrated care evaluations, there are significant challenges to demonstrating
that integrated care pathways for people with mental health problems delivers improved
health and social outcomes for the individual and lowers costs for health care funding
authorities (Cioa & Glassborow, 2009).
It is fair to say, anecdotal and good quality qualitative data supports all aspects of that
proposition, but the quantitative data remains thin in the Australian context (Plant, et al
2015).
A whole-of-systems approach
The World Health Organisation has defined a health system as “all organizations, people
and actions whose primary intent is to promote, restore or maintain health”. Good health
services are further defined as those which “deliver effective, safe, quality personal and
non-personal interventions to those who need them, when and where needed, with
minimum waste of resources” (WHO 2007).
Health systems are complex – this includes the mental health system for the Metro North
Brisbane region. It is useful to analyse health systems by looking at their key elements and
component parts organised by functions. This helps identify bottlenecks to successful
implementation and best value interventions that can lead to improvement. For the
system to function optimally, all parts must be balanced and coordinated. The weakest
part of the system may actually determine the outputs from the entire system.
The six building blocks are leadership, human resources,
information, medical products and technology, financing,
and service delivery.
WHO has specified a framework with six building blocks that can be used as a tool for
analysis of a health system (see Figure 5). The six blocks are leadership, human resources,
information, medical products and technology, financing, and service delivery.
Intermediate outputs lead to the desired health outcomes. This is not a new concept and
other schemata with different groupings can be used, although most are relatively similar
(Roberts et al 2008; WHO 2009; Kelazkowski et al, 1984).
The point is not to concentrate only on the individual blocks or that there is one correct
schema for a health system. An adequate analysis encompasses the entire health system
to the extent possible. Actions to be taken must be evaluated for their potential effects on
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the functioning of the entire system and ultimately for their effect on health outcomes. All
parts of a health system are interrelated and dynamic interactions, both anticipated and
unanticipated, are to be expected.
There is often strategic tension between different approaches within mental health
systems. Examples of potential tensions are the relative emphasis on specialized clinical
services versus generalist support and recovery services; the degree to which referrals are
managed to encourage rational care versus freedom of choice of providers. Clearly there
are opportunities for conceptual tension between clinicians within the hospital structure
and practitioners within the community sector. Successful treatment outcomes for those
with mental illness require a high degree of integration between both sectors to meet the
complex needs of consumers. Defining core values and further articulating expectations
and accountabilities for key roles and responsibilities for mental health services is
expected to help balance these tensions.
For these reasons we have placed an emphasis on
leadership and articulation of shared values with a heads
of organisation agreement to provide direction, clarity and
focus for the complex task at hand.
A well-functioning health system is able to support a continuum of care for those with
mental illness with an increased responsiveness to their specific needs. Interventions are
focused on how they contribute to improved health outcomes using the best and most
feasible scientific methods available. Services must be designed, implemented and
assessed from the perspective of the users of services. The health systems framework is
meant to ensure that dynamic interactions are considered across the entire system and to
minimize the risk of neglecting important parts of the system during any analysis or
intervention, this is why a whole-of-system approach is critical when considering the
mental health system for the BNM region and why we endorse a more rigorous and
comprehensive evaluation methodology for the system as a whole.
In the proposed “To Be” model (Figure 7) two building blocks require further
development - Commitment and Measurement. The “To Be” model focuses on the
interdependency of the medical and community sectors to ensure effective treatment,
recovery and support is provided for those with persistent, severe and complex mental
health issues. This can best be achieved within the context of a whole-of-system approach.
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F IGURE 5: WHO – S IX S YSTEM B UILDING B LOCKS
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Overview of Transitional Pathways and System
Benefits of conceptual overview
An overview of the “To Be” system outlining the main structure and transition pathways is
provided in Figure 7. This has several benefits. Firstly, it provides a conceptual overview of
the whole system at a glance. This helps give perspective and enables a complex system
to be more easily understood and remembered by those who work within the system. This
snapshot approach not only aids comprehension but facilitates system integration by
improving our understanding of the linkages between the parts of the system and the role
individuals play within that system. Anything that engenders a feeling of control and
engagement by participants leads to greater clarity of purpose which enhances both
personal and system effectiveness. Better appreciation of the roles and responsibilities of
other
system
participants
provides
further
opportunities
for
co-operation
and
collaboration. This further enhances system integration and synthesis by breaking down
the barriers between the various silos that often develop within complex systems.
In order to extract maximum benefit from the overview of the system it is important to use
it to promote inclusiveness, coherence and engagement by stakeholders. When the
architectural structure of the system has been finalised the overview of the “To Be” model
should be promulgated as a part of the joint professional training program for all system
participants.
The “As Is” Model
The purpose of preparing the “As Is” pathway (Figures 6a and 6b) is to identify
opportunities for improvement. To build capacity for the future by designing a more
nuanced system to improve the experience of consumers as they transition to and from
hospitals within the region. At the same time the objective is also to provide a more
robust architecture for a more coherent and sustainable mental health system for the
future.
The evidence highlights significant differences between the resources, operational
practices and procedures across the various catchments. These differences have made it
particularly challenging to clearly articulate the “As Is” Overview of the Transitional
Pathways Model. Fundamentally, each hospital catchment within the Metro North region
is operating with a slightly different operating model. This is due to the fact that system
wide changes to discharge planning and practice are still being deployed across the
three catchments and four public hospitals.
It should be noted that some of the differences are significant making it difficult to
extrapolate a common underlying model. Notwithstanding this difficulty, sufficient
similarities have been identified and an overview of the “As Is” model is presented in
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Figures 6a and 6b below. It should be understood that whilst an accurate articulation of
the “As Is” model is acknowledged as important it is subordinate to the role and
significance of the “To Be” model. It is the “To Be” model that ought to be the primary
consideration as it is this model that will drive future improvements.
Essentially the “As Is” model consists of eight key elements - each will be discussed in
turn. Basically key elements 1, 2 and 3 comprise the medical model and the public
hospitals whereas elements 4, 5, and 6 comprise the psycho-social community model.
1. Presentation – this consists of all the available ways a consumer can present to the
Emergency Department at a hospital
2. Plan and Assess – this is the assessment or decision point and entry to the hospital
system. The process consists of:
o
physical entry to the hospital,
o
the triage risk screen process,
o
the development of an Individual Care Plan (ICP);
o
the ICP is periodically reviewed by a multi disciplinary team.
A significant number of consumers who present at ED are not admitted and
subsequently “feel” rejected. Currently relatively few receive a referral to other
treatment providers or community support. Some of the people not admitted will
have few or indeed no community or family supports in place.
3. Hospital - In-patient and out-patient – following the triage assessment the patient is
admitted as an in-patient. Treatment/ medication is then provided. Discharge from
hospital often involves continuing care through out-patients but sometimes may
not.
4. Community – consists of the key community components including primary health
care and informal care from family and friends.
5. Recovery – identifies some of the key functions within the recovery process.
6. Support – outlines some of the main types of support.
7. Measurement – comprehensive evaluation of system performance is essential - but
is currently lacking.
8. Commitment – leadership and a shared vision supported by a clearly articulated
policy and procedural framework is essential to drive such a complex system and
has been identified as a key element requiring further development.
Each key element is composed of a number of subordinate functions or components. If
the components are coloured ‘aqua’ or ‘blue’ then they are functioning at a satisfactory
level of performance within the system. If the component is coloured ‘orange’ then
opportunities for improvement have been identified during this analysis. If a ‘red’ broken
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line is used then a systemic failure or risk has been identified. Basically there are two
systemic failures identified within the “As Is” model.
•
The first systemic failure occurs when consumers present to ED and are not
admitted and feel “rejected” and leave with little or no support. This non-admission
or “rejection” represents a potentially significant risk to the consumer as the
subsequent consequences are unknown. It also represents a significant
reputational risk to the relevant hospital and its staff. While entirely understandable
within the hospitals resource constraints, it is nonetheless a systemic failure
because it has failed to address the needs of vulnerable citizens, particularly those
consumers who have little in the way of family, primary care provider or community
support. The solution is to ensure some form of referral to the community to
mitigate the risk.
•
The second systemic failure has been identified at discharge. A number of issues
have been identified with planning the discharge and the process of transition to
the community. If the transition is not seamless and coordinated then a systemic
failure may result with the consumer exiting the system without adequate support
or accommodation. Once again vulnerable citizens may be inadvertently put at risk
of harm. Again the solution is to ensure some form of effective linkage to the
community to mitigate the risk.
The PIR initiative is shown between the public and community components of the system.
PIR provides a link point for coordination and referrals throughout the system. There are
four sub-categories that do not fit neatly within the key elements, the private system, case
managers, hospital outreach and the GP – this is why they are positioned between the
hospital and the community sectors in both the “As Is” and “To Be” models.
F IGURE 6 A AND 6 B : O VERVIEW OF T RANSITIONAL P ATHWAYS AND S YSTEM - “A S I S ” (P AGES 41 & 42)
F IGURE 7: O VERVIEW OF T RANSITIONAL P ATHWAYS AND S YSTEM - “T O B E ” (P AGE 43)
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Page 41
Page 42
Page 43
The “To Be” Model
The “To Be” model further articulates both the future needs of the system and consumer
requirements.
The same eight key elements are retained in the “To Be” model that was identified in the
“As Is” model. However, there is a change to the colour scheme. The key elements 1- 6
remain ‘aqua’ and represent the “As Is” model working effectively and meeting the
systems requirements. The key elements 7 (Measurement) and 8 (Commitment) and the
“Monitoring systems performance and continuous improvement” linkage are now
coloured ‘dark blue’. The dark blue denotes those key elements that require significant
further development and implementation if the system as a whole is to deliver the
required outcomes and meet the needs of consumers with severe and persistent mental
illness in the future.
These key system changes give rise to the primary recommendations designed to address
the opportunities for improvement identified in the “As Is” model. (For full details see the
recommendations.)
Care Pathways for People with Specific Needs
In the initial scoping for this project it was envisaged that in addition to a generic model
for transitions to hospital and from hospitals in Metro North Brisbane, pathways variations
for people experiencing Schizophrenia, Borderline Personality Disorder, Dual Diagnosis
(AOD), eating disorders and homeless populations would be developed.
Based on the information generated on services across the region from both this project
and the Mental Health Atlas project, there is insufficient service specialisation or capacity
to have distinct care pathways for all but those with dual diagnosis and possibly those
people experiencing complex eating disorders.
For those with unstable housing, the shared care protocols discussed earlier and being
developed in Brisbane South may have application in Brisbane North.
Evidence based clinical care pathways have been described for the most common mental
health disorders (including major depression, bipolar, schizophrenia, borderline
personality disorder, substance abuse and eating disorders) are available (as an example
see Figure 8). They include the roles of and interventions provided by primary care and
allied health providers and in some instances community care (Andrews 2007, Rosen
2008). 7
7
The UK’s National Institute for Clinical Excellence (NICE) has developed over 30 guidelines for mental health conditions. Go
to: http://www.nice.org.uk/guidance/published?type=cg
Metro North Brisbane PIR - Hospital Transition Pathways
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International practice has steered toward the development of shared care protocols –
these set out ‘who does what when’ for clients with specific primary diagnoses.
An example of a “Shared Care Protocol” is included in Appendix 5.
During the consultation period for the draft Mental Health Atlas for North Brisbane, some
further refinement of a transitions pathway for people experiencing an Eating Disorder
and Substance Abuse will be undertaken.
F IGURE 8: C LINICAL P ATHWAY FOR THE T REATMENT OF B ORDERLINE P ERSONALITY D ISORDER (S EVERE)
34% get
4% get intensive psychiatric
referred to
intervention n = 100 sessions/yr
Referral
avenues:
Ø Justice
system
Ø Child
protection
Ø ED
Ø Social
welfare
inpatient short stays
private
totalling 14 days/yr +
psychiatrist
intermittent acute
30% get moderate psychiatric
Severe
Disability
7% require additional
intervention n = 40 sessions/yr
community treatment
(3-4 occasions)
100% get:
Initial GP
assessment
> 4 sessions to
assess hist,
diagnoses,
self-harm, risk,
> seek counsel
66% get
61% get over next 12mths:
referred to
- 50 sessions with case manager
public MHS
- 12 sessions with trained therapist
- 6 sessions with SW
- 6 sessions with psychiatrist
5% get referred to specialist
SPECTRUM program
As part of SPECTRUM, 100% get
intensive day program for 6 mths
13% will require
additional inpatient short
stays totalling 14 days/yr
+ intermittent acute
community treatment (3-4
occasions)
5% get staffed (1/3) or visited (2/3)
hostel accommodation for 3 mths
80% of the severe group will get medication for 12 mths – of these 60% SSRIs, 15% AAPs, 5% mood stabiliser
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Discussion
There is no doubt that mental health reform qualifies as a ‘wicked problem’. (Rittel et al,
1973) that requires systems thinking - ‘holistic rather than reductionist’ critical thinking
(Jackson, 2003). The evidence gathered during this project clearly indicates that good
mental health care requires collaboration between health professionals in different
settings and services and others. However, modern concepts of recovery transcend health
care and encompass many other areas of key interest to people with a mental illness and
their families, including housing, employment and social participation.
Access to timely, appropriate quality care remains a
challenge across all three hospital catchments within the
Metro North Brisbane region …
Based upon reports from consumers and carers significant problems remain in navigating
what seems a complex and disconnected service system. Access to timely, appropriate
quality care remains a challenge across all three hospital catchments within the Metro
North Brisbane region. What is clear from the consultations, is that there is a very high
level of motivation and understanding of the need to change this from all stakeholders.
Overview of data and evaluation of evidence
1. Commitment, leadership and coherence
Addressing and enhancing the mental health and well being of those in the region is a
complex problem that require mental health services to establish initiatives that enable
and sustain interagency and cross-sector collaboration to address the many factors
influencing mental health. Often the involved stakeholders will have diverse and
competing priorities. Finding common ground and agreeing shared goals and principles
will be essential to effective collaboration outcomes.
The Scottish model of integrated care pathways and those operating in parts of the US,
referred to in the introduction, point to the comprehensive nature of the agreement
required in order to achieve best practice. In order for MNB PIR to achieve that level of
integrated care and collaborative cohesion we recommend that a heads of organisation
agreement is the top priority. The objective is to provide a clearly articulated public
leadership statement of intent as the starting point for sustained system reform in the
metro North Brisbane region.
2. Leadership and engagement of psychiatric clinical practitioners
The change management process must start at the top …
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Invariably, change management processes must start at the top. The leadership teams in
mental health at both the Medicare Local (now PHN) and the MN HHS are clearly
committed to achieving better outcomes for consumers, carers and funding authorities.
That commitment needs to transcend those in clinical lead roles within the HHS at each of
the hospitals across the region and the community mental health teams. The active
engagement and participation of the senior psychiatric consultants and clinical team
leaders within the system must be a priority in the early stages of the change program.
PHN & HHS management must engage them early in the process and keep them
engaged throughout the transition of the system. Experience has shown that unless this is
done, effective change is unlikely to be achieved and will not be sustainable. Leadership both governance and clinical is critical to the success of all such change management
programs.
3. Two Cultures – One System
It is clear from the interviews with NGO staff and from our work within the region’s
hospitals that there co-exist two distinct cultures within the one mental health system. This
has been a recurring theme within Australia’s mental health system.
In part this is as a result of Australia’s failure to both develop frameworks of genuine
accountability or to surmount the bureaucratic silos which characterise traditional
approaches to mental health care (Rosenberg et al in press). In part this is also reflected
in the fundamentally different models that co-exist between the medical – hospital – based
model and the community psycho-social model.
An all too common experience reported by consumers and carers is for a person with a
mental illness to get lost somewhere between the hospital discharge and the primary care
provider, or between the employment support services and the housing provider. Down
these so-called cracks lie untreated chronic mental illness with all its personal, and family
costs, and the ancillary health, welfare and social costs to governments. Whilst there have
been some improvements in reducing the traditional silos of hospitals Vs community care
models, there remains two discernible cultures that are embedded within the attitudes of
participants engaged within the system. For these reasons it is imperative to continually
try to breakdown these silos and provide a more integrated care pathway for the benefit
of all concerned.
… it is imperative to continually try to breakdown these
silos and provide a more integrated care pathway for the
benefit of all concerned.
This provides the impetus for the “whole-of-systems” approach taken during this project,
key recommendations concerning commitment and leadership and the need to negotiate
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a heads of organisation agreement; the need to embed experienced community sector
(possibly PIR) staff within ED and the recommendation requiring and promoting joint
training and professional development for system participants from both the hospital and
community sectors.
4. Capacity of Beds Vs Accessibility of Services
The 100 discharges per week requirement set by MN Mental Health Services effectively
drives the mental health care system in the region. In this important respect it is not the
needs of the consumers that drive the system; it is the availability of beds. The number of
beds has to be utilised for the best possible patient outcomes.
This gives rise to questions of capacity and the need to increase the numbers and
availability of beds within the system. However, questions that relate to the capacity of the
system in terms of bed numbers presuppose the appropriateness of allocating this
increased resource. Increasing capacity alone - begs the question. In spite of the
competition between politicians who frequently talk as though beds are an effective
solution for most health resource situations it must be understood that - beds are not a
solution per se. Hospital beds are simply a part of the treatment continuum; one part of
the process - highly effective in some instances and less so in others.
We know this because we also know that many consumers present at ED many times. The
disparaging term of “frequent flyers” is sometimes used to describe consumers who
present frequently at EDs. So clearly treatment in hospital and occupancy of a bed is not
the solution. If hospitals were more effective treatment mechanisms then presentation and
admission would have more impact on either the severity or the duration of the mental
illness – unfortunately for a significant number of the mentally ill the impact on the illness
of hospital admission is modest. This is not to say that hospital admission is not an
appropriate short term stop – gap for some patients – clearly it is.
However, increasing the number of hospital beds is not and should not be seen as an
effective solution to the problem of capacity. The situation is more complex than that and
requires a more nuanced policy and systems response - one which increases the
availability and accessibility of other treatment/recovery modalities. The system needs to
be more responsive and more sensitive to the needs of the clients, providing a greater
number of treatment, care, recovery, support and accommodation options than are
currently available. One of the main problems the current system faces is the lack of
alternatives to accessing care – the ED and hospitalisation should be a last resort – but all
too often it is the only available option. This point was made strongly in the recent
National Mental Health Commission review (NMHC, 2014).
This places an increased burden on the hospital system, causes a bottleneck at ED and
has not proved to be a particularly effective treatment option for many consumers. It is
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also one of the most expensive options available with a hospital bed costing up to $2,000
per day (National Hospital cost database).
The system needs to be more responsive and offer a
greater range of alternative services to meet the needs of
such a diverse group of clients rather than the continued
default reliance on ED …
The system needs to be more responsive and offer a greater range of alternative services
to meet the needs of such a diverse group of clients rather than the continued default
reliance on ED – a point acknowledged by participants from all services in the workshops.
Examples of such services include: temporary and permanent supported accommodation,
weekend activities, a 24/7 safe house, clubs, self help groups, community centres,
community gardens, step –up and step down facilities, peer support services, mental
health ambulances with co-respondents, alternative more direct transition pathways to
care when required other than through ED, more care in the home options – both for
acute and non-acute services, etc.
This narrow spectrum of available care across the region is more fully identified and
discussed in the Mental Health Atlas or mapping project. The point in this project’s
context is simply that improving hospital transitions is in part dependent on building the
broader spectrum of care infrastructure.
5. Admission and Emergency Department (ED)
The lack of available beds combined with pressure on ED has inadvertently lead to a
“revolving door practice” which results in some consumers being declined admission.
Consequently they leave feeling rejected and let down. This has been identified as a
system failure within the current “As Is” model. In addition we have identified a
subsequent lack of referrals for this vulnerable group to NGOs or other community
support mechanisms. Lack of community sector expertise at admissions has been
identified as a major shortcoming of the current system.
Hospital admissions are essentially highly developed event driven, crisis management
systems, and the hospital ED epitomise this logic with the adoption of the battlefield
triage assessment - “to assign degrees of urgency to (multiple wounded or ill patients)”.
This is not the optimal methodology or logic for the provision of treatment and support
services for some of the most vulnerable members of our society. Indeed these transitions
from the community to the ED are often un-necessarily traumatic, exciting and may
exacerbate symptoms, the mode of transportation is often provided by police or
ambulance and sometimes accompanied with flashing lights and sirens. Certainly the
atmosphere in a busy ED is palpable. Evidence suggests that the current entry to the
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medical system through ED is not just traumatic but potentially harmful with reports from
consumers, corroborated by NGO staff, indicating an aversion or fear response by
consumers which may exacerbate potential risks both for the consumer and members of
the community in the future.
Urgency, busy-ness and excitement are not conducive to the needs of those seeking
admission and assistance at ED they require a much calmer, quieter and more restful
approach in order reduce their anxiety and stabilise their condition.
The trauma sometimes accompanying admission to hospital is largely accounted for by
the fact that the ED is often the only available entry point to the health care system for the
mentally ill which is open 24/7 - this is identified as problematic. If there were other
calmer, quieter more appropriate, more sensitive and nuanced entry points to mental
health services then much of the anxiety and associated trauma could be reduced with
emotional stabilisation being achieved earlier.
Admission to mental health services needs to be both more
flexible in terms of availability and timing and more
responsive to the needs of consumers with greater support
being provided within the community …
Admission to mental health services needs to be both more flexible in terms of availability
and timing and more responsive to the needs of consumers with greater support being
provided within the community in terms of safe houses, step up and step down facilities,
self help and peer support facilities and clubs in order to reduce the need to wait until the
situation has deteriorated to the extent that hospitalisation is the only course of action
available. All too often the only option available is a trip to hospital. As we have seen the
current hospital and emergency focus is not the most suitable model of service delivery
for this clientele.
ED is a recognised bottleneck which is under constant pressure to quickly and effectively
evaluate and address the needs of a great number and variety of injuries and illnesses. All
too frequently those that present at ED with mental illness- due to lack of alternatives – do
not present as “emergencies” this has two notable consequences:
•
the attitude of some ED staff is inappropriate - “often shocking” according to the Care
Quality Commission in the UK following an NHS review (Campbell 2015);
•
longer wait times are reported as compared to other patients in ED. Again this is
inappropriate and tends to heighten tension and stress rather than relieve it adding to
the trauma noted above.
Admissions packages have been developed for each hospital. They are all different.
Some of the packages are substantial – more than 50 pages. This information is provided
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to consumers at a time of duress and with limited or reduced capacity. This is seen as an
ineffective method of communication at this critical and stressful time. Overloaded with
information on entry when of limited value compared to nothing or little on departure
when of potential maximum value.
6. Evaluation and measurement
A comprehensive evaluation strategy is required to
measure the whole-of-system performance …
Evidence drives improvement. A comprehensive evaluation strategy is required to
measure the whole-of-system performance. To develop this strategy it is necessary to
clarify the objectives, agreements, roles, responsibilities and accountabilities as outlined
in the key element Commitment in Figure 7, the “To Be” model. It is envisaged that the
Heads of Organisations Agreement (See Recommendation 1) will further articulate the
detail of the systems purpose and operations. Once clarified then the criteria for the
evaluation of the outputs can be identified, data collected and system performance
measured.
7. Client centred software
Presently, the Hospital Based Separations Data (HBCIS) and the mental health CMIA IT
systems are not fully integrated. The goal of fully integrated care cannot be achieved
without all available data being on a shared platform which is easily accessible and
available to all relevant parties (GP, Chemist, Psychiatrist, Hospital (admission, ward, and
discharge), consumer, carer, case manager, NGO etc.).
There is an identified need for a much more client centred service delivery model. This
model could be built around the accessibility of the Individual Care Plan which forms the
centre of the current treatment regime. The software needs to be a controlled document
system by the consumer or carer and be web based rather than attached to the hardware
and software of various institutions. It needs to be highly flexible app based and
accessible from mobile devices on a secure network.
8. Mental Health Ambulance (MHA) with co-respondents - Police &
Clinician
This concept arose on several occasions during the consultations from consumers,
community services and clinicians. It has emerged in response to the recognised need for
increased flexibility, accessibility and mobility of service delivery. Such an initiative could
have a significant impact upon the consumer’s experience of transitioning to hospital
when experiencing an acute episode of illness.
Essentially it is envisaged that the MHA will consist of both police and clinician corespondents who would be the first point of contact in an emergency. The objective
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would be for the clinician to undertake the same triage risk screen used in ED. When
appropriate this intervention service may divert some consumers away from ED directly
into more appropriate community services or to the private sector thus reducing
presentations to ED and potentially freeing up limited public beds. It is also possible that
such an initiative may reduce demand on other less prepared emergency services
personnel (Padika 2014).
It is recommended that that seed funding is provided to trial and evaluate this initiative in
the Brisbane Metro area.
9. Multi Disciplinary Team Reviews (MDTRs)
… Involving community services, or a representative in
these reviews will be another step toward more integrated
care.
MDTRs are carried out at each hospital for all patients. However, there are significant
differences at each hospital between the processes, the frequency of reviews, time
allocated for each review and attendees. Staffing resource allocation varies between
hospitals significantly and impacts the review process. Consumers, carers and community
services are not routinely involved in all such meetings. Involving community services, or a
representative in these reviews will be another step toward more integrated care.
10. Uncertainty re NDIS
The continuing uncertainty of the impact of the NDIS on current service delivery models
within the mental health arena is unsettling. The impact on funding for the provision of
services for some community services is potentially significant and disruptive. Whist this is
acknowledged a more detailed discussion is difficult given the current state of flux and
lack of detailed information. Nonetheless from a risk management perspective this issue
warrants careful monitoring by the lead PIR to minimise its impact on service delivery.
11. AQuA
… the internal AQuA audit documentation clearly
indicated inadequate implementation and ongoing
inconsistency across the system.
A review of the Achieving Quality Across Metro North Mental Health (AQuA MNMH)
project documentation demonstrated that although the project had carefully targeted
three key system needs including patient flows and bed management, discharge planning
and crisis presentation, the planned implementation of improvements was inconsistent
across the four hospitals with significant progress yet to be achieved. Several initiatives
gained initial traction such as discharge checklists, the “7 Golden Rules” and Recovery
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Plans but the internal AQuA audit documentation clearly indicated inadequate
implementation and ongoing inconsistency across the system.
Sustaining the change management program supporting the AQuA objectives is integral
to improved hospital transitions to the community sector and private service providers.
The recommendations in this report will provide further impetus to the AQuA project
goals.
12. Discharge
Inconsistent and poor discharge implementation has
consistently been identified as one of the primary causes
of dissatisfaction (of all stakeholders) …
Effective hospital discharge has been identified as a priority within this region (AQuA). In
spite of this, discharge remains one of the most criticised components of the current
system. Notwithstanding the legitimacy of some of these criticisms a caveat is required.
Some recommendations of the AQuA project are currently being implemented.
Therefore, it is not known if the feedback from consumers, carers, NGOs and clinical staff –
is pre or post - implementation of these improvements. This is one of the reasons why
defining the “As Is” model has been problematic – as noted elsewhere. In addition there is
a lack of accurate evaluation data.
•
The system requires 100 discharges across the region each week (this is split 35 –
TPCH; 35 – RBWH and 30 – Red/Cab.). This helps plan and manage flows across
“leave beds”, High Dependency Unit beds; Psych Intensive Care Unit beds and ED.
•
Discharge planning is still problematic with an uneven flow. Too many discharges
and admissions on Fridays and Mondays. Leave often organised for weekends
when there are minimal support services available in the community rather than
mid-week.
•
Discharge facilitators and transitional discharge arrangements are unevenly
distributed and implemented across the region.
•
Services providers; NGOs or Case Managers are not assigned to every patient at
discharge.
•
Discharge information packs are different at each hospital.
•
Gaps have been identified between Nurse Unit Managers and the wards and
Pharmacists and the preparation of scripts for discharges.
•
Lack of available beds promotes discharges with limited preparation time and
planning – particularly on a Friday. This places community service support staff
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under pressure and can mean that discharge arrangements are far from optimal or
effective.
Consumers, carers, community support staff and hospital clinicians have consistently
identified inconsistent and poor discharge implementation as one of the primary causes
of dissatisfaction. It also contributes to system failure and an increased risk for vulnerable
patients (Kripalani 2007). Improved discharge arrangements should remain a system
priority.
Further analysis of hospital separations data could provide more insight into the peak
discharge periods across the four public hospitals.
13. Proliferation of Community Service Providers
Presently there are over 70 community service providers in the Brisbane North region.
There are significant opportunities for NGOs to rationalise or consolidate, in terms of
numbers, locations and service offerings. The high number of NGOs is probably
contributing to a dissipation of energy and resources within the system. Whilst it is
acknowledged that independence is highly valued within the NGO sector, such a high
number is probably contributing to system inefficiencies. Many NGOs pay rent, employ
staff who undertake back of office functions, HR, payroll, administration, reception,
cleaning, etc.
Such rationalisation could also offer opportunities for
improved service delivery …
In addition the funding model for NGOs is highly competitive and often short-term:
competing for funding is time consuming. Some form of rationalisation through formal or
informal amalgamation or perhaps by co-location would offer opportunities for economy
of scale. Such rationalisation could also offer opportunities for improved service delivery.
Co-location of different service providers offers the possibility of the development of a
One-Stop Shop, or Service Centre. This would have several benefits for both consumers
and funders alike. Currently the number of NGOs makes it difficult for hospital staff to be
across the range and number of services available. Therefore referrals are more difficult to
make and competition between NGOs may develop. A reduction in NGO numbers and
an increased specialisation of services focussing on particular client groups would better
utilise limited resources within the community for those in greatest need.
NGO rationalisation is likely to be seen as an emotive topic but it is in fact a system
inefficiency issue. As such it needs to be considered within that context. This is another
dimension to the whole-of-systems approach advocated in this report. Because this is a
systems issue the primary funders should consider the benefits of providing pooled
funding and financial incentives to NGOs to better meet the systems requirements.
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ConNetica, in partnership with the University of Sydney, is completing the service
mapping across the BNM region. The Mental Health Atlas will show significant gaps in
services and a mal-distribution of both public and community mental health resources,
particularly when layered with population needs. It will show that the current distribution
of services and needs may present opportunities for a more rational distribution and relocation of some resources to better meet system requirements.
14. Case Managers
Case managers are assigned to some patients at discharge but not others. The rationale
for allocation of Case Managers is not fully understood by those in the community sector
that receives referrals or offer services to consumers with and without Case Managers.
Based upon the NGOs experience of those working with both groups of consumers it
sometimes appears that the allocation of Case Managers is somewhat arbitrary given the
many similarities with symptoms and severity between these two groups of consumers. As
a result some NGOs have found it necessary to engage, supply and fund their own Case
Managers for those who are not allocated a Case Manager at discharge. There is general
agreement that more Case Managers are required within the system.
15. Step Up - Step Down
This proposed new services/facility has been identified as an important addition to the
range of current services/facilities available. However, some concern has been expressed
regarding the prospect and risk of this new service being seen as, and used as – a hospital
overflow – rather than as a genuine and new additional service which has been long
overdue within the Metro North Brisbane region. The experience of step up/step down
services in Victoria8 should be taken into account when developing the new service.
16. Funding insecurity
An effective system is a stable system. A stable system requires both adequate
operational funds and financial stability (WHO 2009). A competent workforce cannot be
achieved or maintained in positions that are precariously funded. Expertise takes time to
establish and longer-term contractual arrangements should be entered into wherever
possible to optimise the recruitment and retention of quality practitioners across the
system – including the NGO sector.
The critical point is that you cannot build a system with
“unstable” services …
8
These are known as PARC services – Prevention and Recovery Centre Services – and have some important differences in the
way they operate. They have been in operation since 2004-5 in Victoria (commencing in Shepperton and Bendigo). See Smart
Services (MHCA 2006) for a description of the early PARC programs.
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The service mapping project is relevant here. The project has mapped both “stable” and
“unstable” services – stability of service provision is directly related to security of funding
for those services. The key point is that you cannot build a system with “unstable” services.
While most community service providers receive the majority of their funding form
Commonwealth and State departments, the new regional governance structures in health
with greater budgetary discretion, allows for changes in the way community service
agencies are funded and aligned to regional health and hospital systems. This is a central
theme in the National Mental Health Commission’s review (NMHC, 2014).
17. Indigenous liaison officers and interpreters
Feedback from consumers indicates that there is a need for more indigenous liaison
officers and a more effective utilisation of interpreters.
18. Positives and Negatives from Workshops
The positives identified seem to be more related to the performance of specific
individuals whereas the negatives appear to be more pervasive and systemic in nature.
For example a particular clinician or NGO may have established a good referral network
within a particular area and have built up personal relationships with key staff at local
NGOs or hospitals. As a consequence the feedback from the workshops for this area is
positive. However, because the networks have been developed at the “personal” level
and not the “organisational” level as soon as the personnel change – either within the
NGO or within the hospital both the relationship and the referrals cease to function and
the feedback quickly becomes negative. Generally speaking those that work within the
hospital sector find it much easier to identify positives than those that work elsewhere.
Consumer experience generally negative …
It appears that due to the negative experiences of some of the consumers who attended
the workshops they struggled to identify anything positive about the current system at all.
This is perhaps one of the most challenging shortcomings identified within this report.
Again at the individual level, some consumers were full of praise for particular individual
clinicians and nursing staff, or staff of a particular NGO, however – it is true to say that any
positive experiences with individuals was more than offset by the overall impact of the
negative experience of the system as a whole.
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Conclusion
“Every beginning ends something.” Paul Valery, French
Poet
Every change destroys something that has gone before and some people will regret that
loss even if they are happy with the new process. William Bridges (1981) calls the process
that people go through as they face change ‘transition’. Transitions start with an ending,
go through a period of uncertainty and end with a new beginning.
What is a transitional pathway? A transitional pathway describes a journey or bridge from
one location or state to another. All journeys have both a start and a finish or destination.
Some will have intermediary points or stepping stones along the way and the journey is
expected to take a period of time.
1) Transitional pathways from the community to the hospital
Examination of the concept of transitional pathways to hospital can be seen to rest on two
assumptions;
•
That hospitals are the appropriate destination to provide treatment or care, and
•
That hospitals are available and accessible.
The evidence evaluated during this project indicates that neither a) nor b) is necessarily
the case.
Hospital capacity has been identified as an issue of concern. The bottleneck at ED and the
availability of beds have both been criticised. Evidence suggests that not all clients in
need have been admitted. An unknown number have left ED without referral to alternative
care providers in the community or necessarily any family or carer supports.
In light of this we need to reframe the problem and consider what is the best transitional
pathway into appropriate care – we should not assume that this will be a hospital. Our
collective default reliance on ED is not the optimal response of a 21st Century mental
health system. The system needs to be more flexible and more responsive to the complex
and varied needs of the target group. The suggested solution to the system overload
witnessed at ED is not necessarily more hospital beds but a greater range and variety of
treatment/ recovery modalities – some provided within the hospital context, but others
provided within an enhanced community sector response.
2) Transitional pathways from the hospital to the community
The 100 beds per week requirement not only drives the hospital sector, it has an
equivalent impact on the community sector which is expected to absorb up to 100 clients
each week. We can assume some of these clients will have access to primary care or
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specialist care in the community and / or family and carer supports. Their needs for
community sector services may be low or even nil following discharge. However we do
not know how many of the 100 hospital discharged clients are in this group. Evidence
shows that NGOs do not service 100 new referrals per week from hospitals.
All of this raises important questions for which we do not presently have data. If the NGOs
do not provide this group with support who does? Is the care optimal for recovery?
We have seen that all transitional pathways have a starting point and a destination. The
starting point for this transitional pathway to the community is the hospital. The hospital is
a substantial edifice. It provides a wide range of medical services and usually occupies a
large built form. However, hospitals are more than this – they are socially significant
institutions of high value, this centralised infrastructure consists of a range of elements
some economic and others bureaucratic. In addition hospitals are seen as custodians of
both clinical and scientific knowledge. Therefore, they provide a firm foundation to
‘anchor’ the starting point of this transitional pathway.
So then, what of the other end of the transitional pathway – the destination – the
community?
As we have seen this is less well defined, consisting of a plethora of small NGOs
competing to provide similar services often on a shoestring budget and overly reliant
upon individual relationships to clinicians in the hospital based services for transitioning
clients. This creates a tenuous connectivity to the community one which is all too easily
severed. It is one of the central contentions of this report that, if the community sector is to
be capable of meeting the system requirements of our target group in the future, then the
community sector must be bolstered, become more substantive, develop an increased
capacity and offer a greater variety of support and recovery services than they do
currently. In order to achieve this it is envisaged that more secure funding will be required
and some form of rationalisation will be necessary.
3) Whole-of-system approach
Throughout this report there has been an emphasis on the importance of taking a wholeof-systems approach if there is to be an improved transitional pathway to and from
hospital and an improved experience of care for consumers. To that end, there are a
number of recommendations to address system weaknesses and to build capacity and
responsiveness within the system as a whole and to strengthen the community sector
specifically. These have been enhanced and developed from the input of the PIR
Consortium Management Committee. Only by adopting a whole-of-system approach and
by implementing system reform that service delivery can be meaningfully improved for
consumers.
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Recommendations and Action Steps
The ten recommendations listed here were presented to the PIR Consortium
Management Committee and other key stakeholders on 21 July 2015. The CMC group
broadly supported the recommendations and provided further detail and clarification to
each of the recommendations. That additional work has been incorporated here.
1. That there be a heads of organisation agreement
A heads of agency agreement (HoAA) is the cornerstone of getting to the “To Be” system
in the region. The agreement should be based upon agreed key principles, shared policy
and procedures, defined roles, responsibilities and accountabilities.
The objective of the agreement is to provide leadership, coherence of vision and
direction to the system as a whole. The agreement should be aspirational, inclusive and
collaborative, acknowledging the need to improve the systems performance for
consumers, carers, clinicians and those within the community sector. The new system
requires a clear statement of intent – a public commitment by a coalition to strive toward
improving the current system.
It must involve high-level leadership from the MN HHS, BN PHN and the National
Disability Insurance Agency along with the leadership of community service provider
organisations. Private hospitals and other relevant government agencies need to also be
engaged. The Queensland Mental Health Commission’s strategic plan provides leverage
for state agency involvement.
The responsibility for progressing this was seen as lying with the BN PHN.
N EXT S TEPS :
•
Determine the key organisations and appropriate level of authority
•
Consideration be given to the eligibility for existing programs – that is, based on
the mapping results, the key programs and services will be identified across the
region. This should inform the services and programs to be covered under the
HoAA.
•
Consideration be given to examining the “Police Link” model as a soft referral
model to ED/Hospital
•
Clarify the role of the PIR/NGO worker in ED in the agreement.
•
Develop draft template for consideration and development.
•
Link with the communication strategy.
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2. A Specific Strategy for Workforce Engagement
That a specific engagement strategy be developed and implemented to ensure senior
hospital clinicians, senior community mental health services clinicians and senior
community sector program managers actively participate in the change management
process.
The engagement strategy must build on the high level of engagement developed
through this project among stakeholders and involve additional clinical and community
team leaders and program managers in developing elements of the change program.
Presentation opportunities should be provided in each hospital and in online webinar
format to communicate project outcomes and directions. Key opinion leaders should be
identified and brought into to the ‘tent’ and tasked with developing aspects of the
implementation and/or evaluation.
N EXT S TEPS :
•
For the CMC or TWG to oversee the development of an action plan for workforce
engagement
•
For CMC to coordinate briefings and presentations and a simple 2 page outline of
the project and the directions
•
For the CMC to identify key opinion leaders, program managers and specialist
staff to contribute to the development of aspects of this change management plan.
3. Embedding an experienced community sector worker within ED
This recommendation specifically addresses the ‘systemic failure’ points identified in the
“As Is” model of hospital transitions.
Initially, it was recommended that a PIR team member be embedded within each hospital
ED and participate in the Triage assessment for all patients who present with mental
health needs.
Through the CMC forum this was refined to be an experienced community mental health
worker. It was also agreed that this be on a trial basis for a minimum of six months in two
of the four public hospitals across the region and be concentrated on the times and days
where most ED presentations occurred. It was generally thought that a maximum of 40-50
hours of community worker attendance at ED would be sufficient – or about 2.5 FTE
across the two hospitals.
The purpose of this recommendation is to:
a. To eliminate the risk of non-admission by utilising PIR knowledge of services to
ensure that an appropriate referral is made to community services particularly
where the patient has few or no community or family supports.
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b. To systematically breakdown the barriers that can develop between those who
work in ED and those who work in the community and private practice. To build
professional networks built upon shared work experiences.
c. Identify clients at potential risk of homelessness.
d. Ascertain health insurance status. If appropriate, facilitate admission to a private
hospital.
It is important to understand that the community worker would not undertake any aspect
of the assessment in ED or that undertaken by the Psychiatric Emergency Team in
determining admission or non-admission to hospital. They may however be present
during the assessment and undertake further needs assessment to link the client to
appropriate community and primary care providers.
The development of service protocols, systems support, training and measurement and
monitoring processes would be undertaken prior to the trial commencing and could be
complete within six months.
N EXT S TEPS :
•
Additional analysis of hospital ED and separation data would be necessary to
determine the peak periods for mental health client presentations across the
hospitals.
•
A risk assessment needs to be undertaken to inform service protocols.
•
Following on from the HoAA, service protocols need to be developed and
reviewed by the CMC. These would include a generic care protocol and then
additional elements for particular sub-groups of clients or particular conditions.
•
Selection and training of the community mental health workers would be
undertaken in collaboration with the HSS.
•
Training and support to the participating NGOs.
•
Surveillance and monitoring would be developed with monthly reviews.
•
Review of the trial would be undertaken in late 2016.
4. Joint training and professional development programs
Joint training and development programs are an effective strategy to building the ‘one
system, one team’ across Metro North – a single, inclusive, respectful culture of mental
health professionals in hospital, community mental health services and community sector.
Over time this may be developed into a regional capability framework with identified
competency sets based on the current and emerging community needs. One example of
this would be to ensure that the capacity of services across the region to respond to new
and emerging conditions such as eating disorders or specific substance use problems is
enhanced and proactive.
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N EXT S TEPS :
•
Undertake joint training and information sessions in relation to the Hospital
Transitions Project.
•
Agree, under the HoAA, to open training events to other providers in the region.
•
Integrate existing training calendars and cross-promote events in all services.
•
Undertake an annual or at least biennial needs analysis of learning and
development needs across the sector.
5. Hospital discharge planning
This should be undertaken at least 48 hours prior to discharge and that the content of the
discharge pack be standardised across all hospitals, including private hospitals.
Inconsistency in both the discharge process and package has been recognised.
The discharge package should consist of the following as a minimum:
•
a video of the process – including consideration of any risks,
•
consumer/ carer checklist
•
evaluation survey
•
discharge plan
•
medication verification and prescriptions
•
referrals and appointments with GPs, NGO, Case Manager, physio, etc
A key challenge identified in the CMC Forum was the availability of accommodation. The
need to develop transitional and stable housing for those clients vulnerable to homeliness
was identified as adversely impacting discharge and then recovery.
N EXT S TEPS :
•
The Discharge Pack be reviewed by the TWG and ensure it meets requirements.
•
Consumer and carer input into the review the Discharge Pack and creation of any
new resources.
•
Training and information to support the implementation of the Discharge Pack be
undertaken in both HHS and NGO sector.
•
CMC to undertake monitoring with MN HHS.
6. A comprehensive evaluation system
This is a key element of the system reform required to ensure accurate system
performance, measurement and continuous improvement. Collective agreement on
outcomes measures was seen as necessary.
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This must include a method to capture the experience of the consumer and carer.
Consumers and carers are to be surveyed at discharge and other critical junctures in the
treatment process.
The CMC forum also saw a comprehensive assessment tool or set of agreed tools as
linked to the evaluation system. Assessment at the time of discharge from hospital was
also seen as part of the discharge process (Recommendation 5).
N EXT S TEPS :
•
A draft consumer and carer experience of service/care instrument be developed.
This can be informed by work already undertaken in Australia, the US and Europe.
The instrument should address the issues with transitions to, form and between
care. This should be presented to the CMC and PIR Transitions for review and then
for endorsement by all key service delivery agencies.
•
A key set of indicators and measures should be drafted for consideration by the
CMC for eventual adoption and implementation across the service system (i.e. in
all service provider agencies).
7. Easily accessible shared “consumer” centric individual care plan software is
provided
This would facilitate access to all relevant information about the client by the treatment/
support team. The CMC saw this recommendation as linking to Recommendation 1.
While there do not appear to be ‘off-the-shelf’ solutions for this need at present cloud
based platforms offer significant opportunities for addressing this need without wholesale
re-engineering of existing Client Management Systems.
N EXT S TEPS :
•
BN PHN to explore possible engagement with the Project Synergy initiative
through the Young and well CRC.
8. A funding mechanism be developed to assist and encourage NGO service
integration, alliance-building and rationalisation.
The interests of consumers, carers, service providers and funding bodies are all advanced
if over time, fewer, more sustainable and capable community service providers operate
across the region. The community sector is presently unstable and unable to provide
consistently high quality support to public and private hospital based services. More
sustainable community services can be developed through alliances, strategic
partnerships, shared services (such as with IT, HR, finance, marketing), service hubs and
agency mergers.
The outcomes expected can also be more explicitly stated and aligned with regional
priorities and the relationships to other service elements described.
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West Moreton Oxley region has a new service hub located in the Ipswich CBD, known as
‘Fiorente’, providing greater opportunities for single intake and assessment and service
integration for mental health clients. Costs are reduced in relation to leasing, ancillary staff
and vehicles.
N EXT S TEPS :
•
Consideration needs to be given to developing service centre hubs in appropriate
locations across the region (e.g. Caboolture, Chermside etc.) by the CMC.
•
Develop a discussion paper for community sector consideration of the issues and
options for consolidation of services across the region.
9. Explore and develop longer term funding mechanisms and partnerships for
community sector agencies.
Stabilising funding for community services is a priority and was strongly supported in the
consultation process by all stakeholders. Hospital based services cannot work as intended
without a strong and capable community sector. The funding uncertainty for the
community service providers de-stabilises the entire mental health care system.
CMC members suggested further documentation of the challenges and impacts of short
term funding on the entire system may be beneficial in advocacy efforts for change.
N EXT S TEPS :
•
A working paper with options for addressing at a regional level, more sustainable
funding arrangements for the community sector.
10. A strategy to reduce the number of ED presentations across the region
An additional recommendation was presented to the CMC forum. As has been
highlighted in this report, hospital presentation, particularly for a person in crisis, can be
in itself an adverse outcome. Early intervention and care in the community are widely seen
by consumers, carers and healthcare professionals as more appropriate and more likely to
result in favourable outcomes for the consumer.
A complementary strategy to the recommendations here for improved hospital transitions
pathways, involves creating alternatives to ED. Appendix 4 lists a number of evidencebased alternatives to ED presentations for people with mental health needs namely 1)
Crisis or Safe Houses in the community, 2) 24-hour Crisis Resolution or home treatment
teams and 3) Acute Daycare hospitals.
In addition to these alternatives, there are a number of other strategies to reduce the
pressure on EDs and move away from ED as the default point for accessing mental health
care across the region. These include:
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Ensure that on a first presentation to ED, the consumer and their family are
informed about alternatives to ED.
•
Mental health triage line. A single telephone and web site should be established
for all mental health contacts. Similar models now operate in Adelaide and are
providing effective in care coordination and reduced ED presentations.
•
Establish and support the capacity of GP practices’ to work with complex needs
clients. Under the Second National Mental Health Plan, Victoria developed
“Primary Mental Health Care Teams”. These teams were usually made up of a
mental health nurse, clinical psychologist and a social worker and supported by a
consultant psychiatrist. They linked with GP practices to provide clinical services,
clinical supervision or support and linkage to acute care where needed. The
Commonwealth’s Mental Health Nurse Incentive program (from 2006) was
developed with a similar objective.
•
Invest in collaborative school-community programs such as the Ed-LinQ Initiative
which builds capacity in school communities to better respond to the mental
health needs of student populations. Similar efforts in post-secondary school
settings should also be considered.
•
Promote self-care – social marketing and technology based solutions which could
be used to build the capacity of every member of the community to better manage
their mental wellbeing. Numerous smart device applications are now available for
little or no cost and have proven capability in helping individuals assess, monitor
and/or maintain mental well being.
•
Mental health promotion – almost no action has been taken across Queensland in
relation to mental health promotion. The WA Mentally Healthy Campaign (known
as Act-Belong-Commit) has good evidence to support its roll out across the region.
N EXT S TEPS :
•
Consideration needs to be given to this strategy by the CMC and PIR Transitions
Working Group.
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Appendix 1 – Feedback from Interviews with NGOs
and other stakeholders
Admission and ED
•
the availability of beds drives the system not the needs of consumers.
•
Lack of beds drives system
•
system needs to be more responsive and sensitive to consumers needs, need to
provide greater range of treatment, care and accommodation options
•
“revolving door” to ED is high risk leaves consumers feeling rejected
•
Transition through Ed often traumatic and exacerbates symptoms
•
ED only available entry point to care for the mentally ill open 24/7
•
ACT are initial gate keepers at ED and admission only available if you are a suicide
risk AND a bed is available
•
ED is a recognised bottleneck
•
attitude of some ED staff in appropriate
•
longer wait times in ED for consumers with mental illness than others
•
admissions packages 50 + pages - poor communication
•
Quality, frequency and consistency of Multi Disciplinary Team Reviews (MDTRs) of
concern
•
AQuA audit documentation clearly indicated inadequate implementation and
ongoing inconsistency across the system.
•
ED sets agenda everything else in the system reacts to ED they are the gate
keepers
•
Some NGO clients are admitted but they are not informed.
•
Stigma in ED clients sometimes not respected or treated with compassion when
staff are busy – attitude.
Discharge
•
Discharge planning
•
Inconsistent and poor discharge implementation
•
Discharge into homelessness still occur
•
Informed at short notice by hospital “we need to discharge this patient now
because we need the bed”.
•
NGOs report that they are sometimes phoned from home by client that they have
been in hospital – no contact from hospital – no other details available – no
discharge or handover
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Discharge is not a solution as many of these clients require ongoing social contact
and support to maintain independence and avoid hospital
•
Discharge into weekend problematic due to lake of preparation and availability of
support services when client vulnerable due to being released on own for first time
for a while.
•
Discharge from medical wards can also be a problem as many clients have range
of issues – informed coming home this afternoon – insufficient time to organise
support – therefore increased risk of re-laps
•
Accommodation often takes most of a week to sort out when required – rarely ever
given sufficient notice to get this right.
Service delivery
•
Due to rotation of Drs on wards clients often report seeing a different Dr each time
and having to recount their story many times which is frustrating and upsetting
•
Often no therapy or treatment is offered in hospital just medication
•
Some patients treated in and out of hospital for 20 years hundreds of admissions –
no perceivable difference to behaviour or condition
Distinction between behavioural and mental illness
•
Hospitals only deal with mental illnesses e.g. schizophrenia (mental illness) with a
focus on medication and symptomatology whereas PIR take Borderline Personality
Disorders (behavioural) that can’t get into hospital. PIR take variety of complex
cases including social, behavioural, brain injury, involved in the courts, or with
police, homeless, child protection issues, drug and alcohol - or any - or all - of the
above.
Culture and power
•
Hospital V community culture very different attitudes still evident – hospital/ Dr
knows best v NGO sector works with clients to empower them
•
Medical model V social determinants of health
•
Clinicians on wards have poor understanding of PIRs/ NGOs and therefore do not
refer.
•
Must breakdown cultural differences – must get PIR/ NGOs on wards – educate
from within. Must provide joint professional training for both sectors.
•
Lack of integration has significant negative impact on performance of both parts of
system.
•
Attitude – “We know more than you do clinically – therefore you should do as we
say.”
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“NGOS have to prove themselves.”
August 2015
This attitude is a major impediment to
integration.
•
Must create equal partnership.
•
Leadership is critical – Senior Consultants Psychiatrists have the power and set the
standards of behaviour and expectations – they set much of the culture.
Traditionally they are difficult to reach or influence – they need to be more
collaborative.
•
There is an unequal power relationship between the hospital system and the
community sector
•
The language of recovery is not embedded within the system it is the language of
treatment that is dominant. Language betrays the thinking – it is not “person
Centred”.
•
Leadership and direction for system lacking
•
Hospital staff often assume NGO and community workers unskilled and un
qualified
Private sector
Many of the PIRs and NGOs have excellent and close working relationships with
private sector and good referral networks to facilitate treatment in the private sector
whenever possible rather than refer clients into the public system.
Hospital Outreach
•
one phone call or visit first two weeks after discharge has minimal impact
•
follow up very limited and tenuous
•
fully integrated care requires an integrated and accessible electronic data system
IT
Inreach by NGOs
•
Where driven by NGOs useful
•
Under-utilised by ward staff – generally poor understanding of potential usefulness
of referrals to NGO and community sector
Source of referrals for NGOs
•
1800 #
•
In reach to hospital ward
•
GP
•
Community centre – field team
•
Network
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•
Police
•
Prisons
•
Some relatively few from hospital (Some receive reasonable proportion of referrals
from hospital – significant differences across region)
•
Virtually non from ED
•
One PIR NGO reported that they had 6 referrals from their local hospital in 2 years
– a hospital that discharges 35 patients per week
NGOs/ PIRs and Flexible Funding
•
NGO staff often do all they can to avoid ED – use funding for hotel rooms, rent,
private psych, private hospital, PIR support, treatment programs, home care –
rather than let client access ED because the experience is so damaging and
negative.
•
Flexible funding biggest benefit from PIR program and has saved many lives
•
NGOs and PIRs often pool funding to provide recovery/ support/ treatment for
clients
•
NGOs and PIRs provide own Case Managers from flexible funding because there
are not enough
•
•
Treatment is provided by PIRs e.g.
o
CBT – Cognitive Behaviour Therapy - symptom reduction
o
Wellness Recovery Action Planning – 10 wk group therapy
o
Borderline Personality Disorder – 10 wk “Wise Choices” group therapy
o
The Optional Health Program – Wellbeing – provided by GPs
o
Flourish – Self Development Program – provided by GPs
Competition for funding and referrals between service providers is an expensive
distraction
•
Available funding drives behaviour and services
•
Proliferation of NGOs - there are too many small NGOs competing for funding and
providing similar services within the mental health space – some rationalisation is
required
•
A stable system requires both adequate operational funds and consistency in
financing - short term contracts = instability
•
PIR funding stops June 2016 less than 12 months time
•
NDIS = uncertainty
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Shift to business model for funding of service delivery will remove flexible funding
to meet needs of those who fall through gaps
•
Business model will lead to further fragmentation of services
•
PIR experts needed in ED to facilitate referrals to community sector and provide
advice
•
NGOs/ PIRs often try to keep clients out of and away from public hospitals but they
also try to get clients OUT of the private sector. If client eligible for private sector it
is very lucrative – average stay 3 wks.
•
Many clients do not fit criteria for PIR services – they try to refer on but there are
generally few services available.
•
Flexible funding used for admin staff.
More Case Managers are required within the system.
Greater responsiveness and more support/recovery/ treatment options required
•
24hr Safe House for people in crisis rather than ED
•
Overnight safe house required
•
Temporary hostel accommodation required
•
Supported housing options required
•
Company at Home
•
Treatment at Home
•
Weekends – very few services or activities available – so clients often at loose end
and can deteriorate and seek admission via ED as no other options available
•
Isolation at weekends exacerbate ED visits
•
Generally PIR and NGO services are only available 8:30 – 4:30 Monday to Friday if
discharge occurs late in afternoon, particularly on a Friday- insufficient time
available for effective smooth transition
•
Outreach mobile unit/ bus required – can be called on by clients to provide
support e.g. – safe, secure, warm, coffee, couch, TV company and conversation.
Step up Step Down critical service missing from system
Queensland Health
•
Queensland Health happy to let police respond and make determination as to
whether or not a consumer should be admitted to hospital or the Watch house for
night. Often the decision is arbitrary depending on skills, experience and available
time of police officer on duty.
Uniforms and authority figures frequently
exacerbate symptoms/ trigger poor behaviour.
A Mental Health Ambulance
would mitigate these issues.
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NGOs report that Queensland Health case Managers think they know all clients in
area but claim they only know about 50%. The others are in the community/
private sector and have been kept away from the public hospital sector for their
own good.
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Appendix 2 – Feedback from Workshops and
Forums
Identified Common Themes
Most Common Issues
Standardised documentation - more comprehensive discharge plan needs to be
implemented to avoid last minute and inappropriate discharge.
Data access and sharing - an accessible shared information system and less duplication of
information gathering
Discharge planning involving community organisations (via a community rep)
Family and carer engagement – both on presentation and discharge planning and
coordination.
GP engagement – skilling, and then clinical support
Co-location of community services with CMHS
Shared KPIs (i.e. a therapeutic alliance as such)
There needs to be increased communication between hospitals, private sectors,
community mental health and community organisations, along with multidisciplinary
teams.
A smooth handover between public MH teams and involvement of families/carers.
Listening to family and carers.
Resource priority themes
There needs to be more cultural sensitivity and access to interpreters, and less prejudice
and discrimination. More use of indigenous liaison officers to follow up.
Greater home-based acute and non-acute services
More case managers – to enable better coordination and assertive care
More choices e.g. safe houses for people in crisis as alternative to ED.
Step up/Step Down services.
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Summary of Priority Issues
General
•
One care plan – upload and share
•
Mind-body connection
•
Overarching Access to common information system, referrals/ assessments/care
plans/discharge summaries
•
View of distal goals as well as proximal
•
Efficient long term plan, sustainable
•
Medical management sole person to reduce over medication
Hospitals
•
Access to database listing peoples current 6P for referral/communication
•
Shared KPI’s
•
Identify support and involve post d/c
•
Integrated models of service
•
Awareness of timeframes, private health
•
Flexibility in process to be able to make appropriate referrals
•
More liaison officers/discharge planning coordinators
•
More resources for case managers to decrease their caseloads
•
Being able to enter directly into MH ward instead of through A&E
•
Hospital staff’s engagement with consumers to improve
•
Family & carer engagement; sharing of information; planning; clear discharge
process
•
Recovery approach from first presentation (and green)
•
Team of discharge/transition planners as a specified role – consistent process,
develop high knowledge of NGOs, systems approach – not based on
personalities/relationships
•
Standardisation of discharge documentation (x2)
•
Coordinated discharge – morning discharge, supportive people, food at home,
transport, discharge summary
•
Team of discharge/transition planners as a specified role – consistent process,
develop high knowledge of NGOs, systems approach – not based on
personalities/relationships
•
Discharge summaries – on time – electronic
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Increased support in transitional period (clinical support for 6-12 weeks postdischarge)
•
Increased resources for transitional care
•
More choice of pathways when in crisis
•
Dedicated MH entry point
From consumers and carers
•
Interactions with patients – engage them
•
Consumer empowered to leading of their care
•
Standardised processes and systems and equity across the system
•
More caring. welcoming
Stop/Less of
•
Last minute d/c (x 2)
•
Triage through ED
•
Missing out on follow up services in all areas
•
Conditional admissions – i.e. has to be suicidal
Community Mental Health
•
Database
•
Resources to decrease caseloads
•
Interpreter services Expecting NGOs to do everything for consumer
•
Step up/step down (and green)
•
Crisis house – safe place, supports, de-escalation
•
Continuity of care
•
Hospital presentation plans & relapse prevention plans/safety plan – access to
family & carers
•
Coordinated discharge – morning discharge, supportive people, food at home,
transport, discharge summary
•
Consistent case manager & psychiatrist
Community Organisations
•
Research holistic flexible real support responses
•
Tender process for supporting patients with DE identified information – then
NGO’s are taking on appropriate referrals
•
Take on role of clinicians when not trained
•
Onus on sense of responsibility for client in replacement of hospital
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•
More resources to accept more referrals more timely (increase in $$$)
•
Safe and recovery oriented accommodation
•
Something to decrease wait lists
•
Colocation/integration with clinical services e.g. education sessions; meeting
patients in waiting rooms
•
Crisis house – safe place, supports, de-escalation
•
More supported accommodation (Govt responsibility)
•
More choice of pathways when in crisis
GPs/PCPs
•
GP actively involved in coordinated case plan
•
Notification of medication change
•
MH expertise
•
MHFA training
•
Access to CIMHA
Stop/less of
•
Inflexible practise
•
Waiting lists in NGOs –
•
Mismatch between hospital discharge and NGO capacity
•
NGOs - Stop working in isolation – lack of case coordination
•
NGOs - Funding
targeting
community needs and
not double
up
on
programs/groups
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Activities
Role
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Notes
“Consumer” refers
to the potential
recipient of
services.
Intake and
Assessment
Coordinator
Administration
Officer
Receive phone call
directly from
Consumer
Receive referral
form
Receive referral
• 
Self
Family/carer
PIR associates
MH services
Police
GP
Medical specialist
Ministry of Justice
Outpatient services
Hospitals
Community service
providers
Other
Referral sources include:
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
Complete referral
form
• 
• 
• 
Draft 0.1
Administration Officer
Confirm receipt of
referral
Complete assessment
Enter details to
PCM
Phone call
Receipt of referral form
Other
Referral can be received
through:
Intake and Assessment Coordinator
Interview
Consumer
Review referral
Go to
Review referral
Present assessment
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Appendix 3 - PCEML PIR, Process Flows
F IGURES 9.1-9.4: I NTAKE AND A SSESSMENT P ROCESSES
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Activities
Role
ConNetica
Notes
N
Is it severe and
persistent
mental illness?
Additional information may be required from the Consumer or referrer to
gain a clear understanding of the circumstances.
Generally, referrals received from consortium members or associates are
considered complete because of their understanding of the PIR initiative.
Y
Go to
Complete assessment
Present assessment
Draft 0.1
No referrals are closed without information and pathways being provided
to assist the Consumer.
A check on progress is made with the referrer/Consumer two weeks after
information is provided or appointments made.
Intake and Assessment Coordinator
Intake Support Officer
Close referral
Check on progress
Provide information,
make appointment etc.
N
Update referral
Y
Can needs
be met by a single
provider?
Complete assessment
Contact referrer
and/or Consumer
Y
Review referral
Contact referrer
and/or Consumer
N
Is referral form
complete ?
Receive referral
3
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Activities
Role
ConNetica
Notes
Y
Referrer and services to
try and find the Consumer
for three months before
closing the referral.
Consumers may be
difficult to contact as they
relocate before the
assessment interview.
N
Has Consumer
been located?
Engage referrer/services
to assist (3 months)
N
Is Consumer
locatable for
appointment?
Receive referral
Y
Interview may take 2 –
3 hours, and be a
completed in a single
or multiple sessions.
Close referral
Check on progress
Identify options and
support
N
Is it severe and
persistent
mental illness?
Scheduled appointment
Meet Consumer
Provide program
Information and
consent form
Intake Support Officer
Y
Can needs
be met by a single
provider?
Draft 0.1
No referrals are closed without information
and pathways being provided to assist the
Consumer.
N
Is a follow up
assessment
required?
Check on progress
Identify options and
support
N
Is the
Consumer ready to
engage in the
program?
Assess Consumer
readiness
Assessment includes:
• 
Physical health
• 
Mental health
• 
Accommodation
• 
Social support (family, carers,
friends, medical)
• 
Transport
• 
Finances
• 
Risk
N
Identify and agree
on Consumer’s
needs and record
Complete assessment
A check on progress is made with the referrer/
Consumer two weeks after information is
provided or alternative arrangements made.
Y
Seek and record
information on
mental health status
Undertake Mental
Health Assessment
Review referral
Go to
Complete assessment
Go to
Present assessment
4
Consumer engagement is key to
the success of the program.
Ask key questions to empower
and gain crucial information,
including
“Where are you right now on
your journey?”
“What do you need?”
“Are you ready to help us?”
Y
Y
Obtain other information
and agreement
to proceed.
Present assessment
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Activities
Role
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Notes
Present assessment
at team meeting
A fact based presentation
of the assessment is
provided for review and
discussion.
Intake and Assessment Coordinator
Review and refine
assessment and
prepare for team
meeting
Receive referral
N
Consider other
options.
Contact referrer/
Consumer to
discuss.
N
Is Consumer to
be engaged in
PIR program?
Draft 0.1
• 
• 
Providing other
information
Referring Consumer to
another service/
provider
Reassessing referral
and assessment for
gaps/omissions or
useful information
Other options may include:
• 
Y
PIR Intake team
Support Facilitator
Complete assessment
PIR intake team
Intake and Assessment Coordinator
Intake Support Officer (where information is required)
Go to
Complete assessment
Y
Is more information
required?
Review referral
Nominate Support
Facilitator and
commence case work
Present assessment
5
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Role
Notes
ConNetica
Activities
Co-Morbidity Nurse,
Psychiatrist
Person is requested
to be involved in
research project and
model of predischarge support
with appropriate
organisations linked
whilst in prison in
preparation for exit.
MH meetings held
monthly and non-MH
meetings twice
monthly.
Any MH queries from
non-MH meetings to
be streamed to and
discussed for
potential relevancy at
the mental health
meetings. Non-MH
organisations invited
to meet with MH
when needed for
referral discussions
Approach person for
referral
Referral form to
include receipt of risk
assessment from comorbidity nurse.
Co-morbidity Nurse,
Psychiatrist and other
organisations to own
service as required
Complete referral
forms to PIR and
relevant
organisations along
with research forms
with person
Review referral
Non-MH: RUAH RIO,
UCW, Ngala,
Transitional Manager
MH: PIR, CoMorbidity Nurse,
Psychiatrist
MH meetings
Non-MH meetings
Pre Referral In-Prison
Meeting
Pre-Release Referral Process
19 May 2015
Could occur at
different times
depending on wait
list of organisation.
The first organization
to engage will
continue to discuss
the ethos of the prerelease model and let
other representatives
of organisations
know they have
engaged
Specific to
organizational
requirements
Complete assessments
Individual and case
meetings between
organisations and
client provided with
needs identified and
allocated to
appropriate
organization to work
towards with the
client.
Accepted and
engaged
organisations
Pre-release case
meetings commence
Pre-release case
meetings
Individual and case
meetings between
organisations and
client to continue
linking with
appropriate supports
and assist within the
community.
Accepted and
engaged
organisations
Continued work with
person upon release
and case meetings
with linkages
Post-release case
meetings
Psychiatrist?
Post-release
discharge forms filled
out with person
Post-release
assessment
1
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August 2015
F IGURE 10: P RISON P RE -R ELEASE R EFERRAL P ROCESS
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Appendix 4 – A Summary of Alternatives to ED
Crisis or Safe Houses
Safe houses or crisis houses now account for around 10% of all acute care ‘beds’ in
England & are in place in Europe & some US states & Canada. The features are:
•
Residential alternatives to admission
•
24 hour staffing, community setting
•
Spectrum from hospital like to clinical staff to more distinctive voluntary sector
•
Often advocated, rarely policy
•
UK provision (2012-14)
•
25% of UK Health districts areas have access to one (as at June 2014)
•
Often highly integrated with other local acute service
•
May be managed by crisis team leaders
•
Mixture of statutory and voluntary sector provision
Crisis Resolution (or Home Treatment) Teams
Crisis Resolution teams and home treatment teams are multidisciplinary teams that:
•
Assess all patients who are being considered for hospital admission
•
Provide intensive home treatment instead of admission to hospital where possible
•
Facilitate early discharge from hospital
•
Discharge patients as soon as the crisis has resolved and a longer-term
management plan has been agreed.
•
CRTs are intended to:
o
operate 24/7
o
gatekeep all acute care admissions 18+
o
visit intensively for a limited time period
o
deliver a range of medical, psychological & social interventions to resolve
crisis.
Evidence supports use of CRTs to reduce hospital admissions, crisis presentations at ED,
re-admissions to hospital and have greater client satisfaction that ‘treatment as usual’.
Acute Daycare Hospitals
Evidence from a limited number of RCTs tends to suggest can substitute for some acute
admissions with good outcomes (Priebe, Kallert). Recent fall from fashion but may meet
needs for social contact and activity, allow more extensive therapeutic programs
(Johnson, UCL, 2013)
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Appendix 5 – An Example of a Shared Care Protocol
Borderline personality disorder9
P URPOSE
This SCP outlines the agreed approach of the participating agencies in the Brisbane North
PHN region. Participating agencies have agreed to share information, expertise and
resources for the purpose of supporting people with severe mental illness and complex
service needs. This SCP applies to those people with a primary condition of Borderline
Personality Disorder.
T HERAPEUTIC
ALLIANCE :
Working with people with borderline personality disorder (BPD) is inherently complex.
The chaos and disorder that characterises the internal world of a person with BPD can
impact on attempts of the professionals and agencies involved to engage effectively.
Having a diagnosis of BPD should never exclude an individual from receiving other
services which are required. This is well recognised and research suggests that staff
should devote effort to achieving adherence to care, treatment and interventions which
should:
•
be well structured
•
have a clear focus
•
have a theoretical basis that is coherent to both staff and service users
•
be relatively long term (months rather than weeks)
•
be well integrated with other services available to the individual, using where
appropriate, the Care Program Approach as a main means of networking,
communicating and reviewing plans between different elements of the service
where appropriate, and
•
involve a clear treatment alliance between staff and service user.
With this group in particular, there is a need for the multidisciplinary team to be
supported by the organisations in reducing vulnerability of clinicians and other
practitioners in their endeavour to balance risk with sound judgment. This client group are
also known to be particularly sensitive to any changes in their environment (including care
environment).
9
This is based on Scottish ICP and Logan Care Coordination Panel Protocols.
Former available at: http://www.icptoolkit.org/condition-specific_care/borderline_personality_disord.aspx
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P RINCIPLES
OF MANAGEMENT OF PEOPLE WITH
August 2015
BPD:
The principles of Care Coordination agreed to in the Heads of Agency Agreement (HoAA)
apply to all condition-specific care protocols.
For successfully implementation of the ICPs for BPD, there needs to be a generic training
program that promotes empathy, respect and the implementation of the principles of
management of people with BPD for all staff who come into contact with service users
with this condition.
These principles are applicable to all interactions between service users and staff, with
both staff and service users having responsibility to maintain them:
•
establish & maintain the therapeutic alliance while managing risk
•
maintain flexibility
•
establish conditions to make the patient safe
•
tolerate intense anger, aggression & hate
•
promote reflection
•
set necessary limits
•
understand the dynamics & monitor relationships between service user & staff
thereby reducing the potential for splitting (or conflicting allegiances) between
psychotherapy & pharmacotherapy, & between different members of staff
•
monitor countertransferance feelings (strong irrational feelings that can be
unconsciously evoked in staff) with view to using this to understand the patients
communications and difficulties, and
•
use a consistent approach.
K EY S ERVICE A GENCIES
(List to be developed from MH Atlas data)
R OLE
OF THE COMMUNITY MENTAL HEALTH TEAM :
development of a management plan agreed
with the patient
identification of a keyworker
referral to specialist services if necessary
access to acute inpatient care
risk assessment
family and social support, and
co-ordination of a crisis plan
prescription of medication.
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M ULTI - AGENCY
August 2015
CARE MANAGEMENT GOALS :
emotional support
limiting harm
monitoring and supervision
reducing distress
intervening in crises
treating comorbid Axis I disorders
increasing motivation and compliance
treating specific areas (eg anger, self-harm,
social skills, offending behaviour), and
increasing understanding of difficulties
giving practical social support with housing,
finance, child care.
building a therapeutic relationship
resources section
avoiding deterioration
K EY R EFERENCE S TANDARDS & G UIDELINES (National/Professional/Organisational)
National Mental Health Standards; National Mental Health Recovery Standards; NHMRC
Clinical Practice Guideline for the Management of Borderline
D EFINITIONS (to be added)
P ROCESS F LOW D ESCRIPTION
Assessment
Initial assessment where referral and triage would be part of a pre-care pathway system
Intake and Assessment/Re-­‐assessment • Current and past mental health problems
•
Current and past interventions for these problems
•
Validity of existing diagnosis
•
Previous history of puerperal psychosis
•
Personal, family & social circumstances
•
Consider parenting issues and circumstances of any children
•
Strengths & aspirations
•
Functioning
•
Service user needs assessment (standardised)
•
Informal carer/family needs assessment
•
Capacity to consent to care and treatment
•
Professionally rated assessment tool – e.g. HoNOS
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•
AOD use assessment
•
Physical health assessment inc self care/health promoting activities
•
Need for psychological and/or psychosocial interventions
August 2015
Risk Assessment • Self-harm
•
Suicidality
•
Impulsivity
•
Harm to others
•
Finance
•
Occupation
•
‘Social & sexual vulnerability
•
Abuse, neglect & trauma
•
Specific risks for women of child bearing age
Medication assessment • Effects of medication
•
Suitability if pregnant, or post-natal period or of child bearing age
•
Risk of medication withdrawal
Planning
•
Crisis plan
•
Staying well plan
•
Allocation of care coordinator
•
Advanced directives
•
Record of named person/s
Consider Involvement of: • Informal Carer
•
Advocacy Services
Specific Information • Reason for potential inpatient admission, if admitted, expected length of stay and
discharge pan
•
Clear boundaries and defined timescales
•
Prognosis of condition
•
Discussion about diagnosis
•
Explanation of patient rights
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•
Other organisations and sources of support
•
Awareness of complexity
•
Review of agreed roles and responsibilities
August 2015
Consider treatment options • Condition specific pathways
•
Models of treatment
•
Location of treatment
•
Attempt to avoid inpatient admission. If admitted, maintain one-to-one sessions
and contact with community workers. Consider home treatment options in event of
crisis, inducing the role of the crisis team
Delivery
•
Specific tasks, treatments and interventions (including risk management)
•
Identify treatment needs, formulate plans, including defining boundaries for
working with patient
•
Identify goals and aspirations
•
Record roles and responsibilities of all individuals and agencies involved
•
Include a record of service user desired outcome
•
Records unmet needs since the last assessment
•
Include as part of guidance/principles on care plan, but not explicitly part of
criteria for an individuals care plan
§
Based on the assessment of needs, strengths and past experience
§
Includes a system of record disagreement
§
Records that the service user are invited to hold a copy of the care plan
Outcomes
•
Care plan regularly (at least annually) reviewed
•
Service user needs assessment – AVON
•
Professionally rated assessment tool – HoNOS or diagnosis specific
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F LOWCHARTS (attached)
Overview
Intake & assessment Outcomes Planning Service delivery Transfer of care between services or exit from care
(Detail to be added from MH Atlas data)
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